Hi. Welcome, everyone. I know people are still joining this webinar, so I'm going to just take a few minutes to do housekeeping notes, but I don't want to delay us at all. My name is Aubrey Hsu, and I'm the education and CME coordinator for IISLC, and I'll be running through these notes on today's webinar in support of care of lung cancer patients during COVID-19. I apologize. Let me forward this for you. I just put into the chat a link that will take you to our website where you can access the downloadable slide deck if you want to see that at any time. You will also be able to find a recording of the webinar at that link within the next week. I will send out an email after the webinar with instructions on how to claim your CME credit. Please reach out to me if you have any questions. Your camera and microphone will remain off for this webinar. Please enter any questions you have for the Q&A discussion into the Q&A section at the bottom of your screen. You may also use the chat function for other discussions, but we want to try to keep that off the Q&A channel. We will not be using the raise hand function for questions. We plan to have a short Q&A discussion at the end of each presentation, so please enter your questions into the Q&A section at any point during the talks. We will be using polling questions at a few points during the presentations. When the speaker is finished reading the question, you will see a box pop up on your screen. You can select your answer, and after everyone has answered, we will share the responses with the group. Here are the speaker disclosures. Oops, sorry. Those are the housekeeping notes. Here are the disclosures, and I would now like to introduce Sarah McLaughlin Barrett. She has been a lung oncology clinical nurse consultant for the past 10 years and is currently working at Monash Health in Melbourne, Australia. Sarah has a passion for improving service delivery and patient outcomes. She has been involved in service redesign and developed Australia's first cancer support mobile application in 2016. Welcome, Sarah. Thanks, Aubrey, and thanks, everyone, for dialing in today. I know it's the afternoon and the evenings over there on the other part of the world and a very early morning here in Australia, so we really appreciate everyone taking time out of their busy work and family schedules to join us today. We hope you find the webinar very valuable. So I thought I'd just quickly recap and put up a couple of stats on COVID-19. So the first reported outbreak of COVID-19 was in December 2019 in Wuhan. Shortly after, just a month after that, the World Health Organization declared a public health emergency of international concern. So fast forward now to almost 12 months later from the first reported outbreak. At the time of putting my slides together a couple of weeks ago, it was reported 56 million cases of COVID-19 globally, but as of yesterday, unfortunately, we're now hitting 68 million, and devastatingly, we now have 1.55 million deaths up from two weeks ago with my figures there. So needless to say, we have had catastrophic effects and will continue to have catastrophic effects on our world's economy, healthcare system, and our healthcare workers. So in regards to our healthcare workers, I've just listed here, I'm only touching on a few things that our healthcare workers and institutes are dealing with. On a daily basis, we're dealing with our hospital beds reaching full capacity, we have limited ICU beds and ventilators, and the mental and physical exhaustion of our healthcare workers is phenomenal. The burnout rate currently reported is greater than 50%. We're dealing with ever-evolving policy and procedure changes within our institutes. And on top of this, we're adding the additional emotional and psychological support that we need to provide our lung cancer patients. And as we all know, as healthcare workers, more often than not, we're putting our patients' needs ahead of our own, but I think in a time like this when we're dealing with hopefully a once-in-a-lifetime pandemic, which is going to be prolonged and we haven't got an end in sight at the moment, it's important to remember to, as healthcare workers, to make sure that we take care of our own mental and physical health and at times put our needs before others. And so on that note, I'd like to introduce our first speaker, Dr. Maria Fitanu, and she will be presenting today on her talk, New Emotional Challenges Faced by Lung Cancer Patients During COVID-19. Thanks, Maria. Thank you, Sarah, and thank you to the Organising Committee for inviting me to present at this webinar today. It's a real pleasure to be here in these weird and strange times, and I hope that wherever you're joining us from that you are safe and well today. Before I start my presentation, we've got a bit of a polling question, and if you could take a couple of seconds to read the question and put in your answer, that would be fantastic. So up to what rate of lung cancer patients do you think are experiencing COVID-related stress at the moment, such as depression and anxiety? Just give me a couple of minutes. Okay, so we'll come to the answer as we'll get to the answer as we work through our slides, but the majority of you are saying about 70 percent. Okay, next slide. So the aim of my presentation today is really to talk a little bit about the emotional impacts that COVID is having on our lung cancer patients, and to talk about some strategies that perhaps can support our lung cancer patients through this, and perhaps some strategies that can also help us get through it as well, because we are all in it together. Next slide. So COVID-19 is one of the greatest global public health crisis that we are experiencing in our time. As Sarah has said, there are more deaths each day, and there are more new cases. And the psychological impacts of COVID are many. We're seeing increased rates of violence, domestic violence. We're seeing increased rates of domestic drug and alcohol problems, increased rates of mental health problems, increased rates of self-harm, increased rates of unemployment. There's a loss of what we have sensed as being normal. We're feeling disconnected from our loved ones and people that we love that are in aged care facilities. What seemed to have been certain and normal, like simple things of how to get to work or how to do your job, has been revised. We're unsure about whether we should catch public transport. Everything that has been simple and we never used to think of now requires a complex set of decision-making that is leaving us with feeling out of control, that's leaving us feeling that we're unsure constantly. And we don't know how long this pandemic is going to go on for. We're really hopeful for a vaccination soon, but the effects, as Sarah said, are going to be ongoing. And we're all really worried about our own health, the health of our patients, the health of our loved ones. We're worried about whether we, too, will experience COVID during this time. For our lung cancer patients, lung cancer in itself, as you already know, is extremely challenging. As you already know, people are usually diagnosed with advanced age disease and the prognosis remains poor. Lung cancer patients, compared to other cancer patients, have more distress. They've got high rates of depression and anxiety. They've got greater symptom burden. They've got higher rates of suicide, especially older men with lung cancer compared to other cancer populations. And in addition to all that, 95% of our lung cancer patients experience significant stigma. And that could be self-imposed stigma, feeling that they're not worthy or guilty or feeling like a burden on others. Or it could be more externally, like people blaming our lung cancer patients for the disease and what they're experiencing and sometimes not offering any services and withdrawing services from people with lung cancer. However, COVID-19, can we go to the next slide, please, has made these challenges a lot worse than some of these emotional challenges, a lot worse for people with lung cancer. Firstly, a diagnosis of lung cancer and a diagnosis of COVID overlap in some of the symptoms. So people with lung cancer experience shortness of breath, cough and fatigue, and these symptoms are replicated in COVID as well. So it's often very difficult for people to know what they're experiencing and how they're feeling and to know whether it's a symptom of their lung cancer that they're ignoring or whether it's a symptom of COVID and whether they should be doing more. So it leaves them even feeling more uncertain. And some of the symptoms of coughing might have other people worried about what it is as well for them. Our lung cancer patients are also at a heightened risk of poorer outcomes and mortality. Due to the illness itself and the damage to the lungs. But the people with lung cancer that also have COVID are more likely to die of COVID. The rates of mortality are between 25 to 55 percent compared to other cancers, which remain at about 10 percent. Lung cancer patients are very fearful of whether the hospital system and the shortages of staff and beds and capacity, whether they are actually going to receive optimal care. Because, again, of social restrictions that are preventing the illness from spreading are leaving our lung cancer patients disconnected from others, lonely. And also that some of the formal care that they may have received of people coming into their home or hospice care or respite care have also been limited. So there's an additional burden of coping with a diagnosis of lung cancer on your own. Next slide, please. There's also a very high prevalence of fear of cancer, progression, anxiety and depression for people with cancer at the moment, the fear of progression is up at 85 percent, anxiety rates are up at 80 percent and rates of depression are sitting around 75 percent. So very high, very high rates of distress compared to before COVID. People with lung cancer are experiencing increased feelings of guilt and being a burden on their family because they can't access those additional supports. They're relying on their family and really close ones to go to the supermarket for them to do their shopping because they're fearful of the consequences of leaving the house. There's been an increased financial strain because of not being able to go to work or having family members take on more of a caring role. And this financial strain is decreasing quality of life. It's leading to maladaptive coping and sometimes a lack of treatment adherence. The carers of our lung cancer patients are also experiencing increased isolation, increased mental health symptoms because of the of the increased caring demands on them, but also because they too are doing it alone. But lung cancer patients, as many of you have worked with before, are a very positive group of patients and always try and see the silver lining. So many of them are really appreciating what everyone and the health care is doing. They're appreciating the supports that they have. So there are and they're seeing they're making the most of the small things that that are occurring in their daily lives. So there are some silver linings. To help our lung cancer patients, and I guess in some ways to help our own mental health through this, it really is about self-care strategies. When we talk about self-care, we're referring to the intentional time taken on a daily basis to look after ourselves. So it's really important to encourage our lung cancer patients to look after themselves in a number of different domains in their lives. Self-care leads to building resilience and increasing our resilience. It can lead to the prevention of mental health problems, but also it can lead to the management of mental health problems. So when we do look at self-care, we look at a variety of our domains. So you might want to ask patients about their physical domain. Are they doing everything they need to do to be as well as they can possibly can be? So are they looking after their physical health? Are they taking are they practicing social distancing and hand hygiene? Are they exercising? Do they need some tips on how to get a better night's sleep? Are they eating well? It's about asking our lung cancer patients what they're doing for their emotional and psychological health. Are they switching off the COVID media, having a break from it and accessing information from reliable sources? Too much information about COVID leaves us feeling overwhelmed and constantly seeing bad news on TV can lead us to feel overwhelmed. So it's really about choosing the source of information, a trustworthy source of information, and maybe just checking in once a day. And if that's too overwhelming, checking in every couple of days with that with the media. Are people practicing relaxation? Are they acknowledging some of the fears that they're experiencing or they're acknowledging their emotional states? Do they have someone to talk to about what they're going through? Have they gotten a good relaxation app and learning to practice relaxation and looking at things that they can control and letting go of things that they can't control, looking after their spiritual well-being, finding things each day that are meaningful to do that they can do within their own homes or in their backyards, but looking at things that are meaningful and give them a sense of importance. Are they looking after their professional health and their professional minds and their cognitive selves? Are they doing things that are stimulating and relaxing as well and learning new things during this time? But one of the main things is looking after their social relationships, making sure that if we can go to the next slide, please, if making sure that we are being connected to our family and friends and loved ones, connecting through the Internet, by phone, by other online means and connecting in the way in a way that we are letting people in on our every day, on our every day. So if you're at home cooking dinner, encouraging someone, some of our patients to tune into FaceTime or Zoom and let their family and friends watch them and be part of the dinner. Are they connecting in new ways of playing online board games, but making sure that those connections do not disappear, writing letters, sending photos, talking to someone on a daily basis, finding online community and spiritual groups of interest to make sure those connections, because relationships help us come out of ourselves and stimulate us, but they're really important to breaking the cycle of isolation, but also that there is lots of online telehealth and psychological supports at the moment. So really encouraging patients to connect with those supports. It is really important that patients communicate with their health care providers and their training teams and that they are kept informed of what's going on in the hospitals, kept informed of what they should do if they're experiencing side effects of where they can get accurate information about their health care and what they can do and who to contact if things are worse. So they need to be kept up to update, updated with this regular information. And sometimes it's really worthwhile spending time with our patients to show them how telehealth works. So because it is a reliable and flexible treatment option. And making that available for them. And sometimes people are feeling a little nervous, but so if they're guided through it with their clinician support, this can be really helpful. Next slide. Some of our patients may need more, and one of the most effective treatments for anxiety and depression is cognitive behaviour therapy. Cognitive behaviour therapy looks at the way our thoughts and behaviours contribute to our emotions. And if we can change some of our thoughts and behaviours, that may change the way we feel. For example, if some of our patients are feeling really overwhelmed and they're saying that they can't cope with the pandemic or they can't do this at the moment and they're really frightened and they withdraw from all social online communications or they're withdrawing from their health care providers, they're going to more likely to feel overwhelmed and very stressed. So it's about interrupting that thought process and maybe examining how they have coped before, what they can do each day to cope, finding what they can, what they can control and what they can't control and encouraging, again, increased social connections as best they can. They're less like they might feel less overwhelmed and that creates a bit of a change. There's lots of online CBT programs at the moment in Australia. We have things like Mood Gym, Mind Spot, This Way Up. Overseas, you'll have your own CBT programs and CBT programs online are very effective. So it's really about encouraging your lung cancer patients to find the right online CBT program for them. And some of the online CBT programs that are available now also have clinicians in the background to to help patients work through it. Next slide, please. Another very helpful psychological intervention is mindfulness. Mindfulness is means paying attention in a particular way on purpose to the present moment and not judging the present moment. So it really is about focusing on the here and the now. And mindfulness is really helpful in these times because it really helps us deal with those what if thoughts that that are there, that are focused that we look far into the future and cause us a lot of anxiety. So that so it's really about bringing our thoughts to the present moment that are, again, lots of online mindfulness based programs that people can do. And there are some online. There are many apps that can help people get started with their mindfulness. So some of these apps are like called Headspace, Smiling Mind, the mindfulness app where you get leaders in mindfulness from across the world presenting and helping people get through these pro programs. So that is there's some of the tips that I have for our patients. And and I'm going to hand over to Sarah now for any questions. Thanks, Maria. That was really great. Some really helpful points there that we can help implement with our patients. So now we're going to open up for a quick Q&A in regards to Maria's presentation. So you'll see down the bottom of your screen is a Q&A bus. And if you have any questions, do feel free to send them through. We'll do a short Q&A now. And then at the end, if we've got any additional questions, we can put that to the whole panel. So, Maria, we did have a question come through from Valerie, and she was wondering, do you have any strategies or ideas on how we can tackle and break down that stigma that patients either self-imposed or from the community? Yeah, I think it's a lot of education and a lot of talking about lung cancer and and people not clinicians and patients not hiding, not hiding it. So I think it really is about opening up the language and talking about it. And for our patients, I guess it's really about reframing some of their thoughts through processes like cognitive behavior therapy and, you know, informing lung cancer patients that they are very worthy of treatments and a blaming culture doesn't help anybody. So it's really about educate public education. That's great. And I was wondering for myself quite often, and I'm guilty of it, I get caught up focusing so much on my care and attention on the patients. But, you know, not deliberately at all. But I forget about the carers and the partners. So are there any strategies that you could suggest where we can focus and support our patients carers? I think carers are often they come to a lot of appointments and they sit there and we don't we don't focus on them. You're absolutely right, Sarah. But I think it's it's about remembering that COVID and cancer or lung cancer doesn't just affect the patient. It affects the network and their loved ones and really making sure when we when we ask the patient how they're going, that we turn around and say to the partner or the loved one in the room, how are they going? And if they're not in the room that we're asking them, is there anything is is there anything that we can do to improve support for your partner at home? Because if partners and carers really do provide a lot of the a lot of the health care and they're really helping us in providing the best care for the for their patients. But if they're burnt out, it's going to have consequences on our patients and the supports that they receive. So they they are really essential to to their health care. So it is. And they're also going through the same experiences that our lung cancer patients are going through. They're grieving. They're really sad. They're shocked and distressed about the cancer diagnosis. So it really is about making sure it's part of our practice to just check in. Sarah, you're on you. Thank you. So I was just saying, for the interest of time, we'll move on to our next speaker. So I'd like to introduce Stephanie. Stephanie is going to be talking about physically supporting lung cancer patients through assessment and home based rehabilitation via a virtual platform. So I'll hand over to you now, Stephanie. Thank you, Sarah, and thank you to the IACL for inviting me to speak on this webinar. So just for a bit of background to my presentation, I work at Guy's Hospital, which is based in London, UK, and it's a busy thoracic surgery center. And in May 2020, we received funding to design and implement a new prehabilitation service for patients undergoing surgery for lung cancer. Prehabilitation or prehab is defined as the practice of enhancing a patient's functional capacity before surgery with the aim of improving postoperative outcomes. And this practice predominantly involves a period of supervised exercise training before surgery. And in lung cancer, it's been shown to improve exercise capacity and health related quality of life, whilst reducing hospital stay, complication rates and readmission. We therefore felt it was clinically beneficial to try prehab within our own NHS trust. However, in March 2020, the UK went into a national lockdown and patients with cancer were advised to shield at home. In addition, all patients listed for lung resection surgery were required to strictly isolate for two weeks prior to their operation date. It was therefore difficult for patients to attend in-hospital assessments and supervised exercise training as part of their prehab. So our aim was to provide safe and effective assessments, exercise programmes and symptom management via a virtual platform to patients within their homes. And the aim of my presentation is to share some of our key learning and experience from this to date. And the next slide, please. So I thought I'd start with a second polling question just to see how audience members have predominantly supported their patients during COVID-19. So if people could vote on whether it's face to face, telephone, video, et cetera, that would be great. And we'll just give you a few minutes to submit your answers. So just wait for the. Results to come through. Okay so it looks like the majority there is telephone consults which is interesting and probably quite similar to a lot of services given the virtual nature needed during COVID. Okay can I have the next slide please. So a key consideration for designing a remote service for patients with lung cancer is access to technology. In the United Kingdom lung cancer diagnosis is highest amongst octogenarians and those in the most socio-economically deprived quintile and we felt that this may impact upon technology use such as email and video as part of our service. We therefore took a snapshot survey of the first 20 patients referred to prehab to look at their technology access and we found that in a cohort of patients with an average age of 68, 75% of patients had access to email and 65 were able to use video conferencing as a mode of prehab assessment and intervention. Next slide please. So we designed our pilot service in line with evidence-based guidelines from a British charity called Macmillan Cancer Care and they suggest that prehabs should include three core components physical activity, dietary and psychological support. But more than this we felt that our service would offer a much-needed opportunity to mitigate side effects from the COVID-19 pandemic. For example national lockdown and shielding requirements meant that less people were walking outside for exercise and to access local amenities. This alongside closing of gyms and other exercise services meant that patients with lung cancer were less able or less motivated to remain physically active leading to physical deconditioning, frailty and higher risk of falling. In addition the increase in stress levels and social isolation is known to predispose higher levels of smoking and alcohol consumption leading to poorer general health and higher operative risk. We therefore aim to deliver a remote service meeting the holistic needs of patients with lung cancer addressing multiple cancer related symptoms as well as known risk factors. Next slide please. So a pivotal part of our pilot service was to perform a complex medical and physical assessment for each patient within their home over video or telephone. Thorough assessment allows clinicians to establish a baseline functional level facilitating the delivery of care that's personalized and onward referral to wider teams where needed. A comprehensive assessment is also crucial to identify precautions for unsupervised intervention at home such as falls, pain, past medical history, drugs, medications and also ensuring that patients have a safe decluttered environment to exercise at home. The various components of our assessment is outlined in this diagram and we used a mixture of subjective questioning and patient reported outcomes which were completed either via an email link or postal questionnaires. And to align with the three core areas of prehab we collected questionnaires so the Godden leisure time exercise questionnaire for self-reported physical activity levels, the hospital anxiety and depression scale for emotional well-being and we assessed risk of malnutrition for patients using the Royal Marsden nutrition screening tool. Next slide please. So in addition to completing a comprehensive subjective history we wish to objectively measure our patients pre-operative fitness levels as we felt this would be insightful for directing intervention. VO2 peak measured by a CPET bike or treadmill test is considered the gold standard for evaluating fitness and is used widely in prehab literature but CPET requires specialist and expensive equipment which is not widely available and a six-minute walking test is often used in clinical practice instead. However due to COVID-19 and the need for within-home assessments both the six-minute walk test and CPET could no longer be used. The six-minute walk test traditionally requires a 20 meter track which is very difficult to source within the home and supervision to accurately count the number of lengths walked. So in contrast to this sit-to-stand tests and stepping tests which require minimal space and supervision have shown to be feasible, reliable, valid and responsive to exercise training in patients with chronic respiratory conditions and there are various types of sit-to-stand and stepping tests which are shown in this table but for our assessments we chose to use a sit-to-stand test as it's quick to perform, easy to visualize on camera and not all patients have access to stairs for stepping tests. Next slide please. So more specifically we use the one minute sit-to-stand test for our home based assessment as it measures both functional capacity and lower limb strength and this measure has been shown to significantly correlate with the six-minute walk test and is responsive to exercise training in COPD. We asked patients to rate their level of breathlessness and leg fatigue using a modified Borg scale before and after the test. In addition to this we felt that it was really important to be able to prescribe an exercise program safely within the home during COVID and to do this we needed to assess patients balance. So we chose to use the balance component of the short physical performance battery as shown here on the right because it's easy to view over video and only requires a small space with static support and by completing this we were able to identify patients with a balance impairment which meant that exercise at home could be modified where needed such as a seated alternative to some exercises. Next slide please. In terms of prescribing exercise within the home a recent paper has demonstrated that unsupervised home based exercise training using minimal equipment can improve functional capacity of patients with lung cancer before surgery. The exercise intervention delivered to our patients was similar to this study and in accordance with the American College of Sports Medicine recommendations for cancer survivors. So this meant that patients were encouraged to complete a minimum of a hundred and fifty minutes of moderate intensity exercise per week and this included things such as walking in the garden, climbing stairs, completing exercises within the home. We gave patients flexibility on the type of exercise that they wanted to complete to aid motivation but provided it was performed in line with isolation guidelines i.e. within the home. We asked patients to exercise at a moderate intensity which meant 60 to 85 percent of a heart rate reserve based on the carbon and formula or using the Borg scale of a 4 out of 10 level in the absence of heart rate monitoring equipment. In addition to this we asked patients to try and complete strengthening exercises twice a week and in the absence of specialist gym equipment within the home we advised patients to use household objects such as milk bottles filled with water, tins of beans or posted out elasticated resistance bands to help patients exercise at home. Next slide please. So to aid motivation with unsupervised exercise during isolation periods patients were signposted to online resources such as the NHS Fitness Lab video series. We also ensured that we offered patients weekly follow-ups and specific goal setting using wearable technology such as pedometers or smartphones if patients had access to this. Patients were offered a paper printout of their exercise program with a diary to monitor compliance or they could choose to log their exercise completion on a widely available online app called PhysiTrack. Validated cut-off points for the HADS questionnaire and the Royal Marsden nutritional screening tool were used to inform us of whether an onward referral to psychological support services remotely or dietician was required and where accessible patients were signposted to resources such as mindfulness apps as Maria talked about in her previous presentation. All patients received symptom specific counselling and written advice through a series of booklets some of which are shown here to meet their holistic symptom needs. Next slide please. So just to share a little bit of information about our service we used our data from the first 20 patients in our pilot to help evaluate and refine our future practice. When we first started our pilot back in May all patients were offered a virtual initial assessment but due to local policy changes in our hospital some patients from July onwards were permitted a one-off visit to Guy's Hospital to have a prehab assessment face-to-face but their intervention and follow-up appointments continued remotely. Seven patients were assessed virtually and 13 attended a face-to-face visit and as you can see the uptake rates for virtual assessments were lower than when delivered face-to-face and patients commented that the initial assessment call when it was delivered virtually often came as a surprise and there were some difficulties establishing an initial rapport and getting patients to engage in exercise when it was delivered remotely. In addition during face-to-face assessments in clinic patients had often seen their surgeon first as part of the visit so when it came to be assessed for exercise and symptom management they were already primed for this so we concluded that a collaborative MDT approach is very important. Next slide please. So in terms of feasibility delivering in-home physical assessments and rehabilitation appears to be feasible during COVID however each session did take longer than expected as time needed to be allocated to setting up and troubleshooting technology. At times it was difficult to prescribe and teach exercise over the phone in particular and a cautious approach to unsupervised exercise may have led to a suboptimal intervention at times however it's important to note that only one patient was unable to complete their assessment over the phone due to frequent falls and frailty and they were signposted and referred on to a local community service. Of note patients with high risk therapy needs meaning for a falls history, balance impairment, frailty, pain or high symptom burden did tend to have less access to technology. In fact all patients with high risk therapy needs so out of all patients with high risk therapy needs only 13% had access to email or video. So our key learning from this is that with ongoing COVID-19 restrictions we need to develop some way of a joint medical and AHP screening tool and we're hoping to be able to use this to triage our patients into a high risk group who continue to access a face-to-face clinic review and assessment and weekly follow-up going forward remotely and then a lower risk group which may be able to use tech to their full advantage to receive remote support via video educational seminars and virtual exercise classes. So our last slide is really just to touch on the effectiveness of this intervention. So as mentioned before our pilot aimed to address the three key areas of prehab so physical activity, dietary needs and psychological well-being. So we repeated our Godin leisure time exercise questionnaire, our hospital anxiety and depression scale and our one minute sit to stand test at a virtual end of prehab assessment one to two days before their lung resection surgery. The average length of our prehab window was 26 days and 18 and 15% of patients were referred to dietitian and psychological support services. So in terms of what our preliminary results show, we're really happy to say that a home-based intervention during COVID-19 led to a small reduction in anxiety and depression, but a significant improvement in their exercise time with 100% of patients meeting the recommended levels of physical activity after receiving this intervention. And we're happy to see an improvement in exercise capacity as measured by the one minute sit to stand test, which exceeded the known minimum clinically important difference for this measure. Next slide. So just to summarize with some take home messages, patients with lung cancer are at risk of physical and psychological deterioration during COVID, but home-based rehab may play an essential role in mitigating and improving this risk. A comprehensive assessment is required both for safety and effective delivery of remote intervention. Physical assessments and intervention delivered over telephone or video are feasible and appear to be effective. However, caution needs to be exercised in higher risk patients. We found that remote rehabilitation is unfamiliar to patients and a collaborative multidisciplinary approach, which engages family and carers may help to improve uptake and engagement. And further consideration of how best to optimize vulnerable patients with limited access to technology during this difficult time is definitely required. Thank you. And thank you very much for listening and also to the wider team at Guy's Hospital that have helped to make this pilot service take shape. Thanks, Stephanie. That was fantastic to hear. What a great program and incredibly adaptable in other institutes as well. So thank you for sharing that. We're going to take a quick Q&A now for Stephanie. We're running a bit behind time. That's my fault. I'm a terrible timekeeper. But we have had a couple of questions come in, Stephanie, whilst you've been talking. Maria was wondering, can we access those booklets that were shown in your presentation? Are they available online to other institutes that we could use? So just given how new the service is, we are constantly writing these booklets, refining them with patients' comments and feedback. They are still in development, but I'm sure at some point they will be published on our Trust website. And I can certainly keep you updated with when this information might be available. We'd be happy to share. That's great. I think there'd be a lot of us in the audience that would find those resources really useful. We've had a question coming from Jennifer. She was wondering if these cohort of patients that completed the programme have had their surgery now and what were the outcomes of their surgery? So we're still early days with looking at some of the sort of follow-up outcomes. So in terms of length of stay and where the patient's being readmitted and if they continue to exercise and keep up their rehab. So we don't have any conclusive results at the moment, but we're working on a follow-up pathway where I'm making contact with these patients again. And on the whole, they have found that a lot of the information given in this pre-surgery period has been really helpful for physically and psychologically preparing them. And they're now able to draw on their exercise and the written content that we gave them during their post-op recovery too. So it seems promising, but we've definitely got more work to do to evaluate the longer term benefits of this going forwards. Great. And one last question before we move on. Vanessa was wondering if any of your preliminary work has been published to date yet? So at the moment, we haven't published anything. The small amounts of data that we've got so far are purely there to help us develop, refine our service. So in future, once we've got our service consolidated and to the standard that we want it to be, we do look forward to publishing and sharing. Well, thank you very much for your presentation. And we'll take some more Q&As at the end with all of the panel. So moving on to our final presenter, we've got Michelle Turner here, who's very busy. So we thank you very much for taking time out of your day. Michelle's going to be talking to us about palliative care for lung cancer patients during COVID-19. Thanks, Michelle. Yeah, thank you. And thank you, everybody, for tuning in today. I apologize for my dress. We ended up having some unfortunate call outs just because of COVID. And so I've been covering our biomode unit today. So fits perfectly into the presentation. So just to start off, the question is, what does palliative care offer? Does it provide relief from pain and symptoms? Does it neither hasten or postpone death? Does it provide psychological and spiritual aspects of care, affirms life and regards dying as a normal process, or all of the above? Look at that. Perfect. That's exactly what I wanted to hear, so you all made my job much easier. But we'll go over some things because it's definitely has changed in the world of COVID as has everything. Next slide. What hasn't changed and what has stayed the same in the world of lung cancer? Well, people are still passing away from this disease. This year alone, over 200 and almost 230,000 patients will die of lung cancer or diagnosed with lung cancer in the United States alone. It still remains the leading cause of cancer death in the US and it still claims more lives annually than our top other three cancers of breast, prostate, colorectal, and pancreatic. There's still 20 percent of men and women diagnosed with lung cancer are never smokers. Those are things that we will constantly see throughout this lecture is that we have to understand what stays the same and what's different. The biggest thing that's different is the pandemic that we're in and it has really affected and impacted our patients. Continuing on with this, it still accounts for about 13 percent of all of our new cases and about a quarter of all of our deaths. We still have poor outcomes in terms of overall five-year survival, which is 19 percent. When I started in lung cancer 18 years ago, it was about 15 percent, so we've gained some leeway, but not much, meaning that we have a lot more work to do. These are just diagrams of what we've talked about before in terms of the percentages in relation to our other top three cancers. In terms of breaking it out to sexes, men, it kills about two and a half more times men than prostate cancer and one and a half times more females than breast cancer alone. Next slide. The day that changed medicine, at least here in the US, and it was March 15th, 2019. Unfortunately, in China and other parts of the world, it was much sooner and still to this day, we are feeling the repercussions. I remember vividly the anxiety which was palpable when we walked into our clinic that day. Next slide. What has changed due to COVID-19 in our world? Well, the clinical operations of our day-to-day jobs. It's no longer walking in, saying hello to everybody, shaking hands, giving hugs to patients, etc. We had to institute immediately a team of players to go through our clinic and walk the steps to ensure patient safety. We've started to have to wear personal protective equipment, which we never had to in medicine, or at least not to the extent that we do now. Gowning up, putting on face shields, face masks, etc. What we have found is what that does is it actually starts to make the provider-patient relationship less connected in the sense of you can't really see facial expressions like you used to, and pick up on personal cues. We'll talk a little bit about that more as we move into the palliative care. Enhanced cleaning. Our patient clinics used to be slammed booked and still are with patients, but now we have to allot a certain amount of time for each room to be cleaned after every single patient. Wipe down from our staff, etc. with certain protective wipes. Let it dry before our next patient can go in. Time to see patients has increased, and our clinic flow has certainly been impacted. Staff distancing. We've worked with our colleagues for years, less than six feet apart, and now we all have to be six feet apart, plus wearing a face shield and a mask. The problem is no clinic is actually developed to think about a pandemic issue in the sense of where are you going to put staff? How are you going to make sure that you have adequate providers and nurses to take care of these patients, but yet they're spread out? That also makes it challenging in the setting of responding to an emergency, because the physician, nurse practitioner, physician assistant, nurse, etc, where they normally would sit may not be there anymore, and so it's where is person X? That has been extremely challenging for us. Visitor policies. Here, at least at Johns Hopkins, we've had to institute what we call Code Purple for our inpatient services, which are no patient visitors unless a patient has been hospitalized four or five days, and the person who visits can never leave. Once they leave, they can't come back. For our outpatient oncology setting, there are certain exceptions, but we don't have visitors for daily checkups, treatment visits, etc, even scan results. We typically have to have a loved one either on the phone or on a video chat, just to help cut down the risk of transmission, because what we have found in the US, or at least in our hospital system, is it's not direct provider-to-patient transmission. It's patient-to-patient or more social interaction transmission than with hospital personnel to patient, because we're protected and protecting our patients. We've also had to decouple our visits, meaning that where patients could come in and easily get a lab, draw a CAT scan, and see the provider all in one day, to limit their time within the hospital setting, these now have to be spread out. Well, the stresses and strains of spreading them out is a factor that initially we didn't think of taking into consideration. That's more time for the patient, more money for the patient if they're traveling through tolls, paying parking, etc. Although that one day that they would take off in its entirety was long, some patients preferred that because they didn't have to waste the rest of their precious time coming back and forth into the hospital to make all these separate appointments. Next slide. The epidemiology of cancer patients and the COVID infection. They looked at a very small sample size initially at the time of the outbreak or around the first outbreaks. Eighteen patients of over 1,500 cases had COVID with a history of cancer versus general population. Lung cancer was, of course, the most common type and we did see higher incidence of complications among the cancer patients. Again, sample size was very small, it's very heterogeneic regarding disease, duration, course, origin, and treatment history. Next slide. The challenges that COVID has with our lung cancer patients is the symptoms are similar. Cough, shortness of breath, fatigue, chest discomfort, fever. These symptoms can also be seen post our radiation treatments with a radiation pneumonitis as well as side effects from our oncology therapy like pneumonitis. The two pictures on the screen is actually one is a COVID patient and the other one is a pneumonitis and they look very similar. It is challenging. Sometimes we will have patients that will come into clinic for routine CAT scan and the way the reading is read at this point is could potentially be progressive disease, pneumonitis, or COVID. The minute somebody puts the word COVID in a radiology report, we are now tasked at shutting down the room that the patient was in, making sure that we get them tested appropriately. This whole algorithm goes into play, but it is challenging because we don't know what we're dealing with a lot of the times with these patients. Even though a year ago, two years ago, we knew exactly how to treat these patients. COVID has really complicated a lot of our processes. Next slide. How do we look at palliative care during a pandemic? Because palliative care is really about connection, emotions, managing symptoms, taking extra time with patients. How do we do that when our time now is even more limited and more restricted than before? We have found and we have seen that isolation, quarantine, and social distancing really have impacted people's psychological and social needs. I have had patients in my clinic say, I've never thought about my cancer so much in my life. I can't get away from it. I come to clinic, I go home, I'm stuck in my house, I can't see my friends, I can't go out, there's no distraction for them. We have really seen an increase, or at least I've seen anecdotally, an increase in use of antidepressants with my patients. Because it's been very challenging for patients to deal with the isolation. Next slide. There are three levels where there's barriers with providing palliative care during a pandemic. Infection prevention and decreasing the need of social isolation from the patient perspective, from the caregiver, social distancing, and lack of social support. They can't go and meet a friend or a family member like they used to, to share concerns or help problem-solve for their loved one. Job loss, people are having to bring their family member on multiple days again, because we've had to decouple visits. These are days taken off from their work or half days taken off from their work. Really, there has been a trickle-down effect from this pandemic in the world of cancer, palliative care, etc. The health system itself, moving to telemedicine services, which has been a lifesaver for a lot of our patients. But here in the US, because a lot of us can't practice over state lines, there has been billion challenges of how can we see these patients virtually and still get reimbursed for the services. There was a, at least in the state of Maryland, a lift from our national Medicare services and insurances, where they allowed us to have the ability to see these patients within a certain window of time in the sense of, okay, we'll do it in three months and see what happens and constantly re-evaluate so that we could take care of these patients. Healthcare worker exposure, we have found that to be very low in terms of, again, a COVID-positive patient to a healthcare worker because we have the appropriate PPE now and the adequate amount. But it all leads to isolation, reallocating resources, and provider burnout. Just being on our BioMood unit today, we're all exhausted. None of us across the world in healthcare have had a break. There may have been a little bit less, but it has always been background. It has forever changed our practice and it has been exhausting. Next slide. Interestingly, in 2010, in the influenza pandemic, there was a plan for palliative care preparedness, which is interesting because always hindsight is 20-20, and who knows what we're going to learn from 2020 itself. But just to go through some of these stuff, build up a reserve of medication, equipment, and PPE. We saw this in the United States where we were running out of PPE for our staff and our colleagues, and we're at a point where our safety was jeopardized. Hopefully, we learn from this, and I think we have because this next wave that we're seeing, we are much more prepared in terms of volume of gear. My colleagues have talked about their numbers in their respective countries. I can tell you I can't really talk about the whole United States, but I know in the state of Maryland, we're at a positivity rate where it keeps climbing, and just the other day, we were at 4,000 new cases a day. Our influenza season, cold and flu season is in high gear, and COVID is not making it any easier. Staff anticipate the decrease in manpower due to reallocation of staff. We've moved research staff into units on the floors. We've moved front desk staff to help with rooming patients just because, again, the sheer volume of patients coming into an already stressed healthcare system. That's really the challenge is the patients that need to come in for their oncology care, their palliative care, etc. It's hard for them because now we have a whole new set of sick individuals that we are caring for. Space for end-of-life care. These are sensitive discussions. Isolation wards with access to palliative care services is hard because again, these services are stretched thin. And a lot of times these services also there is a concern with going on these wards because of the fear of transmission, although we've known that to be a little bit lower. A triaging system, palliative care services, home services, home visits, telemedicine visits. Again, these used to, especially home visits used to be freely done for patients. And there is, now it's a proceed with caution. So again, more social isolation. And I think that's what COVID has taught us is that we, as a whole, I think as a global whole, the challenge of social isolation and how it makes us feel, our patients feel, and how do we get through it. Skills of communication, end of life discussions. They're challenging, but more so during a pandemic. I mean, talking to somebody about scans, which I just did the other day, and kind of a hospice discussion into an eye of a computer is not comfortable. It's not comfortable for me. And it's certainly not comfortable for the patient. Again, the physical touch that we're missing, the physical interaction, the body language of patients, providers, et cetera, is very hard to communicate through a computer screen. And very impersonal. And then the self perspective, where physical and mental stress of healthcare providers. Again, not only on the patient side, but the palliative care providers, a separation from our families. Some of our providers that are on these COVID units initially were separated from their families for two weeks because we were fearful and we didn't know a lot about the virus initially. Seeing patients dying daily. In the world of lung cancer, in the world of cancer in general, we deal with that. But where's our stress relief? Where's our communication with our friends, our family to go out to eat, to just get away for a while? We can't even do that. And so our mental health and well-being is also challenged and we struggle with that. And also the fear of infection. So COVID has certainly changed our world in lung cancer, in palliative care. I think we have to be certainly open-minded and very innovative as this next wave goes. And we have learned so that history doesn't repeat itself. But it certainly is scary. I think we are prepared for the future. It's just, how do we make these connections, these physical connections through an electronic world? And I think that's still the challenge and that's where we have to lean on our colleagues, our friends, our psychiatrists, our palliative care folks to help us as best we can. So I'd like to thank you all. I appreciate you with us and happy to answer any questions. Thanks, Michelle. That was fabulous. I think you've touched on so much there and it really does show just how much COVID-19 has impacted every aspect of our patient care, but also how exhausting it is for healthcare workers at the moment. So thank you for all your hard work in treating our patients. As we've come to the hour, I'm going to draw us to a close and I'd like to thank all our presenters for today. So we'll take some Q&As now for the panel. So if you do want to stay online, I'm aware that I've been terrible at timekeeping and we've run over, but I'm aware that everyone does have work here in Australia that they're probably going to now and knocking off at work on the other parts of the world or going to bed. So if you do want to stay online, we'd love to take some more Q&As from you. So feel free to pop them down in the Q&A section down the bottom. There will be a short email sent out to you all later on today. It'll just be a program evaluation. So if you could take the time to fill that out, that would be really great. So Michelle, I was wondering from your perspective, have you seen an increase or a decrease in palliative care referrals during this time? Yeah, we've actually seen, believe it or not, a more of a decrease because again, patients are, they're also just afraid to number one, see somebody and just their comfort level of interactions with providers over the computer. A lot of times, at least in my practice, what we would do is if we're referring them to palliative care, we had the palliative care providers in our clinic. And so we would introduce them. So there was again, that connection between us and them. And so it's just, it's much harder now. And it's challenging. We've lost some staff just due to funding. And so our referrals have had to go down. So it really has impacted the oncology world, which is so frustrating, because these patients really need it. It's just, you know, hopefully we can rebound from it. Yeah, it's really, it's really challenging. We've got a question that's coming from Jennifer. Jennifer was wondering to the panel, what suggestions do you have for vulnerable high risk patients? How do we help these patients access technology? So I can comment on this a little bit from my work. A lot of the time, that vulnerable person might share a household with someone who is a little bit more technologically savvy. So in the past, I've been sort of liaising with them over the phone or via email to help set them up on technology. A lot of the time, it's also just letting patients know that I will give them the time and that it's not going to come easy at first time. I think a lot of my patients at first almost didn't want to know and they shied off at first mention. But I said, look, let's give it a go. We've always got telephone as a backup, but let's give it a go. And I can speak you through on the phone what it looks like. You know, it might look different to you. Try this, you know, press this button just for troubleshooting. So just allocating a little bit of extra time, particularly on that first virtual contact is really important and goes a long way. That's great. Thanks, Stephanie. Now, we've had a couple of questions which sort of cover the same topic. So we've had a question from Mary and both Beth, and they were wondering, they mentioned connectiveness and providing physical touch. It's really an important aspect of our care. And do you have any suggestions in how we can address this with our patients? Yeah. So, you know, it's interesting is what I've learned. And again, it's just it's trial and error. I think when we're physically present with a patient, we remember to pause. We remember to give them time. We remember to, you know, put a hand on their knee or that physical touch. And even on what I've learned virtually is kind of a pause in communication can also just let them know that you're present with them. You know, I mean, it sounds a little odd, but it's like being silent in the room. I have had many end of life discussions with patients where we sit there and I say nothing afterwards, you know, and you're and so it's sitting here and having a pause and saying, you know, I'm here, letting them kind of voice and verbalize, you know, their concerns or questions, et cetera. But and there again, and we all go through it. You know, your patient. So if you know that your patient is one that is really going to need that physical touch that, you know, kind of handholding. I mean, we bring them in if they're not afraid to come in because a lot of patients, the fear of COVID has really pushed them back from getting the care that they need. We'll bring them in and, you know, you gown up, you do what you can to protect them and you give them what they need. But that is that is the challenge. This is really socially isolated people on all respects. And even from a provider perspective, like I mentioned before, we feel so empty because we feel like we are not doing what we should be doing to support them, because I can't touch the screen, you know, like can't hold your hand. I can't give you a hug for their safety. But it's still it's it's extremely challenging. Sarah, can I just add something to that question? One of the things I think it's really important to get better with our words, and I think it's really expressing how hard it is for us not to be not to be able to touch you in this moment. We would really like to do this. We're missing this kind of kind of touch. And voicing how different it is for us as well, I think is another another way to do it is just to verbalise it. But the other thing is a lot of our conversation is done online and on telehealth. So I think it's really important to do at times exaggerated eye contact nods to empathise all those things as we're kind of doing in this communication now. That's great. I know in our practice, one of the things I find challenging in working up and diagnosing patients is the fear of COVID. Patients are putting off coming in and having their diagnostic procedures where we're having patients decline coming in for their bronchoscopies, their CT biopsies because of this fear of coming into the hospital. So what suggestions would you have on how we can help support those patients and and help guide them to have their procedures so they can be diagnosed and treatment starting sooner? I think it's just education, right? And I think it's reinforcing that, you know, each kind of service is going to protect them as best as they can. But you're you're right. I mean, patients that are coming back and we found this with the first wave and you ladies and people listening may have felt this, too. After the first wave, we were getting patients in our clinic and looking at them going, oh, my gosh, like floored because also on our screens, you're only seeing we're only seeing a portion of the patient and you're asking them, are your legs swollen? Is this you're going through all of your review of systems? Oh, I'm fine. I'm fine. I'm fine. And they come in with like three plus, you know, edema and you go, oh, my gosh, you didn't tell me. Well, I didn't think it was that big of a deal. So you're now you're in a crisis mode. So it's really like we're going to keep you safe. Your health and your cancer care is extremely important. And we can do this, you know, and help kind of work with you through this pandemic. But you're going to get some people that are like, absolutely not. And it's challenging because when they see you, then it's either a more advanced diagnosis or advanced symptoms. That's what we've been seeing an increased presentation to emergency with stage four because of delayed coming in. They're too scared that fear of covid. It's really impacting. It's really impacting their choices in coming to get health care. And just one last question before we wrap up. Mary's wondering, Maria, are there any good resources you touched on focusing on your choice of words when we're communicating with patients? Are there any rapid courses or good resources out there that we could tap into to educate ourselves on and how we can have a better choice of words and upskill? I think you're on. Sorry, I think that's a really good question. I'm not. I think any communication communication courses that we've done in the past, it's probably about revisiting some of those courses and a lot of the counselling courses that we've done through throughout training. But it's just going really back to the basics and using our communication training. And I mean, the one thing that patients will tell us. So I think it's important to just be going back to the basic silence, listening, asking the patients if we're meeting their needs. What else do we need to do to meet their needs? Some of the the skills that we use. But it is new for all of us communicating through telehealth. It's one of the advantages, I guess, the silver linings of covid is that we have embraced it, but we're all learning together to do it again. So they already treated him. There we go. Well, thank you to everybody. Thank you to all our presenters. All of your presentations have been so valuable and incredibly insightful. So with that, on that note, we'd just like to stay safe, everybody. And if you do have any further questions, feel free to email them through. And if we have any further resources, we'd be happy to share them. So thank you. Thank you.

lung cancer patients

COVID-19 pandemic

emotional challenges

physical challenges

supporting patients' well-being

anxiety and depression

remote prehabilitation service

holistic needs of patients

virtual assessments

palliative care

virtual communication