Alex Shoushtari, MD Profile picture
Mar 24, 2020 9 tweets 3 min read Read on X
A few thoughts on outpatient oncology care here in #NYC.

10 days ago, we melanoma med onc @sloan_kettering agreed to cut back in person clinic from 1-2x / week to once / 1-2 weeks. My clinic frequency was quartered. I was excited to leave the apt (I'm allergic to combs). Image
My commute to work is entirely by foot, and I'm privileged to be able to do so. Ordinarily I walk by hundreds of people in 15 min.

Today, I counted about 30 people. We are successfully distancing! Yay!
The in person visits that remain are the most complicated ones, where infusion and scan review are done on same day. Our (very smart) new visitor policy doesn't allow family members to attend, with rare exceptions.

Skeletal, 50% staff on site in clinic.

So today was...eerie.
No fellows to teach, no RNs entering rooms. Gloves, masks obscuring facial expressions, blunting gestures.

Once inside the room, we spend a bit of time connecting FaceTime on their ancient iPhone so we can loop in their concerned daughter or son. Or futz with the speakerphone.
It's slow and difficult. Bad news hits harder, echoing around the clinic room that's emptier than usual. The buoyancy normally afforded by good news is gone, either weighed down by uncertainty over the virus or dissipated by giving it over the phone ("no need to come in!).
Making decisions for salvage, palliative intent therapy is hard in the best of times. Doing it during social distancing is torturous. We are doing the best we can but I can't be doing it as well as normal, right? BC that would mean my personal touch isn't crucial. Lose-lose.
BUT then I train myself to see the other side of it.

We are striving, and dare I say mostly succeeding, to keep patient care excellent while we all protect ourselves. It's inspiring to see how patients and staff all have adjusted to the uncertainty, clumsy technology, PPE.
And I'm proud that our small team (@DrBetofMDPhD @MPostow @wolchokj and others not here) and our admin, RNs, NPs have nimbly adjusted our entire lives to serve our patients.

I'm proud that others all over the city, country, globe are doing the same.
Even the loneliness of a peaceful walk through Midtown reminds me...

I MISS BUMPING INTO RUDE PEOPLE on my walk to work. I miss you, NYC.

We will do our best to keep our patients well, however possible, until we can get our real, crowded, noisy city back. It's a privilege.

• • •

Missing some Tweet in this thread? You can try to force a refresh
 

Keep Current with Alex Shoushtari, MD

Alex Shoushtari, MD Profile picture

Stay in touch and get notified when new unrolls are available from this author!

Read all threads

This Thread may be Removed Anytime!

PDF

Twitter may remove this content at anytime! Save it as PDF for later use!

Try unrolling a thread yourself!

how to unroll video
  1. Follow @ThreadReaderApp to mention us!

  2. From a Twitter thread mention us with a keyword "unroll"
@threadreaderapp unroll

Practice here first or read more on our help page!

More from @alexshoushtari

Mar 6, 2021
I am excited to share our manuscript "Therapeutic Implications of Detecting MAPK-Activating Alterations in Cutaneous and Unknown Primary #Melanomas" published at @CCR_AACR. I think it offers important clinical and translational insights into melanoma. 1/x

clincancerres.aacrjournals.org/content/early/…
All of the genomic and clinical data are available on @cbioportal at cbioportal.org/study/summary?… – thank you to @nikolausschultz Lab, esp @chatila_w + @fjsanchezrivera (bioinformatics/data viz), Arshi Arora (stats), and @sloan_kettering molecular path (all the sequencing) 2/x
This will be a loooong thread for my fellow #melanoma geeks! All other melanoma-curious oncologists and #medtwitter can skip towards the end where I try to highlight some themes for investigating other tumors. 3/x
Read 33 tweets
Aug 19, 2020
Hey everyone, the first-in-human clinical trial of tebentafusp, the HLA-specific fusion protein targeting gp100, is now online @CCR_AACR! Cool mechanistic proof of concept that you can get CD3+ cells into a poorly infiltrated tumor like #uveal #melanoma.

clincancerres.aacrjournals.org/cgi/content/ab…
A prelim efficacy signal for uveal melanoma in this trial with a dose (50mcg weekly) that is lower than the 68mcg weekly dose later expanded upon and presented at ASCO last year. Fingers crossed for our patients with this rare disease!

(note: I have fCOI with @Immunocore) Image
Cytokine Release Syndrome: uncommon but potentially serious side effect. Manageable with everyone's growing experience with adoptive T cell therapy. This trial predated the approval of tocilizumab for severe CRS. Hospitalization mandatory for first 3 doses on study. Image
Read 6 tweets
Jun 29, 2020
Hi #medtwitter + new onc fellows! I treat patients with advanced #melanoma, especially rare ones like #uvealmelanoma (UM). This #tweetorial will discuss:

1) Why UM is unique
2) When does(n’t) immunotherapy work for UM
3) Why we prefer clinical trials for advanced UM

1/x
UM affects about 5/million, and about 3-5% of advanced melanomas in the US arise from the uveal tract (iris, ciliary body, choroid). Of these, iris is rarest + least aggressive, so we often call it “choroidal” melanoma.

Get your dilated eye exams, folks!

2/x Image
Choroid and cilio-choroid melanomas can be aggressive. ~50% of the largest tumors metastasize; about 20% of medium ones do.

Look at that lack of plateau! Plenty of mets happen late, >5 years out. It's sad but fascinating when immune system controls disease for years, then (🤬) Image
Read 26 tweets
Jun 2, 2020
Throughout our medical training, many of us were taught it was "unprofessional" to voice our beliefs or broadcast political opinions. But we must acknowledge most of the (well-meaning) people counseling us to stay silent stood to gain by maintaining the status quo. #medtwitter
Those who maintain political activism harms the soul of medicine suggest it cripples the patient-doctor relationship. But I find this simplistic, even disingenuous. Surely most people can divorce political stance from compassionate care? Can't we trust them to make that decision?
When I am in a patient room, their well-being is paramount. When I leave that room, I need to apply that same level of dedication to bettering my community. We should be welcoming, not punishing, people who enter into political discourse.
Read 5 tweets
Feb 13, 2020
Beautiful retrospective work suggesting the clone of melanoma that recurs after an initial complete response to checkpoint inhibitors is often different than the one that presented initially.
Our group has taken these data to heart. I've changed a few things about my approach in clinic as a result:

1) When patients ask if we can just retry the same medicine if the disease comes back, I try to take time to say "yes, but it may not work the same way as before."
2) This recurrence rate was a little higher than the clinical trial recurrence risks of 10-15%. While length of tx wasn't statistically associated with recurrence, I now am much more reticent to stop therapy if no toxicity and length of therapy is only 6 months.
Read 4 tweets
Nov 7, 2019
GITR + nivo efficacy ~ nivo efficacy.

Paper says, "...a clear signal has not emerged demonstrating that GITR agonism may be an effective therapeutic strategy in a broad patient population."

...yeah... OR maybe it doesn't add anything to PD-1.
jamanetwork.com/journals/jamao…
Some of my best friends work on GITR!!! But that kind of language should have been edited out as Pollyanna nonsense. Don't make me sic Vinay Prasad on all y'all...
To echo a couple of my colleagues, it's great that this very well run trial found a high profile venue to disseminate the important message. Kudos to them!
Read 4 tweets

Did Thread Reader help you today?

Support us! We are indie developers!


This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3/month or $30/year) and get exclusive features!

Become Premium

Don't want to be a Premium member but still want to support us?

Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal

Or Donate anonymously using crypto!

Ethereum

0xfe58350B80634f60Fa6Dc149a72b4DFbc17D341E copy

Bitcoin

3ATGMxNzCUFzxpMCHL5sWSt4DVtS8UqXpi copy

Thank you for your support!

Follow Us!

:(