A War on Two Fronts: Cancer Care in the Time of COVID-19
Authors: Alexander Kutikov, David S. Weinberg, Martin J. Edelman, Eric M. Horwitz, Robert G. Uzzo, Richard I. Fisher
Journal: Annals of Internal Medicine (2020)

Ideas and Opinions27 March 2020A War on Two Fronts: Cancer Care in the Time of COVID-19FREEAlexander Kutikov, MD, David S. Weinberg, MD, MSc, Martin J. Edelman, MD, Eric M. Horwitz, MD, Robert G. Uzzo, MD, MBA, and Richard I. Fisher, MDAlexander Kutikov, MDFox Chase Cancer Center, Philadelphia, Pennsylvania (A.K., D.S.W., M.J.E., E.M.H., R.G.U., R.I.F.)Search for more papers by this author, David S. Weinberg, MD, MScFox Chase Cancer Center, Philadelphia, Pennsylvania (A.K., D.S.W., M.J.E., E.M.H., R.G.U., R.I.F.)Search for more papers by this author, Martin J. Edelman, MDFox Chase Cancer Center, Philadelphia, Pennsylvania (A.K., D.S.W., M.J.E., E.M.H., R.G.U., R.I.F.)Search for more papers by this author, Eric M. Horwitz, MDFox Chase Cancer Center, Philadelphia, Pennsylvania (A.K., D.S.W., M.J.E., E.M.H., R.G.U., R.I.F.)Search for more papers by this author, Robert G. Uzzo, MD, MBAFox Chase Cancer Center, Philadelphia, Pennsylvania (A.K., D.S.W., M.J.E., E.M.H., R.G.U., R.I.F.)Search for more papers by this author, and Richard I. Fisher, MDFox Chase Cancer Center, Philadelphia, Pennsylvania (A.K., D.S.W., M.J.E., E.M.H., R.G.U., R.I.F.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-1133 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The rapidly expanding coronavirus disease 2019 (COVID-19) (SARS-CoV-2) acute respiratory pandemic has assaulted all aspects of daily life (1, 2). As of 25 March 2020, there were more than 450 000 cases worldwide. In the absence of a vaccine or a therapeutic agent, a “social distancing” strategy is the primary intervention to hamper the spread of infection (1). A major fear of most governments and individuals is the heavy impact on the health care delivery system. Cumbersome diagnostic testing, inadequate protective supplies for frontline providers and first responders, and limited hospital capacity—including intensive care—have all conspired to create an environment compared to warfare (3).During this extraordinary time, the oncology community faces unprecedented challenges. According to the American Cancer Society, this year nearly 5000 new cases of cancer will be diagnosed per day in the United States. Initial reports suggest that COVID-19 can be particularly lethal in patients with cancer (2). As such, oncology specialists as well as other providers regularly involved in the diagnosis, active treatment, and longitudinal follow-up of patients with cancer must consider how to 1) balance a delay in cancer diagnosis or treatment against the risk for a potential COVID-19 exposure, 2) mitigate the risks for significant care disruptions associated with social distancing behaviors, and 3) manage the appropriate allocation of limited health care resources in this unprecedented time of health care crisis.Risk From Delay of Treatment Versus Harm of COVID-19 ExposureIt is known that COVID-19 disproportionally harms elderly persons and those with comorbid conditions (4). A current or past cancer diagnosis appears to place infected patients at substantially increased risk. In early reports from China, patients with cancer who acquired COVID-19 had a higher risk for significant morbidity, including requirements for ventilatory support or death (hazard ratio, 3.56 [95% CI, 1.65 to 7.69]) (2). Thus, in patients with cancer, the utility of intervention must be weighed against the risk for inadvertent COVID-19 exposure in the health care system, especially during the initial weeks of the pandemic, when the risk for viral dissemination cannot be quantified and remains largely unknown.Furthermore, the potential for increased vulnerability to adverse outcomes from COVID-19 after oncologic treatments, such as surgery, systemic chemotherapy, or radiation therapy, must be considered. The Figure provides guidance for nonspecialists in oncology about the effects of delayed diagnosis or treatment in common cancer scenarios. Many solid tumors (such as lung or pancreatic cancer) and some hematologic cancers (such as acute leukemia) require immediate diagnosis and treatment. However, other common early-stage cancers (breast, prostate, cervical, nonmelanoma skin) may not. The quality of evidence in some cases is inadequate to support “one-size-fits-all” statements applicable to every patient. However, experienced oncology providers should feel confident exercising judgment regarding which patients need to initiate or continue treatment owing to their tumor's more aggressive biology versus those who can tolerate a delay. Decision making may change as efforts by the health care system to mitigate risks for exposure to COVID-19 improve (5). Indeed, consensus recommendations swiftly began to appear to help providers make appropriate triage decisions (6). For persons with advanced oncologic disease, futility of treatment in the context of COVID-19 must be frankly considered and discussed.Figure. Guidance on decisions about immediate cancer treatment during the COVID-19 crisis.Robust outcomes evidence supporting a decision to initiate or delay cancer care is often lacking. Recommendations in this figure are consensus-based and should be used as a general guideline only. Expert oncologic opinion tailored to individual patient and local health system conditions should always be obtained. COVID-19 = coronavirus 2019; HR+ = hormone receptor–positive; HER− = human epidermal growth factor receptor–negative. Download figure Download PowerPoint Social Distancing and Its Compromise During Care DeliveryRestrictive social distancing has been promoted as effective to stem pandemics in the past and appears to be the most promising strategy during this early stage of the COVID-19 crisis (1, 7). This strategy emphasizes the concept of “mitigation,” where the number of severe cases in the health system at a given time is minimized to reduce preventable deaths from resource overload (1).Every patient who engages with the traditional oncology care delivery system significantly disrupts this social distancing tactic, resulting in innumerable ripple effects. Clinic visits, surgical stays, infusion sessions, radiation planning and treatment appointments, hospital admissions, phlebotomy visits for laboratory tests, and radiographic imaging studies—all often attended with family members in tow—result in a massive number of personal contact points and many potential opportunities for viral transmission.Another consideration are clinical trials, which are a unique part of medical oncology and cancer care in general. Entry into a research study is considered standard of care for many patients with locally advanced or advanced cancer. Most trials require additional appointments and tests, further increasing the potential for infection. Furthermore, the supply of novel drugs, both in terms of manufacture and distribution, may be compromised. The National Cancer Institute and the U.S. Food and Drug Administration have issued preliminary guidance regarding these issues (8), but there is an urgent need for clear instruction and methods to preserve the integrity of the studies while enhancing patient safety during this period.Implementation of nontraditional care delivery strategies and harnessing of modern information technology platforms, especially for patients who are receiving survivorship care, offers tremendous opportunity to minimize the negative effect of cancer care delivery on public health efforts. For instance, many hospitals and health care systems have prepared telehealth options for their patients. Nationally, the Centers for Medicare & Medicaid Services has expanded telehealth benefits for Medicare beneficiaries during the outbreak, a decision that will allow individuals to receive health care services without traveling to a health care facility. In addition, the U.S. Department of Health and Human Services will not impose penalties on physicians using telehealth in the event of nonadherence to the Health Insurance Portability and Accountability Act.Allocation of Limited Health Care ResourcesCancer care consumes significant health care resources (9). During the COVID-19 crisis, cancer care utilization of ward and intensive care unit beds, ventilators, pharmaceuticals, blood products, staff, and basic medical supplies may directly conflict with care delivery for those with COVID-19. A new cancer diagnosis is frightening for patients and families. Although most cancer care is not typically considered “elective,” as resource constraints grow owing to supply chain issues, variations in geographic needs, and reallocation of medical infrastructure to care for infected patients, difficult tradeoffs will need to be made. Education of providers and patients can help in this setting. Similarly, many standard postacute treatment strategies that bring patients into care centers and utilize such resources as laboratory testing, imaging, and office visits can also be thoughtfully postponed to reduce burden on the health care system.In summary, as cancer care and COVID-19 collide, patients and providers will face extremely difficult choices. The combat plan during this battle must involve patience, communication, diligence, and resolve. Risks must be balanced carefully, public health strategies implemented thoroughly, and resources utilized wisely. Furthermore, the policies and procedures developed today will serve as the basis for addressing the next outbreak or similar crisis.References1. Ferguson NM, Laydon D, Nedjati-Gilani G, et al. Report 9: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. Imperial College London. 16 March 2020. Accessed at www.imperial.ac.uk/mrc-global-infectious-disease-analysis/news–wuhan-coronavirus on 17 March 2020. Google Scholar2. Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21:335-337. [PMID: 32066541] doi:10.1016/S1470-2045(20)30096-6 CrossrefMedlineGoogle Scholar3. Di Marco F, Barbaro M. ‘It's like a war.' New York Times. 17 March 2020. Accessed at www.nytimes.com/2020/03/17/podcasts/the-daily/italy-coronavirus.html?showTranscript=1 on 19 March 2020. Google Scholar4. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395:507-513. [PMID: 32007143] doi:10.1016/S0140-6736(20)30211-7 CrossrefMedlineGoogle Scholar5. Chopra V, Toner E, Waldhorn R, et al. How should US hospitals prepare for coronavirus disease 2019 (COVID-19)? Ann Intern Med. 11 March 2020. [Epub ahead of print]. doi:10.7326/M20-0907 LinkGoogle Scholar6. Stensland KD, Morgan TM, Moinzadeh A, et al. Considerations in the triage of urologic surgeries during the COVID-19 pandemic. Eur Urol. 16 March 2020. [Forthcoming]. Accessed at https://els-jbs-prod-cdn.literatumonline.com/pb/assets/raw/Health%20Advance/journals/eururo/EURUROL-D-20-00380-1584548684213.pdf on 27 March 2020. Google Scholar7. Bootsma MC, Ferguson NM. The effect of public health measures on the 1918 influenza pandemic in U.S. cities. Proc Natl Acad Sci U S A. 2007;104:7588-93. [PMID: 17416677] CrossrefMedlineGoogle Scholar8. Mooney M, McCaskill-Stevens W. Memorandum: Interim guidance for patients on clinical trials supported by the NCI Cancer Therapy Evaluation Program and the NCI Community Oncology Research Program (NCORP). Public Health Service, U.S. Department of Health and Human Services. 13 March 2020. Accessed at www.ncicirb.org/system/files/Interim_Guidance_Clinical_Trial_Activities_Affected_%20by_Novel_Coronavirus_3-13-2020_0.pdf on 18 March 2020. Google Scholar9. Mariotto AB, Yabroff KR, Shao Y, et al. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011;103:117-28. [PMID: 21228314] doi:10.1093/jnci/djq495 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Martin CS Wong MD, MBChB, MPH, FRCP (Edin), Jeremy YC Teoh MBBS, FRCSEd (Urol), FCSHK, FHKAM (Surgery), Sunny H Wong MBChB (Hons), DPhil (Oxon), FRCP (Edin), FRCPath1. JC School of Public Health and Primary Care, 2. Department of Surgery, 3. Department of Medicine and Therapeutics; Faculty of Medicine, The Chinese University of Hong Kong24 April 2020 Attribution of higher risk of COVID-19 to cancer: a need for an evidence-based approach to inform guidelines To the Editor,We read with great interest the article by Kutikov and colleagues published in the Annals of Internal Medicine [1]. Their work should be commended as they have produced an excellent guidance on decisions about cancer treatment during the COVID-19 pandemic, based on the risk for significant morbidity from COVID-19 vs the risk of progression with cancer care delay. In our opinions, this guidance could be further refined if it is supported by more robust evidence that establishes the odds ratios of COVID-19 and cancer.Let’s review the current evidence about the risk of COVID-19 imposed by cancer and its treatment. One study evaluated the clinical records of 1,524 cancer patients in a hospital in Wuhan [2], and found that their infection rate was higher than the cumulative incidence of COVID-19 in the general population of Wuhan city (0.79% vs. 0.37%). These findings are compatible with that of another study [3], where a higher proportion of hospitalized patients with COVID-19 was found to have cancer (1%) than that of the Chinese population (0.29%). Whilst the exploratory nature of these studies is appreciated, the findings should be interpreted with caution. In the first study [2], there is an absence of confounder control and the study involved a small number of cancer patients. It was observed that most patients (seven out of twelve) have received chemotherapy or adjuvant radiotherapy, which may require frequent hospital visits with potential exposure to SARS-CoV-2. Besides, their cancer patients might have poorer access to healthcare and lower capability to receive necessary medical services; could have poorer immune functions; had higher likelihood of concomitant chronic diseases; and might encounter disruption to infusion-based treatment in hospitals [4]. These cancer patients might also be older (data not presented in the article) [2], and less capable to receive necessary medical services [5]. These could all explain their significantly higher vulnerability to COVID-19.To attribute a higher rate of COVID-19 infection to cancer, researchers should demonstrate that cancer and its associated treatments are clear independent factors associated with incident COVID-19. Understandably, details of COVID-19 patients in various countries could be difficult to capture, and a properly designed age- and sex-matched case-control study with adequate control of potential confounders should be conducted. We should seize every opportunity to establish multi-centre collaborative initiatives to examine the actual risk of COVID-19 among cancer patients so as to develop and inform evidence-based guidelines. We declared no conflict of interests.References1). Kutikov A, Weinberg DS, Edelman MJ et al. A War on Two Fronts: Cancer Care in the Time of COVID-19. Ann Intern Med. 2020. DOI: 10.7326/M20-1133 2). Yu J, Ouyang W, Chua MLK et al. SARS-CoV-2 Transmission in Patients With Cancer at a Tertiary Care Hospital in Wuhan, China. JAMA Oncol. Published online March 25, 2020. doi:10.1001/jamaoncol.2020.09803). Liang W, Guan W, Chen R et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol 2020;21:335-337 Published Online; February 14, 2020; https://doi.org/10.1016/S1470-2045(20)30096-6 4). Wang Z, Wang J, He J. Active and Effective Measures for the Care of Patients With Cancer During the COVID-19 Spread in China. JAMA Oncol. Published online April 1, 2020. doi:10.1001/jamaoncol.2020.11985). Wang H, Zhang Li. Risk of COVID-19 for patients with cancer. Lancet Oncol 2020 Published Online March 3, 2020. https://doi.org/10.1016/S1470-2045(20)30150-9 Ker-Kan Tan, PhD, FRCS (Edin), MMed, MBBS; Jerrald Lau, MPH, BPsyYong Loo Lin School of Medicine, National University of Singapore3 April 2020 A War on Two Fronts: Cancer Care in the Time of COVID-19 - Time for a Paradigm Shift We read the article by Kutikov and colleagues with great interest [1]. We argue that compromising oncological services cannot be a long-term solution in this COVID-19 pandemic, as we are not likely to return to a state of normality any time soon. While there is the need to safeguard precious resources for patients in need of critical care, we agree that affording appropriate cancer treatment is still necessary. It is therefore an apt time to consider a paradigm shift in models of care for cancer management. For example, in colorectal cancer where the most commonly modality of diagnosis is colonoscopy, general practitioners can triage patients and then list them for direct access colonoscopy to be performed by endoscopists in “clean” community healthcare institutions. Likewise, subsequent imaging and phlebotomy services can also be decanted to dedicated centres. Although colorectal cancer resections will still need to be performed in tertiary institutions, most patients are likely to recover expediently without complications due to the adoption of enhanced recovery after surgery (ERAS) and minimally invasive surgery. Post-operative convalescence of these patients need not always occur in tertiary hospitals; we are currently exploring a “hospital at home” concept in Singapore where post-operative patients may recover at home with the support of a dedicated team of healthcare professionals who conduct home visits and the necessary monitoring equipment. This could free up valuable hospital resources to help tackle the COVID-19 situation while mitigating disruptions to essential surgeries [3].Non-critical consultations with oncologists and surgeons can also be conducted through telemedicine. Along with home-based phlebotomy and community-based imaging services, most patients can be safely monitored for disease recurrence without visiting acute or tertiary hospitals. For example, a review of 507 patients who underwent curative colorectal resection within our acute hospital from 2012 to 2014 revealed 75 patients with cancer recurrence over a median follow-up of five years. Apart from a single patient whose rectal cancer recurrence was discovered via digital rectal examination, none of the other 74 recurrences diagnosed would have required face-to-face contact with a colorectal specialist. In addition, recent research suggests that home-based administration of intravenous chemotherapy and remote delivery of oral chemotherapeutic drugs are becoming increasingly feasible [4,5].These are unprecedented times, but it does not mean that oncological care must be compromised. With this commentary, we wish to encourage a change in mindset to better prepare ourselves for a continuity of care in future pandemics. References:1. Kutikov A, Weinberg DS, Edelman MJ, et al. A War on Two Fronts: Cancer Care in the Time of COVID-19. Ann Intern Med. 2020; [Epub ahead of print 27 March 2020]. doi: https://doi.org/10.7326/M20-11332. Iacobucci G. Covid-19: all non-urgent elective surgery is suspended for at least three months in England. BMJ. 2020;368:m1106.3. Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care. Cochrane Database of Systematic Reviews. 2006(4):1-80.4. Kim SJ, Lim GJ, Cho J, Côté MJ. Drone-Aided Healthcare Services for Patients with Chronic Diseases in Rural Areas. Journal of Intelligent & Robotic Systems. 2017;88(1):163-180.5. Evans JM, Qiu M, MacKinnon M, Green E, Peterson K, Kaizer L. A multi-method review of home-based chemotherapy. European Journal of Cancer Care. 2016;25(5):883-902. Saber BOUTAYEB, Amine SOUADKA, Ibrahim ELGHISSASSI, Hind MRABTI, Hassan ERRIHANIUNIVERSITE MOHAMMED V3 April 2020 Why adjuvant chemotherapy for colon cancer shoud be delayed with caution in time of COVID 19 We read with great interest the article written by Kutikov and all (1) trying to simplify the recommendations on prioritizing chemotherapy prescription in several cancers. This adaptation is in difficult situation imposing the heavy ethical shift from individual cancer patient management to public health priorities As it was said by the authors this proposal is more based on consensus than on evidence.However we should keep in mind that for stage III colon cancer several concordant studies showed that the optimal interval between surgery and chemotherapy should not exceed 8 weeks. (2) (3) By Delaying Chemotherapy Beyond 8 weeks the overall survival drops by 5% at five years and beyond 16 weeks by 24%. (4)Moreover, a recent analyze of 42,901 patients from the US National Cancer Database showed that high risk stage III colon cancer (pT4 or pN2 or tumor deposit in the peritoneum) are correlated with bad prognosis with only 23.4% five year overall survival. (5)In our opinion, these findings seems to be strong arguments for moving high risk colon cancer in the category “High” (Ideally No delay).We think also that in addition to the risk of cancer progression and the risk of severe forms of COVID 19, this classification should take into account the risk of complications under anti-cancer treatments, in particular those linked to immunosuppression.At last,We agree that delaying of chemotherapy for patients at high risk for severe morbidity with COVID 19 is mandatory, However the oncologists, in this difficult battle should remain honest in explaining the truth to their patients concerning the real risk of this delay. Today,even more, patients should be in to this difficult decision to delay or not. References : 1. Kutikov A, Weinberg DS, Edelman MJ, Horwitz EM, Uzzo RG, Fisher RI.A War on Two Fronts: Cancer Care in the Time of COVID-19. Ann Intern Med. 2020 Mar 27. doi: 10.7326/M20-1133. [Epub ahead of print]2. Czaykowski PM, Gill S, Kennecke HF, Gordon VL, Turner D. Adjuvant chemotherapy for stage III colon cancer: does timing matter? Dis colon rectum. 2011;54(9):1082–9. 3. Peixoto RD, Kumar A, Speers C, Renouf D, Kennecke HF, Lim HJ, Cheung WY, Melosky B, Gill S. Effect of delay in adjuvant oxaliplatin-based chemotherapy for stage III colon cancer. Clin Colorectal Cancer. 2015;14(1): 25–30. 4. Gao P, Huang XZ, Song YX, Sun JX, Chen XW, Sun Y, Jiang YM, Wang ZN. Impact of timing of adjuvant chemotherapy on survival in stage III colon cancer: a population-based study.BMC Cancer. 2018 Mar 1;18(1):234. doi: 10.1186/s12885-018-4138-7.5.Pricolo VE, Steingrimsson J, McDuffie TJ, McHale JM, McMillen B, Shparber M.Tumor Deposits in Stage III Colon Cancer: Correlation With Other Histopathologic Variables, Prognostic Value, and Risk Stratification-Time to Consider "N2c".Am J Clin Oncol. 2020 Feb;43(2):133-138. doi: 10.1097/COC.0000000000000645.4. Gao P, Huang XZ, Song YX, Sun JX, Chen XW, Sun Y, Jiang YM, Wang ZN. Impact of timing of adjuvant chemotherapy on survival in stage III colon cancer: a population-based study.BMC Cancer. 2018 Mar 1;18(1):234. doi: 10.1186/s12885-018-4138-7.5.Pricolo VE, Steingrimsson J, McDuffie TJ, McHale JM, McMillen B, Shparber M.Tumor Deposits in Stage III Colon Cancer: Correlation With Other Histopathologic Variables, Prognostic Value, and Risk Stratification-Time to Consider "N2c".Am J Clin Oncol. 2020 Feb;43(2):133-138. doi: 10.1097/COC.0000000000000645. Richard M Fleming, PhD, MD, JD (FHHI-OI-Camelot); Matthew R Fleming, BS, NRP (FHHI-OI-Camelot); Tapan K Chaudhuri, MD (Eastern Virginia Medical School)FHHI-OI-Camelot; Eastern Virginia Medical School30 March 2020 A War on Two Fronts - Our Current Problem Finding and Treating the Enemy and an opportunity to learn from our mistakes. Coronary artery disease (CAD) and Cancer have been the #1 and #2 cause of death since the introduction of penicillin (PCN) for the treatment of bacterial infections. Prior to Fleming’s discovery of PCN, infectious disease was the # 1 cause of death worldwide. Only recently have we been reminded of the ferocity of viruses.The role of infectious diseases worsening inflammatory tissue changes, resulting in CAD and cancer, was laid out in the mid-1990s, with subsequent studies demonstrating that successful treatment of pathogens would reduce the extent of CAD, resulting from the increase in inflammation caused by the infection [1-3]. Herein lies one of the fundamental reasons for the increased morbidity and mortality of CoVid-19 – lack of actual effective treatment for the inflammatory invader. The similarities between CAD, Cancer and infections – including the current CoVid-19 pneumonia (CVP) pandemic – goes beyond mere etiology. They share a common problem with diagnosis and treatment monitoring. As with any medical problem, mere screening of disease does not guarantee accurate sensitivity and specificity – and more importantly, such screening tests, including PCR, does not tell us what the outcome of the infection is going to be [4].The diagnosis and treatment monitoring of CAD, Cancer and CVP, share a similar fate – the need to quantitatively measure the severity and response to treatment [4,5]. The use of FMTVDM will enhance our treatment outcomes by measuring treatment responses – consequently guiding our treatments - thereby reducing deaths and expenditure of our medical resources needed by so many patients.Until then, we will live in a world of insanity, were treatment is focused not on objective measurements of tissue changes in the lungs, but the same old practices, blood tests and measurement of oxygen saturation – that frequently tell us too late that we haven’t found the right treatment and another life has been lost. We can chose either to continue doing the same old thing, or learn from our mistakes and measure the effect of treatments - and consequently guide the patient’s treatment - using FMTVDM.References:1. Fleming RM. Chapter 64. The Pathogenesis of Vascular Disease. Textbook of Angiology. John C. Chang Editor, Springer-Verlag New York, NY. 1999, pp. 787-798. doi:10.1007/978-1-4612-1190-7_64. 2. Fleming RM. The Fleming Unified Theory of Vascular Disease: A Link Between Atherosclerosis, Inflammation, and Bacterially Aggravated Atherosclerosis (BAA). Angiol 2000; 51: 87-89. 3. Fleming RM, Boyd L, Forster M. Reversing Heart Disease in the New Millennium - The Fleming Unified Theory, Angiology 2000;51(10):617-629. 4. Fleming RM, Fleming MR, Dooley WC, Chaudhuri TK. Invited Editorial. The Importance of Differentiating Between Qualitative, Semi-Quantitative and Quantitative Imaging – Close Only Counts in Horseshoes. Eur J Nucl Med Mol Imaging. 2020;47(4):753-755. DOI:10.1007/s00259-019-04668-y. Published online 17 January 2020 https://link.springer.com/article/10.1007/s00259-019- 04668-y https://rdcu.be/b22Dd 5. The Fleming Method for Tissue and Vascular Differentiation and Metabolism (FMTVDM) using same state single or sequential quantification comparisons. Patent Number 9566037. Issued 02/14/2017. Disclosures: FMTVDM issued to first author. FMTVDM will be made available for use by first author in this pandemic without cost with NDA. Author, Article, and Disclosure InformationAuthors: Alexander Kutikov, MD; David S. Weinberg, MD, MSc; Martin J. Edelman, MD; Eric M. Horwitz, MD; Robert G. Uzzo, MD, MBA; Richard I. Fisher, MDAffiliations: Fox Chase Cancer Center, Philadelphia, Pennsylvania (A.K., D.S.W., M.J.E., E.M.H., R.G.U., R.I.F.)Acknowledgment: The authors thank all of their colleagues at Fox Chase Cancer Center, especially J. Robert Beck, MD; Richard Bleicher, MD; Hossein Borghaei, DO; Christina Chu, MD; James Helstrom, MD; Sanjay Reddy, MD; and Patrick McGee.Disclosures: Dr. Kutikov reports personal fees from Merck & Co., Oncosec, and UroToday outside the submitted work. Dr. Fisher reports personal fees from Imedex, Beigene, Portola, Celgene, Barclays, prIME, Gowling WLG, AstraZeneca, and Ion Solutions outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-1133.Corresponding Author: Alexander Kutikov, MD, Department of Surgery, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111; e-mail, alexander.kutikov@fccc.edu.Current Author Addresses: Dr. Kutikov: Department of Surgery, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111.Dr. Weinberg: Department of Medicine, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111.Dr. Edelman: Department of Hematology/Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111.Dr. Horwitz: Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111.Dr. Uzzo: Department of Surgery, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111.Dr. Fisher: Department of Hematology/Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111.Author Contributions: Conception and design: A. Kutikov, D.S. Weinberg, M.J. Edelman, E.M. Horwitz, R.G. Uzzo, R.I. Fisher.Analysis and interpretation of the data: D.S. Weinberg, E.M. Horwitz, R.G. Uzzo.Drafting of the article: A. Kutikov, D.S. Weinberg, M.J. Edelman, E.M. Horwitz, R.G. Uzzo.Critical revision of the article for important intellectual content: A. Kutikov, D.S. Weinberg, E.M. Horwitz, R.G. Uzzo, R.I. Fisher.Final approval of the article: A. Kutikov, D.S. Weinberg, M.J. Edelman, E.M. Horwitz, R.G. Uzzo.Administrative, technical, or logistic support: A. Kutikov, D.S. Weinberg.Collection and assembly