The COVID19 pandemic has changed healthcare in ways we never could have expected. In this Season 1 bonus episode, we catch up with Dr. Robert Montgomery, Dr. Deborah Axelrod, and Dr. Stephen Ross about how their professional and personal lives have changed in this new era of medicine.
Vital Signs - Follow Up Visit - Part 1 Transcription:
Beth Ameen:
Hi, I'm Beth, Executive Producer of Vital Signs. If the COVID pandemic over the last year and a half has revealed anything, it's that the pace of research innovation and patient care never slows down. In these bonus episodes, we'll follow up with each of the doctors from season one to talk about the challenges COVID has brought into their lives and the groundbreaking advances they've made in their fields. First, we'll hear from heart transplant recipient and director of the NYU Langone Transplant Institute, Dr. Robert Montgomery. The pandemic has presented unique challenges to transplant patients and their healthcare providers, and Dr. Montgomery himself is no exception.
Dr. Robert Montgomery:
I'm good. I'm feeling great. You know, I was just recently appointed as the new chair for the department of surgery in addition to being the director of the Transplant Institute. So that's been super exciting. My health has been great. You know, I'm kind of suffering a little bit as I think most people are from not being able to go to the gym, but I've taken to walking around Manhattan. And so I walk to work every day from the west village and do about five between five and six miles of walking a day. A lot of transplant patients that I know have really been very isolated this past year. I think that's true of the elderly too. So the way I've approached this myself is look, my work involves operating on patients and seeing patients and clinic. That's what I do. And so I take the proper precautions. I take those risks at work, but I'm very careful in my personal life. I don't take chances outside of the hospital. And in the hospital, I feel like I'm pretty well protected.
Honestly, as far as progress goes for medical science and transplant in particular, I think really that there's been more innovation research and advancements that have occurred this past year than probably in previous years. Our understanding of transplant patients in terms of their response to novel infections has increased tremendously. You probably know that in the very beginning of the pandemic, the mortality rate of our transplant patients who were symptomatic was between 20 and 30%, which is staggering. We were losing transplant patients. That has dropped precipitously based on the work that we've been doing to try to better understand how the disease behaves in transplant patients and how to manage those patients. Transplant patients don't respond normally to the vaccine. I was one of the first transplant patients in the country to get the COVID vaccine, but then I enrolled in the study that sought to look at the response of transplant patients to the vaccine.
I think I was their first patient to be enrolled again because I got the vaccine so early. And it turns out that when they checked my antibodies, I hadn't formed any. And it really was the first indication that immunosuppressed patients weren't going to respond normally to the vaccine. And then over the ensuing, couple of months, the results started coming in and the numbers started going up and over half of the immunosuppressed patients that were in the study had no response to the first two doses of the vaccine. So, you know, this was being discussed and actually somebody in the administration here at NYU heard that I wasn't protected and just called me and said, look, you know, we can give you another dose. And so I took him up on it and this was sometime in February. And then we rechecked my antibodies and they were at kind of the normal level that you would expect somebody who is not immuno-suppressed to have after that third dose.
Dr. Robert Montgomery:
So, you know, I became pretty vocal about this to at least get the information out there that transplant patients should not assume that they're protected and they should continue to exercise the same precautions that someone who hadn't yet been vaccinated was observing. And, you know, one thing led to another, and there was a consensus finally that we should offer a third dose to immunosuppressed patients. So to really be sort of that "Canary in the Coal Mine" that raised this issue, I felt quite satisfied in the end that it was taken seriously and then actually resulted in a change in the CDC recommendations. So that's one of our biggest triumphs that, that ended up going into policy. You know, I'm in a unique position where I can kind of study myself for the benefit of my brothers and sisters who also have transplants. The current CDC recommendation for transplant patients is to get a third dose of their original vaccine. So if they got Moderna, they would get a third dose during it. If they had a Pfizer, a third dose of Pfizer, where there is evidence is that a third dose does significantly increase the likelihood that you're going to have a response.
I've never worked harder than I have this past year. This has been just an amazing year of ingenuity and hard work to get our patients and our staff and everybody through this crisis, there was a period of time where we had to pause and stop doing transplants because the hospital was filled with COVID patients. So, you know, that was a very difficult time for transplant patients because a lot of these patients are very sick and we had to defer and move down the road, you know, their transplants. But I think once it became clear that the hospital was safe and we had capacity to manage new patients, transplant patients, the patients came back. The only kind of ramping them up that had to occur was probably with live donation because living donation is an elective procedure. And so we had to be extra careful with, with those living donors.
We've now done over 200 transplants from hepatitis C positive donors, if you can imagine that. So it continues to be an extraordinary development. That's kind of approaching somewhere between a quarter and a third of our total transplants are from hepatitis C donors. We continue to work on trying to change the equation of transplantation, which is that right now somebody has to die for someone else to live. So we're doing a lot of intensive research and that's only going to get greater on renewable sources of organs. And what I sort of considered to be the wind and the solar of organ supply for transplantation are bioartificial organs and xenografts. Xenografts are organs from pigs that have been genetically engineered to make them less likely to be rejected by the human immune system. So those are, I think the frontiers and we're playing a big role in that future. Couple of years, Xeno transplants.
Beth Ameen:
Initially breast cancer surgeon, Dr. Deborah Axelrod was hesitant to tell her story of being diagnosed with breast cancer herself. But as she marks 20 years since she went from surgeon to patient, she's now embracing what her journey represents.
Dr. Deborah Axelrod:
Well, next month will be 20 years since my diagnosis and surgery for breast cancer. I never thought that I would really tell my story because I'm a pretty superstitious person. And I always felt, I always thought that was kind of bad karma to do that. But after 20 years or almost 20 years, I felt it was real grassroots to do it in this kind of setting. And I also felt, you know, maybe after all these years, maybe I should kind of come clean to myself, but I've never wanted myself really to be the center of attention. And you know, when we have a busy practice, that's the last thing you want to do is start talking about yourself. Even though it would have implications for other people, or they would use that advice and information. Even though I like to talk a lot and I have a lot of friends, I'm actually pretty private person. It was kind of freeing and gratifying people called me and they texted me and friends of friends said something. And just in a lovely way.
It was so strange sometimes. But you know, when you're going through this, you really want to go through it by yourself before you bring anybody else on your journey because of things that happen like this. So yeah, I, I kept it to myself and I guess I feel better that I said it in a forum that I could trust because it was, it was, um, you know, it was kind of freeing to say it.
When the pandemic came, you know, people didn't come and we were close for awhile for routine screening all across America. This is not just New York city. And so people missed their mammograms. They miss getting diagnosed with small cancers. And so I think that people did take a hit on this. And I think it is a problem because we did find later cancers. I remember a few months into the pandemic, I saw, uh, several women who were just watching and waiting on their tumors because they didn't want to go out and get care. And to that, I think may have impacted their prognosis because they ended up presenting with more advanced breast cancer. We really had to try to prioritize who would get surgery first, who wouldn't, because we only were allowed in the ORs a certain amount of time. As a group of surgeons we've volunteered and move first responders in the COVID units. Not only did I learn a lot more about critical care medicine because I hadn't practiced it in a very long time, but I got to meet colleagues that I wouldn't have been able to meet. Had I not been on the wards. So I feel that that was a very positive experience.
But I still think people are afraid to go for their mammograms. I think they're still afraid and hesitant to come out. In the last few months. I'm very proud to say that NYU received a multi-center large grant from the NIH. The lead is anesthesia, and we're going to be looking at ketamine in people who are recovering from mastectomy. So we're going to give a dose of ketamine, which is an analgesic instead of an opioid. We're looking at the utility of that and, uh, I'm their lead surgeon. So I'm very, very excited. I think that we're going to find and help a lot of women who are recovering from breast surgery,
Beth Ameen:
Psychedelic research is in the spotlight right now. And few people are more excited about it than psychiatrist, Dr. Stephen Ross. His work is primarily focused on terminally ill cancer patients suffering from debilitating anxiety, but people living with other serious mental health issues may also benefit from psilocybin, the active ingredient in magic mushrooms. His desire to make this controversial drug more available for therapeutic use is almost within reach.
Dr. Stephen Ross:
There's about 8 million cancer patients just in the U.S. About a million of them have terminal illness, 30 to 40% of them have some diagnosable anxiety or depressive disorder. Another 25% have some kind of existential distress problem. So that's a lot of people. My goal has been to try to do larger trials of using psilocybin assisted psychotherapy to help patients with life-threatening cancer that are suffering from anxiety and depression and existential distress, loss of meaning in life, a hastened desire to want to be dead. And it's kinda been a mission of mine for awhile, and I've made some good progress recently. I'm now getting close to petitioning the FDA to move towards phase three trials of psilocybin and advanced cancer. And my hope is that within the next six to nine months, I'll be able to initiate phase three trials, pivotal trials in this area when studying about 200 people at a time, it'll be pretty much the same design to what we did in the pilot studies using one dose of psilocybin versus one dose of placebo delivered in conjunction with a psychotherapy platform, with the goal of helping people that are having anxiety, depression, and existential distress with cancer.
So it's been a five-year process to try to take it to the next step. And it's been frustrating and difficult at times, but I've been emboldened by the patients. I continue to get hundreds or thousands of queries from terminally ill cancer patients who are suffering and wondering how they can get psilocybin and treatment. And it's just been frustrating that there is no mechanism to give them the treatment. We just need to do more research. So that's the stage that we're at. And if we can demonstrate what we did in the phase two, then it puts you in a position to petition the FDA to say, Hey, you know, can this now be a prescribable medication? And that will be a big deal because that'll take it out of schedule one, where it's not available at all, totally illegal, and make it a prescribable medication for cancer patient.
And then phase four, as the drugs been out on the market for a while, you're now giving it to a lot of people. And you're looking to see, are there any new emerging safety concerns? So those are the various phases of drug development.
Psychedelics appear broadly therapeutic from our cancer work, because it seemed to work quickly for cancer depression, our next line of thinking, can it work for regular depression, regular major depression, and that's an area we've gone into and we're actively involved in a multicenter trial studying psilocybin to treat major depression with a very similar design to our current design, one dose of psilocybin. And there's converging evidence that psilocybin is helpful for major depression. There's also evidence that may help anxiety disorders. It's now being studied for things outside of psychiatry, like pain disorders and problems of inflammation and neurodegeneration.
It appears that psilocybin has very potent anti-inflammatory properties and inflammation is involved in a lot of neurological and psychiatric disorders, including depression. So there, there seems to be a potential, very broad application of psychedelics to treat psychiatric and medical disorders. It appears that psilocybin strengthens the connections between neurons makes them more robust. We know that dysfunctions of neuronal connectivity underlies several psychiatric disorders, including again, things like depression. So that's on the neuro-biologic side of things on the psychological, emotional, spiritual side of things, we found in our pilot studies that's unusual mystical experience occasioned by psilocybin where participants upwards of three out of four said it was one of the most meaningful spiritual experiences of their entire lives. They had death experiences. They encounter God-like entities. They had a reconceptualization of their identity relative to cancer. They got in touch with, you know, forces of infinite love.
And so the experiences are very powerful for people that are dying. And we want to see if the mystical experience, again, mediates outcome. With cancer, distress, and depression, a lot of other things, addiction, too, your thinking becomes constrained. Your world becomes constrained. You get in this like negative kind of loop, you know, with cancer, it can be "Oh my God, my life is over, there's nothing worth living for, I can never get out of this thing. I'm stuck. And I wish I could be dead." You know, or the depressed person is "I'm always going to be like this. You know, everything is negative." Or the addicted person, "All I want to do is get this drug to the exclusion of, of doing other things." It appears that psychedelics can take people from these rigid, constrained, pathological ways of thinking and can increase psychological or cognitive flexibility. They can become more open to thinking about things in new and novel ways. And that's at the core of cognitive therapy. You know, people have distorted thinking, you help them come up with more constructive thinking. And it's interesting, we don't really know how any medications work in psychiatry. If you ask somebody what's the neurobiology of depression, it's unclear and how does Prozac work. But with psychedelics, we actually have a decent sense of like what they're doing.
COVID really, in addition to all the death, is really making mental health and addiction problems worse. We were anecdotally hearing a lot about it, but the data's coming out more substance abuse, more opiate abuse, more overdoses, more suicide, more violence, just more distress. And what really got to me is, you know, I work at Bellevue, so I was seeing my colleagues on the front lines, dealing with COVID and being traumatized by it. And I started to think of how psychedelics could be used to help frontline healthcare workers who are experiencing this kind of existential distress. You know, here's this pandemic patients are dying quickly. You know, they're dying in unprecedented circumstances, all alone, no family. And I was just starting to hear enough from my colleagues who were just feeling burnt out overwhelmed and just very distressed. And what's the meaning in life. So I designed a trial using psilocybin to treat existential distress in frontline healthcare workers and our group thought about other studies, you know, could you use MDMA to deal with the traumatic experiences? And ultimately, I think you could apply psychedelics to help people that have had COVID related problems.
Beth Ameen:
Whether it's transplant cancer or mental health COVID has impacted the entire world of healthcare. In part two, a follow up visit, we'll catch up with Dr. Gabby Mayer, Dr. Sean McMenomey and Dr. Eduardo Rodriguez about their journey through the pandemic and their vision of the future.
CREDITS:
Vital Signs is a co-production of NYU Langone Health and SiriusXM. The podcast is produced by Jim Bilodeau, Julie Kanfer, Keith King, and Rob Schulte with sound design by Jim Bilodeau and writing from Julie Kanfer. Vital Signs' executive producer is Beth Ameen in partnership with Allison Clair and Jim Mandler at NYU Langone Health. You can listen to all of Vital Signs, season one on the SXM, Stitcher and Pandora apps, or wherever you listen to podcasts. To hear more from the world-renowned doctors at NYU Langone Health tune in to Doctor Radio on Sirius XM, channel 110, or listen to anytime on the SXM app. And be sure to subscribe as Vital Signs. season two is coming later this year.