About this Webinar:

It’s no surprise to find that colonoscopy screenings, as well as other oncological tests, have ground to a halt during the height of the COVID-19 pandemic. But declines in diagnoses and marked drops in surgeries point to troubling delays in patient care for rapidly progressing forms of cancer. All the while, patients continue to face uncertainty around how the health care system will manage a 2-month backlog.

• New gaps in colorectal cancer screening, diagnosis, and treatment
  The colorectal cancer patient experience amid the pandemic: fears, anxieties, and uncertainty when their medical care will be rescheduled
• How patient-level data can help us understand these nuances and ensure patient needs are met, even amid a disrupted healthcare system

Webinar Transcript:

00:00 Bill Evans: Thank you all for joining us this afternoon for our webinar on, "Cancer Care in an Upended Health System." I'll introduce my panelists in a couple of minutes, but for the sake of clarity, my name is Bill Evans. I'm the Chief Marketing Officer at Komodo Health, and I will be serving as the moderator for today's discussion. To take you through quickly the agenda so that we can get to the reason you're all here, I'm gonna introduce our speakers very quickly, before we get started. We're gonna spend some time reviewing some findings that Komodo Health and the Fight CRC team have uncovered around the current state of what's going on in the colorectal cancer oncology market. And then have some observations on how that's affecting the US health system, and then use that as a springboard into a discussion with our distinguished guests.

00:57 BE: By way of introduction, the three folks that will be spending the most time with you this afternoon. First, we have Usha Periyanayagam, who is an emergency medicine physician at Kaiser Permanente in Redwood City Medical Center. She also wears many hats, she's a medical director here at Komodo Health, connecting the missing links in the fragmented patient journey to help us better understand disease burden, to develop earlier interventions, and optimize patient outcomes.

01:29 BE: Andrea Dwyer is from the University of Colorado Cancer Center, and is an advisor to Fight CRC, which is a non-profit focused on the colorectal cancer community. And in her role at UCCC, she directs state-wide screening interventions and serves as a co-investigator on various practice-based research and science initiatives currently funded by the CDC and NCI.

01:52 BE: And Dr. Darrell Gray, is a gastroenterologist, enterologist, and associate professor of medicine at The Ohio State University. He's a key opinion leader in addressing barriers to colorectal cancer screening and serves on the National Colorectal Cancer Roundtable, the Strategic Planning Advisory Group, and the Fight CRC Medical Advisory Board. And with that, I'm gonna turn it over to Usha to start us with today's discussion.

02:18 Usha Periyanayagam: Okay, thanks, Bill. So I just wanted to start it, start by introducing Komodo Health, what we do, and what our background is coming into this research brief. We are a company of about 250 people now and we're addressing a really known problem with healthcare software. A lot of data in healthcare is really siloed and Komodo Health takes this siloed data and puts it together and stitches it into our healthcare map, which is basically a description of patients that are weaving together all the touch points that they have with the system, from primary care doctor visits to procedures, prescriptions, and labs, so we could really understand that patient journey. And so by getting this large amount of information, we're able to look at trends over time as we discuss later in this presentation, and really understand how people and patients are moving through a system, and some of the changes that occur have lots of partners and thousands of users, and we're expanding across the healthcare ecosystem. I'll let Andi introduce CRC now.

03:25 Andrea Dwyer: Hello everyone, thanks so much for having us. On behalf of Fight Colorectal Cancer, we are a patient empowerment and advocacy organization that is central to really looking at advocacy and research-related issues for the colorectal cancer community, thinking about research, treatment, and then also policy initiatives aimed at increasing access and reducing barriers to care for screening and early detection, and supporting cancer survivors through their journey. On behalf of the organization, I'm an advisor and Fight CRC does provide a lot of opportunity for patient support, legislation initiatives, as well as being an agent of the collective good, ensuring the voice of the Fight CRC and colorectal cancer community. So I'm really excited to share some of the results that are coming out of the work done with the patient advocates and patient survivor community.

04:21 UP: Thanks, Andi. We work together to answer a few different questions here. We knew we had a couple of different perspectives and really wanted to understand colorectal cancer better. As we know, colorectal cancer is the second leading cause of cancer deaths in the United States, and we really wanted to both look at how the clinical chair has changed over the last few months in the setting of coronavirus, how has patient volumes changed, how have treatment regimens changed, and how are patients reacting to this change. Knowing all the things that are going on in our broader healthcare ecosystem, this is a vulnerable population that needs care, both within the healthcare and hospital system, as well as in private clinics, and we wanted to see how safe they felt in this situation.

05:10 UP: So we went through... Next slide please. We went through a couple of different methodologies to look at this, and I'll start by describing some of the work Komodo did. And so what we did is we took our map of 320 million patients and really looked to compare the rates of colonoscopies, of surgeries, of new diagnosis of colon cancer, week over week, compared to last year. And so when we looked at how many cases occured per 100,000, we really realized there's a sharp decrease in both colonoscopies, but also in colon cancer diagnosis, as well as surgeries, which I'll review in the next few slides. Andi, can you review your methodology as well?

05:52 AD: Sure. Essentially, what Fight CRC aimed to do was understand, as noted, really the impacts of patients based on COVID-19, but in terms of the acute healthcare issues that people would be experiencing related to the virus, and to ultimately, a diagnosis of COVID-19 or protective measures against ultimately the disease itself, but in addition, we were really interested in understanding the impact on care. A survey was designed, and ultimately, several questions that had already been in circulation from some of our cancer partners, such as the American Cancer Society, who had already been looking at disruptions in care, as well as some of the validated instruments around anxiety, depression, and the like, were adapted into a survey that was distributed through the patient community through the Fight CRC channels of folks who are coming for patient education, advocacy-related efforts.

06:48 AD: In some attempt, there was a bit of a means to try to control the denominator, essentially, but it ended up really essentially being a convenient sample approach with about 250 respondents that we used for the initial analysis of the survey data. We've looked at some of the trends, some of the general characteristics as well as some specific incidents where we're seeing statistical differences in terms of respondent types, in terms of what their response was, and again, to ultimately thinking about the COVID-19 response directly as well as the impact on their care for colorectal screening and diagnoses as well.

07:29 UP: Great. Next slide, please. Here's a first couple of pictures of our results, and then Andi will go in through some of the qualitative results as well. And so the way to look at this graph is look at the x-axis as being week one through week 16 of the year, and then the y-axis is number of cases per hundred thousand patients. And so, you can look at colonoscopies, and honestly, for the first 13 weeks... As you may remember, shelter in place began on March 19th, and for the first 13 weeks, they were actually pretty similar throughout, both the blue line, which is 2019, and the purple line, which is 2020. And as you can see, starting on about March 13th or the week of, you'll start to see that sharp decrease in colonoscopies, and we're seeing about 90% of the amount of volume in colonoscopies that we're seeing in 2019.

08:27 UP: If you look on the next slide, you'll also see a similar thing with new diagnosis. And this is probably related to the fact that colonoscopies are a big source of new diagnoses, and without having those colonoscopies, we're not seeing that new diagnosis. The similarly, there's a drop-off at around the same rate, around the same week as well, but not nearly as pronounced as the colonoscopy drop. I think one of the more profound things that we saw was on the next slide, is the amount of colon cancer surgeries. And so, we looked at all colectomies, all resections that occurred for colon cancer, so associated with that colon cancer diagnosis. And as we'd expect for the first 13 weeks of the year, it was actually pretty similar between the 2019 data and 2020 data.

09:19 UP: And so, when we start to see that really big drop that occurs around the same time, around week 13, that's pretty concerning, 'cause we don't believe there are less patients with colon cancer, right? We think that it should be about the same from 2020 to 2019. We don't think that they are not existing, we think they're not getting treatment. And that delay of treatment, especially that delay which could be over a couple of months, could have significant effects on the actual prognosis and then also progression of disease. I'll let Andi go into some of her findings as well in the next slide.

09:56 AD: Okay, great. Well, thanks. And I think one of the things that we aimed, as noted, is really understanding if and what were those disruptions in care. And I think what's interesting about this slide right now, as you look at the distribution spread across the spokes, we're really asked to identify what were the main areas where they saw disruption. So if you look, actually, I think, at the good news, ultimately, when you think about medication and supplies that are pertinent to a colorectal cancer diagnosis, which I mentioned ostomy and the like, folks actually didn't report a lot of disruption in care in terms of being able to access those resources to help take care of an ostomy or to have the medications that they needed. But if you look up, I think, at the first responses, the in-person visits with the providers were the things that were most impacted, were nearly, 80 percent-ish or just thereof, ultimately responded that those were impacted.

10:51 AD: And I think what's interesting about this is that we heard a dual response to this connection, is that, while that in-person visit where people could hear a heartbeat, take a pulse, have a full physical and visual exam, that that was actually not something that happened, that ultimately on times, there was a telemedicine opportunity that provided also an opportunity for folks to not complete, have disruption in care, for those in-person visits and the like. And I think what was interesting about what we heard anecdotally from also our qualitative input is that patients who did have in-person visits felt a real void by not oftentimes being allowed to have a support person with them in tow to hear the information, to be someone who could drive them, to really help be a supportive care component of their visit, but ultimately, with telemedicine, there was also an advantage of having a caretaker friend, relative, that could also join in if they desired to hear the appointment.

11:51 AD: I think what's interesting is, as we're getting ready to come out of this situation, and Fight CRC is also looking at some of the perceptions of clinicians and the like, telemedicine will play a huge role, I think, moving ahead. But it was interesting to hear the patients' responses to the use of in-person versus telehealth visits, so I think there's some real great opportunities, but then also some folks that really notice some anxiety around the in-person, and if patients aren't allowed supportive care, is that something that will be a barrier moving forward? But I think if you really look at, I think, some of the clustering moving ahead, we did see medical imaging that... Oh, I'm sorry, can we go back quickly?

12:32 AD: The medical imaging component was also impacted by half the folks really looking at some of that or noting delays in those cares, as well as supportive services and active treatment. And I think that at this time, 40% of the group actually talked about some level of disruption, but about 25% of the group weren't quite clear on what the next directive points in care were around treatment and the like, and I think that's something that we're keeping a keen eye to, moving ahead as well. But we did see some impact with clinical trials and I think that's something that we're advocating and really moving forward and also thinking about the pipeline research development and the like. So some good news, some interesting things, but some definite things that we're going to have to do in terms of even patient education, I think, moving ahead with telemedicine, but some really interesting opportunities that have emerged as well. So, next slide.

13:25 AD: I think that one of the things we were also very interested, of course, is really the patient fears and then frustrations are high. I think the anxiety component on edge is just sort of the general angst about the unknown, about how to really support folks, and how to really, themselves as patients, really care for themselves in collective with the family unit. And I think that idea of that worrying and thinking about that anxiety component was something that we're really interested, and I think as an advocacy organization, is something that we're thinking about, that when we start to...

14:00 AD: As we're emerging, I think, into this acute phase 1 of COVID, and we're seeing those elective procedure bans lift, the treatment began, that we might actually see a second wave. And so, we need to really be thinking about maybe the fall or the like when there might be another shelter in place or the like, what we need to be considering moving ahead, because I think as Usha noted, the information that's being presented today was really, I think, at the height of when we were seeing a lot of the elective procedure ban, the disruptions in care. We may emerge, but if we come back in, I think it's really thinking about how do we think about this idea of really meeting patients where they need and around their issues.

14:39 AD: And so I think if you really pinpoint that, of course, it's really thinking about concern about contracting COVID-19, shelter in place, isolation, and then ultimately thinking about how do people take care of the direct finances, and then ultimately, the basic needs and the like. I think these are the things that we're really going to be queuing in on. And I do think one of the things that we heard, I think, somewhat complicit with 45% are concerned about the government and the leadership. Ultimately, folks also talked in the qualitative interviews that we conducted in parallel with the survey, there's also some confusion about what to do and how to take care of themselves.

15:18 AD: And there was a sense of, ultimately, that as the restrictions got heavier with PPE, as well as providers really starting to take more direct issues, patients began to feel more secure in safety and not contracting the disease of COVID, really tending to their colorectal cancer needs, but there was also this balance of feeling connected, or that warmth when you have providers who are wearing face masks and who have a lot of PPE, where do we have that feeling of warmth and connectivity with the provider-patient interaction. I think these are the things that we're really queuing in on in terms of thinking about how we move forward and how do we meet the patient needs where we are. And so, I think there's a really nice quote in here, and I think this is actually something that came forward.

16:04 AD: One of the patients talk about having a upper respiratory infection, a lady who is a survivor, two to three years out from a diagnosis and active treatment, who is a survivor, but is actually on recurrence therapy for maintenance therapy. And she talked a little bit that she now thinks that when she had this upper respiratory issue, that it was probably related to COVID-19. And although she hadn't been tested, she was fearful, but she actually thought a little bit about moving ahead, what this would mean for her care, but she ultimately remember thinking, and thinking at the time when she was sick, that she is high-risk for colorectal cancer, and that ultimately, she could be more susceptible to COVID-19, thinking she might have had a diagnosis. And she said since the time that she was diagnosed with stage IV colorectal cancer, it was one of the only times she really thought about her own mortality and that she may pass away and that she may die from a disease.

17:00 AD: And so I think what we were hearing as this came up several times in our focus groups is that a lot of folks really talk about the magnitude of dealing with COVID-19, also might be as severe as really taking on the diagnosis that they were given as a colorectal cancer patient and realizing their own mortality. And so I think that's quite profound and in concert with the rest of the things that we're considering, is how do we talk to patients and how do we create these good opportunities for information sharing, resource sharing, and really supporting folks as they're going through a diagnosis, also coupled with the complexity of something like COVID-19. Next slide.

17:36 AD: And so, we did do a bit of work. Again, we are basically showing the results of the first 250 people who responded to the survey. Ultimately, we did break out based on demographic. And although our numbers are somewhat smaller for the distribution of rural, as well as looking at the break out of race and ethnicity, there was statistical significance. And when we looked at differences between rural, suburban, and urban communities, what we did notice is that, ultimately, there was a difference between rural folks being able to afford treatment and their concerns about affording a treatment in terms of thinking about that need and financial assistance. And so, that goes beyond treatment, but for basic needs such as rent, mortgage, basic food, transportation, we really did see a stark difference between those who were rural and urban, as well as suburban, in terms of looking at those who felt confident that they had the resources to really help care and support their families.

18:38 AD: And then this whole idea that "I'm just having a hard time and I'm struggling.", there was a profound difference between the rural, urban, and suburban community. And so I think one of the things that Fight CRC is considering as we move into a further response from the survey and looking at trends, is ultimately, what are we seeing in terms of health disparities?

18:57 AD: We are really interested, I think, in the socioeconomic components, racial, ethnic differences, and then also looking at what we're seeing also in terms of where people live, work, and play, and what does that mean in terms of their perception or their real ability to seek access to care and just for basic needs. So moving forward, this is something that we're really taking into great consideration, and these are some of our preliminary results again from that very designated time that I think that we saw the most acute response to shelter-in-place, safer-at-home initiatives.

19:32 UP: Great, so next slide. I think as we listen and hear all these findings, we really need to think about what does this mean and where do we go from here? So the ripples of COVID-19 and as Andi mentioned we're slowly coming out of the shelter in place, but we still have to compensate for all the backlog of work that has not happened in the last couple of months, and so that decline on colorectal screening rates is not really surprising as those procedures occurred in the hospitals and surgery centers and all the places that people have been scared to go to.

20:04 UP: But given that degree of decline and given that we know that 32% less colorectal cancers were diagnosed in April of 2020 versus 2019, what do we do with that 32% who probably still have the disease but have not gotten care? We really need to start thinking about the morbidity and mortality associated with that. Similarly, compensating for that backlog or re-scheduling all the patients that were not, who had their colonoscopy delayed in the last couple of months. How does this happen? How long will this deferral of care last and if these patients will get their colonoscopies that were missed in the last couple of months, and unfortunately, vulnerable populations are less likely to have easy access to these specialists and therefore less likely to be able to get their colonoscopies and their backlog of surgeries scheduled as quickly as possible.

21:01 UP: Those high risk patients, patients that have a family history of colorectal cancer where a few months delay can make a huge difference in their diagnosis are specifically a particular concern. And then, and I obviously want Dr. Gray to expand them on this quite a bit, but I think the disparities, we know that all our care is not equally distributed across our patient population in the United States, and so knowing that vulnerable and uninsured populations not only have been de-prioritized, so have been also not gotten the care they needed in the last two months, but then also we'll have to shift through this ongoing backlog in getting the care is something that I worry about in the future.

21:45 UP: So obviously we wanna make cancer screening a priority in our healthcare system's recovery efforts, but we really need to think and track that pattern of patient behavior, understand these gaps in care, and really try to solve these problems before they come to fruition. And so we started in this analysis to capture the vital preventive care services that have been compromised by the pandemic, but it's important for us to continue to track these trends over the next weeks, months, years as we start to come back to our new normal to ensure that we compensate for the care that was missed in this patient population. And so it is in our duty as members of this healthcare system to really move into this period of recovery, into this first phase after the coronavirus pandemics and create new trends to really rectify these clinical delays that have happened in the last couple of months. Bill I'll let you take it from here.

22:49 BE: Excellent, so we're gonna move into some Q&A with our speakers. Before we do that, I just wanted to let everyone listening know that there is a button in your Zoom that will allow you to submit questions. We've already got a couple that have been submitted, but if you were unaware, you can submit questions for our panel through there. Dr. Gray, I'm gonna ask you to unmute and I'm going to volley the first question to you, but I guess given all of these trends, what are you seeing in your practice? And I think one of the questions that's come up quite a bit is which of these transitions do you think is temporary, meaning just the nature of COVID, and what do you think is going to be a more permanent shift in how care is both delivered and received?

23:41 Dr. Darrell Gray: Thank you for that question. And if you'll give me the liberty I'll not only address that question, but I'll speak to some of the points that Usha made around health disparity because I think they are really interlinked. And so if we take a step back and we look at over the past couple of decades, the progress that we've made in colorectal cancer decreasing mortality over time. But we also look at well, what's happened with certain populations within that? You see that there's still a gap, so even though the numbers are going down for colorectal cancer mortality, there's some people that have a disproportionate burden of colorectal cancer.

24:15 DG: And particularly if we look at groups like African-Americans, Native-Americans, for example, African-Americans have the highest incidents and death rates from colorectal cancer. We know that they're also less likely to get screened. We know that they're also diagnosed younger with later stage of disease, and there are multiple factors that play into that, whether it's anything from healthcare access, access to insurance, where there is competing health priorities. You know you're working three jobs to support... Find it hard to even find the time to go to a PCP to do whether it's a stool-based test or then get referred for a colonoscopy. So there are numerous barriers. Or whether even your primary care provider recommends you get a colorectal cancer screening test, which remains the number one barrier to someone actually getting screened for colorectal cancer. And so there's a number of barriers, and certainly as I tie that to COVID-19 and what we're seeing.

25:11 DG: What you've observed whether you're reading the headlines or listening to the radio is that you know that these same groups have been disproportionately impacted by COVID-19. And certainly a lot of attention has been paid to the comorbid conditions, whether it's cancer or diabetes or heart disease, but it's really those upstream factors, whether it's access like I just mentioned, or other upstream factors that contribute to these downstream poor health outcomes. And so what are we seeing now? Unfortunately the fact that COVID-19... The response to COVID-19 has led to the suppression of elective and even some diagnostic procedures, certainly that delay that even medically underserved or hard-to-reach populations or those who are more likely to get colorectal cancer and die at a younger age from it aren't getting necessarily into the office to get their either diagnostic colonoscopy after a positive FIT or Cologuard or to get their screening test. And so what this means is that there's likely going to be, we're likely going to see a wave.

26:10 DG: To kind of... To tie in one of Andi's terms, where we'll see late-stage disease and people being diagnosed when it could have been diagnosed at an earlier stage. And so I'm not trying to be dramatic or fatalistic about this at all, but I just wanna be realistic that these are some of the challenges that we're facing, and as a practitioner, as someone who sees these patients in the office, as a gastroenterologist on the prevention side of cancer, as someone who performs colonoscopies, in which removing polyps and diagnosing cancer, unfortunately, this is all too real. Because one of the things we know that as we are... We're being opening up at our offices now and doing more procedures and trying to ramp up and catch up from the backlog, we had to be very strategic in doing so. And there's no uniform way that people are doing this in their practices, whether private or academic, about triaging who is getting their diagnostic colonoscopy, for example, first, and who's getting their screening colonoscopy first.

27:12 DG: So we have to be definitely thoughtful as a practice, as a health system, in how we make sure that we address these issues, and certainly keeping those who are most vulnerable and at highest risk in mind. So I hope that kind of ties into some of your questions. And I did see there was a comment or question in the chat bar that kinda ties into this a little bit. It was a question about, "Well, do we have data on Cologuard?" and I think a lot of this experience with COVID-19, you'll definitely be seeing more and more papers and data coming out about the impact on stool-based testing and what impact that has had during this time.

27:48 DG: But certainly, even giving someone a stool-based test, we have to be able to tell them what's gonna happen next. So let's say it's positive, the next step is gonna be colonoscopy. Well, if you're not doing colonoscopies, what's next? Or if there's a backlog, what's next? So even I think doing stool-based tests, we have to be very thoughtful about what's the next step. Did I answer your questions, Usha and Bill?

28:09 BE: Yes, absolutely, and I'm glad you took the follow-up 'cause I was going to give that to you as a note. I guess, so that was a great overview of in the clinical setting. I guess, Andi, going back to some of your findings on sort of the thought process and the fears in the community, what are some of the things that are currently being implemented to help with some of this transition in the short term, and again, I guess the same question, which is, what changes in behaviors do you think are going to permeate once we come out of the other side of shelter-in-place orders, COVID, all of that?

28:44 AD: Right, so I think there's a couple of things right now in terms of what's happening. I think a number of organizations and particularly Fight CRC for the colorectal cancer community actually did real-time updates weekly, and I think that's something... Let me... My video likes to shut me off on occasion where I think it thinks I'm having a bad hair moment. So, apologies, thank you Gray. So I think right now, the responsiveness that's happening is essentially getting updates about basically the elective procedure ban, what that means for patients, how patients can be effective in scheduling what people can ask for in terms of non-invasive tests. So FIT and FOBT, Cologuard, stool DNA testing, talking to folks a little bit about what they should expect for delays and then ultimately advocating for folks, particularly I think those who might have public insurance and uninsured, to talk a little bit about access and advocacy efforts around those, around the health disparity component.

29:49 AD: So I do think, Fight Colorectal Cancer, the American Cancer Society, Cancer Action Network and others, have actually done really proactive opportunities to talk with health insurance commissioners throughout states, working through the advocacy component to also say that for people who do have FIT and FOBT testing or non-invasive testing, if they are positive, that can oftentimes launch a co-insurance or a payment out-of-pocket. So there's actually some great efforts happening right now to say, how can we reduce the fiscal barriers for paying out-of-pocket for the procedures, even if a follow-up colonoscopy is needed. I think in addition to really dealing with the anxiety, and ultimately thinking about some of the pieces that come out, I think part of the idea is really thinking... I think there's some trepidation and anxiety about using technology on occasion within the patient community, and especially older folks.

30:45 AD: So we're trying to get the word out about how to actively use tele-medicine. And that ultimately using phone and video capability will give a greater opportunity for people to be seen and heard through Telehealth visits. There's currently some information being disseminated, talking about that being probably an opportunity that provides care in the future, and how do we really make that access and to teach folks about that opportunity for engaging in healthcare and how to be active participants.

31:15 AD: I think with the Fight CRC survey that's coming out, we saw almost 80% of the providers talked about using ultimately Telehealth and the like, and that the medicine of that means to disseminate the care through that manner. So I think that's something that we really thought a bit about around how do we really engage folks in a meaningful experience based on the lessons learned. And I think what's interesting is when we first started at the height, or actually at the beginning of the pandemic, we did have a number of discussion with our psycho-social health providers, our psychologists and folks to say, "What are we gonna do around the fear and the anxiety and the unknown, and how do we deal with that strong sense of... There's a sense of urgency and really, really looking mortality in the eye again, the same way that I did with the cancer diagnosis?" And so we've been having some discussion in some level, what we're up against is different in some ways, but that idea of resilience, self-efficacy, the idea that you do have the opportunity with telehealth, and other opportunities to really connect with your provider, that there is a lot of empowerment in that opportunity, and really having patients in the driver seat to drive their own health is something that we've really been... Really centered on.

32:28 AD: But in addition, trying to provide timely and real information for the community is something that we've also really made sure that we stress, again, around timely updates, what's going on with the medical care, how the pandemic did change people's response to the type of procedures that they were able to receive, and the like. And I do think that, honestly, in terms of webinar and patient education, it's also providing forums for patients to connect and share their concerns, and really have that supportive care element. So for instance, Fight Colorectal Cancer had put into play a Wellness Wednesday they really did talk about the opportunity that even if folks feeling are isolated because they are immunosuppressed or had the shelter-in-place that was really fairly restrictive at the time, how were their opportunities for mindfulness, how was their opportunities for physical activity. Things like journaling, and the like. And so that's what we've tried to do in terms of rounding it all out. So I think I covered it all, Bill, right?

33:28 BE: I think you did. Yes.

33:29 AD: Okay.

33:30 BE: But I actually... You make an interesting point there, which I'll start with Usha to ask the question which is... And I wanna bring some positivity to the world with everything that's going on, but I have this feeling that a year from now, whatever it is, there's this profound transformation happening, and we're all consumers of the healthcare system, and I think... I would ask all of you, what do you think we should anticipate as what's coming next? Because I assume, hopefully, there'll be a lot of positive transformation. You mentioned this focus on wellness and mindfulness from a consumer of healthcare standpoint, pushing on the adoption of telemedicine and really driving that curve, but I'm curious for the people listening, what are some of the other positive outcomes we think are gonna be a result of the time that we're in now?

34:20 UP: Go ahead, Dr. Gray.

34:21 DG: Oh, thank you. I was gonna say, I think that the time we're in now has really highlighted disparities that for some who... For which it's been convenient to ignore, it's, you can't ignore it now. And so the positive thing is, I think, really we have an opportunity, we have some momentum to push us closer to health equity. And so I think even as we're thinking about those who are not at high risk, but certainly keeping those who are vulnerable in mind, I think we're gonna raise all votes, but hopefully it will be at a place where everyone has an equal and just opportunity to be as healthy as possible. And so I think whether it's... We're talking about COVID-19, and cancer or the both of them together, I think really what's happening and what I'm seeing is that there's a lot of energy and there's funding, and there's enthusiasm going towards addressing this.

35:16 UP: Yeah. That was a great point. I agree. You can't fix what you don't measure. And so if you are not aware of what problems exist, it's really hard to address solutions to them. And I think Coronavirus has helped highlight some of the problems in our system, but also has highlighted some solutions. Telemedicine is a great one of those, and I think we have learned quickly in the pandemic that honestly, access to telemedicine isn't the same throughout the United States, but that's an addressable problem that now that we understand it, that as telemedicine grow, we can also expand telemedicine access. Similarly, I think, if you don't understand how all these socio and economic factors play into your care, you're not going to be able to address the changes that come with them. And so just being aware of this, I do think that there's a new movement towards awareness, and this is a big change to our healthcare system. As a country, we are already starting to discuss healthcare policy, and we're starting to discuss efforts to expand healthcare access. And I think having a catalyst like this will spark more discussions, and hopefully more change.

36:31 AD: And Bill, I think the one thing I wanted to add... One of the things that was really interesting is although patients were very concerned about the health of... Their health related to COVID-19 and their families, one of the things that I also thought was interesting is when we did look at the trends and Fight CRC about materials and information that was being downloaded, we still had people who were facing ultimately a diagnosis in this period of time, were thinking about how do they still continue to have access to treatment, and the like. So I do think one of the things, I think, to your point that we shared about what we've learned and around the disruptions, and who's being affected is that although Coronavirus and COVID are really an issue, also just not losing sight of the matter-at-hand, that ultimately colorectal cancer diagnosis is also something that people are really facing, and that we, as an organization, also need to be thinking about what are those specific needs for the populations that we're working towards or that we're supporting and working towards supporting their needs.

37:38 AD: I think that's something that became also apparent is that it's really keeping both things balanced and thinking about how we talk and what support we bring that losing... Or that we shouldn't lose track, also, of what are those acute issues that might be really front-and-center... Independent of the... Not noise, but all of the work that's happening around the prevention and components around COVID. I think that's one of the things that we learned for sure, is we have to keep track of the real needs of our specific communities.

38:11 BE: Awesome. Well, we're just about out of time. On behalf of Komodo, I wanna thank all of our speakers for joining us today. This was an awesome discussion and very informative. For those of you listening, we will be sending out a follow-up with the recording to today's presentation, so you can share with your co-workers and your colleagues. And we just like to thank you for spending some time with us this afternoon. Be well. Be safe. And thank you for joining. Have a good day.