Coronavirus in Context: Why It's so Important to Resume Cancer Screening and Care

[MUSIC PLAYING] You're watching Coronavirus in Context. I'm Dr. John Whyte, Chief Medical Officer at WebMD. Have you been delaying going back to the doctor? Maybe putting off that colonoscopy or mammogram? What's the consequences of that delay?

To answer these questions in the field of cancer, I've asked Dr. John Deeken. He is the president of Inova Schar Cancer Institute. Dr. Deeken, thanks for joining me.

Thank you, John. Good to be here.

- You know, for a long time, we were telling patients, don't come to the hospital. Now we're telling them come back to the hospital. It's OK. It's safe. That can be confusing to patients. So what's the latest on the recommendations about how they decide whether or not to come back to the hospital or to the physician's office?

That's a great question because it's been a confusing and struggling time for, for all of us, for our families, for our neighbors, for ourselves, and for our patients. I think the good news is, we've learned so much over the last four months about the virus, about protections that we need to impose, about effective screening, about the role of testing.

So we've learned so much, I think. And, and every health system has struggled with this. But I think we've gotten to our new normal whereby we've created a safe environment for patients to come to the emergency room or be in the hospital. For getting surgeries, and certainly for getting cancer treatments, and also screenings now in a safe and effective way.

So I think we've provided those environments and those precautions to make it safe for people to return for those aspects of care they should not postpone. And certainly cancer treatment, cancer screening are, are areas that we should not postpone.

You know, we've been talking on the show that, you know, in many ways, a hospital or a cancer center right now is safer than a grocery store, or is safer than a lot of other places. And we're saying the reason why that is, is everyone's getting temperature checked. There is good infection control. Trying to control physical distancing and not having people typically in the waiting room as usually would occur pre-COVID.

Help us understand. You know, how do we convince patients that it is safe to come back? We can say it is. But, but how do we help them recognize that?

You bet. I mean, I think a good thing that, that a patient should do before they go in is ask the questions to the clinic staff when you're making your appointment. What are they doing for the precautions? Are they doing temperature checks? Are, is everyone wearing a mask?

Are they having people sit in the waiting room for a long period of time? Or are they rapidly getting people from their car to the exam room so that there isn't that waiting in that larger area?

I think those, like any good consumer, you can ask those tough questions. And if you don't have, get good answers, then think about whether you should go in or change the place of care. Most places--

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--we've learned so much that most places have put in place, very effective, those screening technologies, those pathways, and those mechanics of, of allowing patients to, to, be, you know, to not have to wait, to not have to wait in, in, in, uh, in public areas with a lot of, uh, other patients in waiting rooms. That sort of thing. So that's a tough question.

That's a good thing because we were used to waiting--

Right.

--a long time. And--

Right.

--and cancer centers such as yours typically had separate entrances--

Right.

--than someone who would go in with symptoms of COVID. You know, Dr. Deeken, I want to get to this issue of screening. For those patients who don't know whether or not they have cancer or don't have signs and symptoms of cancer. So we're talking about screening.

And you know, we've interviewed people early on in March. And they would say, you know what? It's OK to wait a month or two for your mammogram. But now we're approaching three, four months.

What happens is people don't come back at all this year. They may lose their insurance. In some areas, mammograms are down, correct, 75, 80, 90%, even colonoscopies. Help our listeners understand. What are the consequences?

The huge advance in cancer care over the last 30 years has been early detection and by screening. And we talked about screening, we're looking for early stage tumors or precancer lesions that might turn into cancer.

And we know that our whole cancer staging system we have is set up to better understand cure rates and treatment modalities. So if you have a stage one early cancer-- high cure rate. Easily treated. Probably only needing one modality of treatment, just surgery or just radiation.

Where if it's higher stage, the prognosis is worse. And, and that's a time issue. That's, the, the longer a tumor has to grow, the bigger it can get, the more readily it can spread. So that's why screening and early detection have made our cure rates in the US so dramatically improved over the last 30 years, is by those initiatives.

And you know, for some cancers, every month matters. We're starting to see in our, for example, our melanoma skin cancer clinic, patients coming in with more advanced tumors. They're, they're deeper in the skin. They've already spread to lymph nodes. And that's probably because they weren't getting those screenings for those months. And that's a disease where months matter.

So we don't want to put off those kind of screenings now that we've learned to create the safe environment for patients to come in. Back in March was a different thing. But now, we have, we have these safety precautions.

You don't want to put off those screenings that we know save lives. You know, across our society and individual patients, it saves lives. So we can't, we shouldn't be putting those off if it's safe where you are.

You know, National Cancer Institute estimates an excess of 10,000 cancer deaths due to delayed screening. You know, other organizations have put it at even higher, 50,000 60,000, you know, excess cancer deaths.

You know, patients are trying to evaluate risk. Let's be honest. They're saying, I don't want to go in to a center or an office or a hospital because I'm scared of getting COVID. Right, versus, you know, I need to get my colonoscopy. Which you and I know people, you know, I still see patients-- that's something they're always canceling. They forgot the date. They didn't have a driver to, to--

Right.

--to take them.

Right.

They don't like the prep.

Right.

So really, to reinforce when you're weighing, weighing risk-- and correct me if I'm wrong. You know, everyone's a little different. You have to estimate the risk with their position. But the risk of catching COVID, you know, for screening, is, in a cancer screening, is much less than perhaps missing an early stage cancer that could be receptive to early and aggressive treatment.

By all means. And you know, much of what we could do for screening is a combination of in-person and virtual. A lot of times, that discussion you can have with your primary care physician about what screening is appropriate and the timing of that. That can be done via virtual telemedicine visit.

Obviously the colonoscopies, the mammography, the breast exam, the prostate exam, all that needs to be done in person. One cancer screening in person with CT scans. But again, most places have set up so by, you know, that, that one stop quick shop for things like a CT scan, a mammography, or a colonoscopy is done rapidly.

And oftentimes, especially for procedures, patients are being tested prior to those procedures for COVID. And obviously all the staff are protected and wearing high degrees of personal protective equipment to keep the patients from being exposed. So those are being streamlined at most centers so that, again, the risk is minimized as much as possible, as much as possible. And certainly the need to catch early lesions far outweigh those those risks at, again, at most centers now in our country.

COVID infection, as we've learned, is, is high risk. And for certainly older patients, higher risk in terms of outcomes. But cancer, left to its own devices, can be a death sentence. So we don't want to put off those colonoscopies and those mom, mammographies.

And again, the timelines for those are no, no less than every 10 years for a colonoscopy. No less than one to three years, depending on your age, for a mammogram. We don't want to push that much more than that because, again, tumors left to grow will be higher stage and they'll have a lower chance of cure.

What about some of these apps for skin lesions? Are those adequate, in terms of getting checked out for potentially melanoma or others? Or are they leaving some things behind?

That's a great question. Because our dermatology team here, for example, is one of the teams that really couldn't make the jump to a high degree of virtual telemedicine visits. They need to see the lesions under the, the microscopes they use in the clinic.

So our clinic in, in melanoma skin cancer and screening is more than 90% in person. And again, set up to be very safe for those patients that come in an come out. It's really hard to see the nuances of what could be a benign lesion versus an early cancerous lesion versus a full blown squamous cell, basal cell, or melanoma cancer lesion. And, and, and, I would not, we're not there yet with any sort of virtual evaluation of those.

But now that those clinics have opened, back open, that's oftentimes needs to be in-person. Again, done in a safe way. But we want to catch those abnormal lesions early and treat them at the early stage.

And those apps serve a, a different wall. And certainly, in discussion with their physicians.

I talked to a physician a couple of weeks ago. And you've been an oncologist for many years. He's actually had a neck surgery. And he would talk about almost once a week for the last 15 years, he would see a patient who presents with previously undiagnosed no cancer lesion.

And for the last four months, he hasn't seen anyone that's presented that way. So where are those patients going? It's not all of a sudden, you know, we're having a decreased incidence of cancer.

You know, I think that's the concern that many clinicians have. That delayed care then becomes they don't come back year, two years, maybe not until it's much, at a much later stage. Have you had that experience over your career?

Oh sure.

In terms of--

Oh sure. Am I, I, I, focus on head and neck cancer, as you mentioned. And, and, the average time from when a patient-- and they're, and they're mainly males. Most patients who have cancer are males. And you know, we're probably not the most aggressive in terms of seeking primary care or screening care as a gender.

But the, the average time between a patient noticing something-- a bump in their neck, a soreness in their throat-- is nine months between that symptom onset and being diagnosed with cancer in the US, nine months. And that time doesn't help. It's probably been brewing for years before that.

But by the time it got big enough, and building the cancer cells enough to be symptomatic, that's when exponential growth of that tumor is going to increase the risk for it spreading locally, and then distantly. And as soon as it spreads, spreads elsewhere, we can no longer cure it. So if you add to that nine month average delay four, six, more months because patients don't want to come in because of COVID, then again, the risk of that is, is increased.

I think there are certainly many patients. And we're certainly seeing it in some of our disease areas. Where that nagging problem or that delayed screen is still being put off. And we'll see over time how much that increases the higher stage presentation of cancer patients, and therefore the decreased cure rate. But unfortunately, that's going to be in the rear view mirror when those patients have already suffered worse outcomes.

And, and, and that's why it's our job as physicians-- and I thank you for this sort of discussion-- to highlight this for patients. It should be safe now. Check it. Make sure you're comfortable with the safety. But don't put it off. So I, we we, we often see that across the board. And I do think we're seeing it now, unfortunately even more.

Let's talk about for a minute or two those patients that already had cancer. That perhaps the treatment regimen has been interrupted or changed by the COVID pandemic. Perhaps they were changed from an IV to an oral medicine and they had some anxiety about that. Or you know, an elective surgery on, in terms of an aspect of their cancer treatment has been delayed. And in some areas, we're seeing cancellation of surgeries again.

How do they deal with, you know, these changes? And what do you expect, you know, in the next month or so in terms of a greater resolution to kind of pre-COVID treatment of cancer?

Great question. And I think, you know, as we're seeing this evolve and becoming a bigger issue in parts of our country, in the South and the West. There are a lot of lessons we learned early on in March, April, May from the Northeast and the, and the Northwest. And all of our cancer societies have put out recommendation about how to handle a newly diagnosed cancer patient in this era.

And we've pivoted pretty well, I would say, as a community to things like, if you can't do surgery right now because the hospitals are overwhelmed, do the chemotherapy first. Because a lot of our cancers, you can do chemo first, then surgery. Or surgery, then chemotherapy. And if they are equally curative, then you can alternate delivery of care to-- and, and, and keep out of the hospital, if your hospital is that overwhelmed right now.

So we've learned a lot. And a lot of the societies have given us guidance based on the data we have to say what is safe, and how we can alternate that therapy to make sure we don't delay, but we maybe stagger what is done first versus second versus third.

Again, we've learned a lot. And, and, and that we can deploy I think at this time. Because again as you say, a lot of hospitals, a lot of health systems might not be able to do that, that surgery that is a suspected cancer surgery.

But if we have a diagnosis, a biopsy, then we can move forward with treatment. Radiation, chemotherapy first. And then that surgery gets kicked down the road a few months. And then hopefully things are better by that time, if your area is a, is a current hotspot.

Are we going to see more cancer care delivered in the home?

That's a great question. I think there's a lot of people looking at that. For chemotherapy, you know, it's an interesting area right now. Where certainly we're having more and more--

Yeah, we used to think they couldn't have it at home. And now--

Right. So I think that, I think there's a lot of interest in certainly oral chemotherapies and how we monitor those and continue those from home. Most of our chemotherapy drugs, even newer immunotherapy drugs that are much safer, that, that have fewer side effects, they still have some risks in terms of acute events during infusion. There's the rare patient who has an allergic reaction that we need to be there if that happens.

So I'm, I'm worried there might be pushes from either payers or from patients who want to get that care at home or not in a setting that can provide that urgent delivery of resuscitation if they have a bad reaction to a medication. So I think there's a lot of attempt at looking for that. I hope we don't use COVID as an excuse to provide lower cost care that might not be as safe or as good.

And it's our job as the physicians to you know, call balls and strikes about what's safe and what might not be if we're getting pushed to do that from, from, you know, insurance companies. And, and it's our job to convince patients of what's necessary to keep them safe when they come in, but still having them come in for some of that acute care.

Now we've seen, at our cancer center, you know, we took a obviously a, a pivot quickly to telemedicine early on. But our, our active treatment chemotherapy radiation sort of stayed fully active because all those patients that needed care didn't change on, at, at the end of March when all this started.

So, so that's, we've learned a lot in, in I think in providing that care. And we can reassure patients that, that, it is safe to come in for that. And they definitely, if they have cancer, should not delay treatment in any stretch.

Well, Dr. Deeken, thank you for taking the time to reassure patients about the importance of those screenings. About the importance, as you talked about, dialogue with your physicians. Hospitals and physicians' offices and cancer centers are by and large safe to go back to. You, you want to look at the individual one and talk to clinicians. Any other tips for our listeners?

No. I think just stay safe. And be assured that we're learning a great deal along the way. This is a difficult journey for all of us, for our country, for our families. But we've learned a lot. And, and we're doing-- and it's up to the physicians I think to reassure patients and put those safety precautions in place. But cancer didn't stop for COVID, so all of us oncologists haven't either.

Know that it's safe and cancer screening, cancer care is, is as important as it ever was. So talk to your physician. Get, get your screenings done. And if unfortunately you have cancer, be, be assured that we can do that in a safe way despite COVID for as long as we have to deal with this.

Dr. Deeken, President of the Inova Schar Cancer Institute. Thanks for joining me today.

Thank you. Thank you, John.

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