S1E1 | Opening up America: What does this mean for cancer patients?
Dr. Pat Basu: Hi, I'm Dr. Pat Basu the host of Focus on Cancer, a show that focuses on the everyday questions that cancer patients have. It is a pleasure today for me to welcome the Chief Medical Officer of Cancer Treatment Centers of America, Dr. Julian Schink. Dr. Schink is a world renowned cancer expert and it's a delight to have you on the show. Dr. Schink, how are you today?
Dr. Julian Schink: Dr. Basu, thank you for having me. I'm going to slip my mask off which I wear really all the time that I'm in the hospital. I wear that during these COVID- 19 pandemic times to help keep both our patients and our stakeholders safe. So thank you for having me today.
Dr. Pat Basu: So Dr. Schink, there's been a lot of talk around opening up America and the milestones, the phases, the guidelines. Can you share with us as an expert in cancer care, what are the key guidelines or the tenets of opening up America?
Dr. Julian Schink: Well, thank you for asking me that question, because I know there's a great pent up demand. People are ready to get back to the world that they know and love and the activities that they want to do. The key guidelines in my mind though, are to continue to practice that which we have learned in the last eight weeks, continue our social distancing, that's still relevant. COVID is still out there. It didn't go away. We flattened the curve because we learned about social distancing. Wear a mask when you're out in public, that mask protects you. When I say you, I mean my mask protects you, your mask protects me. So wearing masks decreases the chance of getting COVID or spreading COVID. Do hand hygiene, it is critically important and it has been shown over and over again that washing your hands as many as 10 times a day, can significantly lower your risk of getting this virus. So do those things. And then finally, respect your environment. Respect the fact that there are others around you, the groups that you go into, the settings that you put yourself into, the more people that are around, the more risk you have.
Dr. Pat Basu: So is it safe to say that it doesn't have to be one size fits all, it doesn't have to be all or nothing, you can go out as long as you're practicing some of these tenets that you mentioned?
Dr. Julian Schink: Absolutely. And I think they will continue to evolve, and we will continue to learn more and more about what is safe and what isn't safe. And that's the beauty of it. So we continue to get better at this. We continued to figure out how we as a community can do the things that we like to do, and yet keep ourselves and our neighbors safe. So absolutely. It's not one size fits all and it's not black and white. It's a new world that we're learning to live in and we can do this. We can succeed at this.
Dr. Pat Basu: What are some of the policies and procedures that you use to keep patients safe?
Dr. Julian Schink: First of all, we've learned a lot about COVID. There's certainly much yet to be learned, but we've learned a lot. And one is you notice that I was wearing this mask when I came up. And so we have learned that wearing masks is a really important component to staying safe. And it not only keeps me safe, it keeps you safe. I wear this mask for you and you wear your mask for me. And it really works to decrease the chance that I might shed virus to someone around me, someone that I'm seeing, or caring for, someone I care about. And likewise, you wearing a mask decreases the likelihood that I would be receiving virus that you have and didn't know you had. So that's certainly one step. But there's really four elements to this and the mask is one. So social distancing helps. Hand hygiene is incredibly important, and whether that hand hygiene is 20 seconds of washing your hands with soap and water, or the use of alcohol products, which are much more abundant now and much more available. That hand hygiene needs to happen many times a day and certainly after any close encounter with other people or with potentially contaminated surfaces, although it's the encounters with other people that are certainly most important about that. And then the last component is really a social awareness. It's our screening of people as they come and go from our hospitals, by doing that we have had remarkable success in avoiding people bringing COVID in from the outside. And as you know, our patient population, the cancer patient population is at increased risk for the complications of COVID. So these safety measures are doubly important to us.
Dr. Pat Basu: Dr. Schink, you mentioned some really important procedures that you've implemented as a medical leader to keep patients safe. Can you talk a bit about the role of testing? Both specifically for cancer patients inaudible hospitals as well as just generally across the country.
Dr. Julian Schink: Absolutely. So testing right now falls into two categories. And so the first one is, how do we test people going forward to keep them safe? And what we're doing in that regard... And when I say keeping people safe, I'm talking specifically now about our cancer patients. So before we do anything to or for a cancer patient where they might be at increased risk if they had COVID and didn't know it, we are testing those patients. So what do I mean by things where they could get in trouble if they didn't know they had COVID but actually did? So we know that patients who have major surgeries and have COVID have significantly increased complications. So we're testing those patients before their surgery. We're testing them generally late or later in the day right before their surgery, so that we don't have any surprises.
Dr. Pat Basu: Dr. Schink, you and I both used to work for general health systems that then had emergency rooms and treated all aspects of disease. Both of us still have many friends who are physicians or leaders of those hospitals. Is there any difference for a cancer patient in terms of going to a cancer specialty hospital, like Cancer Treatment Centers of America versus a general health system during this pandemic?
Dr. Julian Schink: So absolutely. I mean all we do is cancer, patients with cancer, patients who might have cancer who need directed screening tasks, or surgeries to rule out cancer. We are not an acute care hospital where someone with a cough and shortness of breath is going to walk in the door. So we do not have COVID people appearing at our front door and that really keeps our patients and our caregivers and our stakeholders safer. It makes a huge difference. And it has allowed us... I don't want to say it's business as usual because it's not, we have all of these new safety measures in place. But we haven't lost a beat when it comes to taking care of cancer patients. We're full on in business providing cancer care and we're doing it in an environment where we don't have the noise of COVID within our walls. We have much less risk of somebody having any kind of cross- contamination, because the patients just are very unlikely to be here.
Dr. Pat Basu: I have had the privilege and I know you have to have of speaking to so many patients and cancer patients in a care setting. And the number of patients that I've spoken to with emotional stories of not being able to get their care during these last couple of months here has really been emotional and tragic. And I'm glad that we've been able to help so many of them, but there are just so many more than have had their care disrupted. So let's go back a couple of months ago to some of the earlier guidelines that were put into place across the country and across states. Some of them unfortunately confusing to both patients and even to providers. How did those early guidelines affect cancer patients?
Dr. Julian Schink: Well, sadly, some of them really put a halt on cancer patients receiving the care that they needed or deserved. And that kind of waiting is so painful for patients who either have cancer and know they're waiting, or someone who's concerned they might have cancer. I know you've heard me say before that in my mind for a cancer patient waiting is suffering, waiting for a test result, waiting for a treatment, waiting to know what's going to happen is just so difficult when you know you have a life threatening illness. And so those early messages of just stop, don't do anything, cancer patients are at huge risk. What they're at huge risk for is cancer. It is true that if a cancer patient gets COVID, the complications are much higher. That said, they still need their treatment. And so it was unfortunate in the early days, some of those mixed messages were a barrier. We were able to work past those barriers, but it was a bit unfortunate.
Dr. Pat Basu: Thank you for sharing that. Even recently the American Cancer Society has shared studies that said that maybe half of cancer patients have had significant disruption in their cancer care. There's recent data to suggest that there's been a dramatic decrease in cancer patients being screened and inaudible potentially the cancer diagnoses are down 20, 25, 30%. Can you talk to us about this idea of the decrease in screening, the decrease in receiving care. What might be the medium and long- term effects of that on the cancer population if this doesn't get quickly reversed?
Dr. Julian Schink: Yeah. The consequences of that delay could just be terrible. Really sad. Cancer screening works because it moves cancer from a late diagnosis when it is symptomatic and you can't deny that you have it, to an earlier diagnosis when it's treatable and curable. And so those cancers, whether it be breast cancer, or colon cancer, in particular cervical cancer as another example, those cancers are much more treatable when they are in the first stage or in a precancerous stage than they are later. And by standing in the way of that, unfortunately, some people will go from treatable or curable to harder to treat, less likely to cure and so that's unfortunate. We've got to move past that. We have to adopt a new normal, where we can continue to provide that kind of preventative care in the background of COVID staying safe. Using those safety measures I talked about. If we continue to rely on our four safety measures of face masks, and social distancing, and hand hygiene, and screening in this environment, we can then safely provide these cancer prevention strategies and the time has come to do that.
Dr. Pat Basu: Yeah, I very much agree. As physicians, we often think about the risk benefit analysis. And during a pandemic during a crisis sometimes the one side of that equation gets over- weighted. But certainly cancer is the definition of a very serious life threatening condition and one that is incredibly common and far too common with one out of every three Americans who are going to be diagnosed with cancer in their lifetime. Can you talk about how a patient should think through this risk benefit ratio? You mentioned earlier that cancer is the serious condition that unfortunately will almost certainly affect them and in the long run be life threatening. How should we think about the risk benefit analysis of having a diagnosis of cancer in a time of COVID?
Dr. Julian Schink: You've got to treat the cancer or most cancers not all, but the vast majority will kill you without treatment. And so it is absolutely imperative that you get that treatment and ideally you do it in an environment that respects your risk for COVID and protects you and does everything in its power to help prevent you getting COVID or having to deal with that at the same time. Again, we have the advantage at a single specialty hospital of doing that in a safer environment, no environment's perfectly safe, but it certainly is safer.
Dr. Pat Basu: You mentioned something earlier I wanted to come back to and it's very important in my mind. You mentioned that a given patient who, if we were to catch their cancer, let's say three months later or six months later because of a disruption in their diagnosis, how might that affect their likelihood of survival potentially for a given patient, or if they were to survive, how might that impact the quality of life for the next several months? Can you talk about the exponential increase in mortality and morbidity that occurs as a cancer progresses over time?
Dr. Julian Schink: Well, yes and no. So there's no question that when we catch cancers earlier, the treatment options that are available, the organ preserving treatment options, using breast cancer as an example, if we do lumpectomy and radiation or other local therapy, that's certainly far more acceptable to many people than more radical surgery like mastectomy. Avoiding chemotherapy that might be required if you had metastatic disease, find it earlier, avoid the metastatic disease, much higher chance of being cured. Do we have numbers? We don't have numbers because thank goodness, have never done the experiment of saying, " Hey, I think we're going to wait on your treatment for six months or so and see what happens." We don't know what happens when we delay. Sadly, we might someday look back on this time and say, " Oh, what happened to cancer in 2020 when there were delays? What happened to survival?" I would hate to think what we may discover. I hope that's not the case, but people really can't put this off.
Dr. Pat Basu: Yeah, I agree with you. It would be tragic if we were to look back a year from now or three years from now, and there is some study that shows an increase in cancer mortality due to patients dying from not getting the treatment that they need. And fundamentally the morbidity would increase too. So is it safe to say Dr. Schink that a given patient who might've been eligible for a lumpectomy, their cancer progressed they now had to have a bilateral mastectomy. That their recovery would be longer, the likelihood that they might miss important life events, a marriage of a granddaughter, a graduation of a grandson. That even if they were to survive their morbidity, their quality of life could be decreased if their care is delayed?
Dr. Julian Schink: Yeah, I mean certainly delaying care is getting an increase all of those factors. The social disruption as well as the medical consequences. Now having said that, I don't think that fortunately at this time, that the eight weeks of delay are going to have those dramatic results or consequences. The story is if we don't get back to business quickly and soon, then those will begin to mount. That's the real challenge that we face. Now having said that, as you know, people don't usually start their journey with an oncologist, right? They start their journey by going to see their primary care doctor or someone who says, " Gee, I've found a problem." Or going for their screening mammogram or screening colonoscopy. And so we need society to get back to that sense of normal as well. Now I will say primary care doctors are ramping up and they're doing their tele- health and they're really getting a lot smarter about that. In the process of doing that, obviously we can't have them neglecting cancer screening, nor do we want them to postpone any of the diagnostic tests that might be necessary to identify cancer. Because as you know screening is one part but responding to a patient's symptoms and ordering the workup is the other part of making cancer diagnosis. And we can't let that wait either.
Dr. Pat Basu: In other words, what you're saying is so many cancers are detected indirectly, or because they went to a primary care physician or a physician of another sort. A dermatologist, a gastroenterologist, et cetera, with symptoms or maybe an incidental finding that led to their diagnosis of cancer. So if patients are putting off all their medical care or the treatment of generalized symptoms, it's possible that, that could lead to a delay in their diagnosis and a delay in their treatment.
Dr. Julian Schink: Yeah, absolutely. And sadly I know that patients are worried about seeking out healthcare with their primary care providers and others. I mean, I spoke with my father yesterday who is putting off going to see his primary care doctor, because he doesn't want to go into an office. I said, " Well, do a telehealth visit. But if you're having symptoms you kind of talked to your doctor about it." So as you know, there are symptoms of cancer that people need to be aware of, and they need to respond to whether that symptom is bright red blood in your stool or its new shortness of breath, new abdominal pain that wasn't there before, a mass that you feel that you didn't feel before. These are all signs or symptoms of cancer that people can't suppress or put off because of the threat of COVID. We've got to respect those symptoms and people do. But then it's time to say, " Okay, I'm going to go see my doctor."
Dr. Pat Basu: Dr. Schink, you've done a lot of work in the areas of risk assessment and risk stratification. The idea that different patients obviously have different risk factors for getting a disease. In the context of cancer on one hand and COVID on the other, just for the general patient, can you give us some guidelines in terms of how one might think about if they don't have an active diagnosis of either disease? They don't have an active diagnosis of cancer, they don't have an active diagnosis of COVID. In those camps, how might a patient think about assessing their risk? Let's start with cancer.
Dr. Julian Schink: Right. Well, so we certainly know that one in three Americans will develop cancer in their lifetime. We've got to acknowledge that and respect that, that's a fact that's life- threatening. Because if you ignore it, it can kill you. There are screening tests to help lower the risk of dying from skin cancer with skin surveillance. Those skin cancers include squamous cancers and melanoma, but they require an exam by a professional who's directed that way. We can significantly lower the chance of dying of breast cancer with appropriate breast exam and mammography, even greater impact on lowering the risk of colon cancer with colonoscopy, or with testing with things like cologuard. Either of those is appropriate for colon cancer screening. Cervical cancer, as you may know, 50 years ago before pap smears, more than 50 or 60 years ago now, before pap smears was the second most common cause of death in America for women in America, cancer death for women. And that has fallen way down the list because pap smear screening prevents cervical cancer death, but you got to get a pap smear to do that. So all of those risks are real and they haven't stopped for COVID. People have to continue to pursue that screening. We can prevent those cancers in particular.
Dr. Pat Basu: That's very helpful. Let's move to COVID- 19 side. If somebody is sitting there somewhere around the country and they have a set of medical conditions on one hand or they have cancer as a diagnosis. But they're wondering what their risk factors might be for contracting COVID- 19 or getting extra ill if they were to. What are some of the risk factors that you might advise a patient to think through in terms of COVID-19 risk?
Dr. Julian Schink: Well, so there's the risk of getting COVID and then there's a risk of having life- threatening complications from COVID. Right? And so the risk of getting COVID certainly is related most importantly by your social interactions. Your ability or inability to do social distancing, how concentrated is your housing situation? Are you with people? Can you stay relatively isolated with just those people who you know and who are not going out too much into the general public, versus people who are out in public and have lots of exposure? So that is the risk factor of getting COVID. We also know though that younger people appear to be at somewhat less risk, both of getting COVID really young. Now I'm talking about kids, under age 18. Seem to be at less risk of getting it and much less risk of having serious consequences. On the other end of the spectrum as we age or have comorbidities, our risk of life threatening complications goes up. So when I say comorbidities, it's a medical word for saying what else is wrong with you medically. If you have diabetes, if you have high blood pressure, if you have heart disease, especially heart failure. If you have asthma, chronic obstructive pulmonary disease, which probably means you smoked too much earlier in life. Those people have a lot more consequences if they get COVID and it's a much more life threatening illness. Cancer is on that list. It can be high the list. It doesn't have to be high on the list. I get upset when they generalize and say, " Oh, you're a cancer patient. You're at a horribly high risk." That actually isn't quite true. Some cancer patients whose immune system has been impaired either by their cancer or their cancer treatment are at higher risk. Others, if their cancer is gone and it was treated, possibly treated surgically and had no impact on their immune system, really aren't at that much higher risk.
Dr. Pat Basu: That's a very helpful point, Dr. Schink. So in other words, what you're saying is that the type of cancer that you may have had, as well as the type of treatment that you may have had, a patient should not really think of their COVID risk as just being cancer or not, but really the risk might be different for lung cancer, versus ovarian cancer, versus prostate cancer. And furthermore, it might be different if you had surgery alone versus chemotherapy. Is that what you're telling our viewers and listeners?
Dr. Julian Schink: Yeah, absolutely. If you had breast cancer 10 years ago that was treated with surgery and maybe some radiation or maybe not and you've been fine for 10 years, your risk complications of COVID aren't any different than someone who's your age. On the other hand, if you had an acute leukemia and were on significant chemotherapy four months and then had a bone marrow transplant, and you're just finished all that treatment six months ago, your immune system has not fully recovered and you are definitely at much higher risk. So those are two ends of the spectrum and people sort of layer out in between. I don't want anyone to be cavalier about COVID, don't get me wrong. But I also don't want people to be paralyzed to think that they're prisoners in this world just because cancer crossed their path at some time in their life.
Dr. Pat Basu: That's extremely helpful. You've taken care of so many cancer patients over the years and certainly you've taken care of many over the last couple of months. Before we move to many of the direct questions we've received from patients, can you just share some advice that you would have. What's the one piece of advice that you might share for a cancer patient during this time?
Dr. Julian Schink: Well, it goes back to the things that I mentioned at the top of this show, which is by combining these protective measures, wearing a mask, social distancing, hand hygiene in particular and then finally paying attention to symptoms that either you or someone that's close to you, someone that you're interacting with, have. If you use those tools, pay attention to them. We can come out of this, okay. You can protect yourself. And that's the key. You can keep yourself safe. Now, I don't want people to say, " Oh my God, I got COVID. It's my fault." That's not true either. None of us have complete control of our environment. And I don't want people to feel like I victim shamed them if they got COVID, it wasn't their fault. But there are things you can do to lower your risk. And I think that's really important.
Dr. Pat Basu: Dr. Schink as chief medical officer, you've already led the practice of the safest and high quality medicine before the COVID pandemic. You've done an exceptional job keeping patients cared for and safe during the pandemic. And now as we enter this open up America phase, given your expertise and your incredible success in doing this, what advice do you have for other providers or hospitals as they enter the open up America phase?
Dr. Julian Schink: As you know, at Cancer Treatment Centers of America, we were never closed. We've been open for business all along and that gives us the advantage of knowing what works and what are those things. A single point of entry where patients and the caregivers who come with them are rigorously screened for signs and symptoms of COVID, and their temperature's taken. Masking for our patients and their caregivers, as well as masking for our stakeholders, those people on our sites, So two way masking. Those things significantly reduce the risk.
Dr. Pat Basu: I'd love to move to some of the direct questions that we get from patients. We have a lot of questions that have been submitted and I think it's a tremendous opportunity to be able to ask such an esteemed expert like you Dr. Schink some of these questions. So here's one that I think is a pretty good segue in terms of what you've just been talking about. It's one that we get a lot. How safe is it, this patient wants to know, for her to travel by airplane? Can you talk generally about your thoughts on that matter?
Dr. Julian Schink: Yeah. Well, certainly right now with so few people traveling, it is relatively safe and again, wear a mask, practice hand hygiene and I can't tell you how many times, carry your alcohol wipes or your alcohol hand sanitizer, and your Lysol wipes. And you can be relatively controlling your environment. It's not perfect, but it's relatively controlled. And having said that, we have patients who travel to see us and I ask those patients, did they feel safe. What was their environment? And they share with me that in fact, for the most part, they do feel pretty safe. The airplanes are pretty empty, and the flight attendants and the staff in the airports have become incredibly respectful at least from the patients that I talked to. And so I think it's reasonably okay. Now, I'm not planning any vacations to Europe or China right now, but I think that for people who need to travel, they can. They can do so safely.
Dr. Pat Basu: That's helpful. In recent weeks, I have been very impressed with the measures that airlines and airports have put into place to respond and increase the level of safety. So I appreciate that response. Here's another one that we've gotten from a patient. The submitted question says, " If I have tested positive for COVID-19, can I come to Cancer Treatment Centers of America for treatment?"
Dr. Julian Schink: Absolutely. That said we want... And we have had patients who tested positive for COVID- 19, including patients who have shown up at our door with symptoms, were detected or diagnosed by way of our screening at the front entry and tested, and then they are quarantined if they have had COVID- 19 for two weeks. When we know that their fever has resolved and their symptoms have resolved for an adequate period of time, then they can be tested.
Dr. Pat Basu: A followup question from a patient that I think fits pretty well with that is, " If I'm coming in for a treatment, what should I do to prepare?"
Dr. Julian Schink: Monitor your symptoms, because if you suddenly have COVID symptoms, let us know. And to that end, we actually contact people in advance and talk to them to make sure that they're still well. We want to test you. We want to make that you can in fact safely pursue this rather than pursue the COVID treatment. So that's what you need to pay attention to. We have created what I perceive to be a safe environment to come into and we are very careful about that. So people should feel comfortable coming into this treatment environment.
Dr. Pat Basu: And would you say that even if somebody has had their treatment before somewhere and their treatment got disrupted in terms of continuity of care, is that something that you feel comfortable and still being able to transition care, if a patient has barriers or some reason why they can't get in?
Dr. Julian Schink: Oh yeah, absolutely. I mean, there are certain cancers where if you stop the treatment in the middle, you really lose ground and eventually that earlier treatment you've had becomes meaningless. Not right away, but those delays are really hard on the ethicacy of a cancer treatment. This is especially true in radiation, but it's also true in part with chemotherapy. I think it's safe to say that nobody's surgery got stopped in the middle, I think we can say that with some degree of humor. But short of that chemo and radiation should not be interrupted.
Dr. Pat Basu: Another patient question that I wanted to pose to you is Dr. Schink are opening up America guidelines affecting all of your hospitals in the same way?
Dr. Julian Schink: We have five hospitals around the country, so the number of COVID cases or the incidents of COVID in each of those regions is different. That said, certainly in Chicago land, Philadelphia, Atlanta, they have seen a fair bit of COVID and that has tamped down or made those communities pretty aware and heightened awareness of that. Now it's a new world. Right now all of a sudden we're opening up America and restrictions are changing and people might be coming more. They're moving around more, they're more willing to come in. How does it change what we do? I don't see it having a dramatic impact. Personally, we are still screening at the front door. We're wearing masks. We're putting in place those safety measures that are absolutely necessary, and I think we're going to be doing that quite a while yet. We have become more willing to allow caregivers access to patients in the hospital a little more liberally as America's opened up. But that's the main change.
Dr. Pat Basu: Well, Dr. Schink we're running close to time for this segment. Is there any final thoughts or advice or guidance that you'd like to share for our viewers and listeners?
Dr. Julian Schink: Yeah. Sure. I'd love to just sum up by saying cancer doesn't wait for COVID. COVID is clearly a threat to all of us in some way, but a bigger threat would be to not get your cancer treatment, one. Two, we still have to continue our healthcare. We have to do those things that keep us healthy. So even if we were to get COVID, we're in a better shape to deal with it. Waiting for cancer treatment, really, causes suffering. Causes suffering for the patient, causes suffering for the patient's family. We have to do everything in our power to continue to treat people the way they deserve to be treated. And then finally, and I've said it many times in this show, but it can't be said enough, wear masks, it's not a sign of shame. My mask protects you, your mask protects me. Continue to do social distancing. Any distance helps. Six feet's better than three feet, but any distance helps. Hand hygiene, hand hygiene, hand hygiene, and avoid those social situations that might put you at risk. Too many people, whether it's too many people in an elevator, too many people in some closed space. If you can avoid that, you're going to be better off.
Dr. Pat Basu: I just want to thank you so much for taking the time today to spend with me answering these questions for our listeners. I know so many valuable insights and a lot of great advice.
Dr. Julian Schink: Well, thank you for having me. Certainly, my pleasure.