Working In Oncology
Working In Oncology

Episode · 1 month ago

Navigating COVID-related Surgical Delays for Oncology Patients w/ Joshua Shaw

ABOUT THIS EPISODE

In the midst of a pandemic, many patients are finding themselves making difficult choices: Should I go to my biopsy follow-up and risk catching COVID?

Unfortunately, many patients feel the risk isn’t worth it to visit a medical facility. But this is creating huge implications when it comes to diagnosing and treating high-mortality diseases like liver and pancreatic cancer.

Dr. Joshua Shaw, Transplant Surgeon & HPB Surgical Oncologist at Broward Health, joins the show to discuss his experiences, including ways to avoid delays in surgery, encouragement for those still avoiding in-person appointments, and new developments in surgical oncology.

Here are the show highlights:

- Patient tips & best practices to prevent delays in treatment (2:41)

- The evolving definition of operability & what it means for cancer patients (6:16)

- How COVID-19 has delayed treatment for cancer patients (13:27)

- What to say to patients who are afraid to come in because of COVID (17:16)

- How Dr. Shaw deals with stressful situations (23:50)

Check out these resources we mentioned during the podcast:

- J1shaw@browardhealth.org

- https://www.browardhealth.org/services/transplant-services

To hear more interviews like this one, subscribe to the Working In Oncology Podcast on Apple Podcasts, Spotify, or your preferred podcast platform.

...o You are listening to working inoncology. A podcast and video show that spot lights, oncology, practice, staffand industry influencers who work behind the scenes to shape the futureof oncology, the more knowledge the oncologycommunity shares with each other, the more we all grow, let's get into theshow, welcome to working in oncology. I'myour co host, Alisa Evans, I'm joined here today by Josh, Dr Josh Shaw, he'sa transplant, surgeon and H, P B, surgical oncologist at Broward Hell.Thank you very much for having me, Dr Sea, happy to have you ker. Welcome tothe show, I'm excited about our conversation. You were able to providesome really interesting insights into pancreatic and liver cancer and howwhat that looks like from a surgical perspective. Yeah go ahead! No sorry! That's okay! So Dr Shot, if you couldjust give us some information before we jump in a little bit about yourbackground and what you do sure so, as you said, I'm a abdominal transplantsurgeon. I focus primarily right now on liver and kidney transplant and livingdonation on the oncology side of what I do. I deal primarily with liver cancers,biliary cancers of the gold ladder and the bile ducks, and then cancers up thepancreas as well. Okay, so all Domina, and so what brought you into oncology?What inspired you to on college is an incredible field. It's current, it'salways involving, and it's one of the few feels similar to transplant. Thatreally has a multi disciplinary approach. So it's not surgery is theend ill be all, but it is. It is truly a team approach with every otherspecialist who deals in oncology, whether it's medical oncology,radiation oncology and all of the you know, Ancelin support teams that wehave working together to come up with what is the very best way to treat thispatient and sometimes that include surgery and other times. Importantly,it doesn't include surgery, so you know, I think, it's important to know thedifference of when to do which- and you know it's like I said it's- it's rare-to see that in most surgical specialties, a field that works asclosely with our medical colleagues, as we do in Sergeran, cology andtransplant for that matter as well say, you're, all working as a team for thepatient, of course, but well being so often there's like a handout right. Soyou go from one specialty, medical oncology to surgical and so patientsyou know they're doing that that hand off what are some ways from like themedical accolitis perspective, handing it off to you that we can help patientskind of hit the ground running right and prevent any delays in treatment.Sure. So I think one of the biggest problems we see in surgical oncology ispatients are often referred to a surgical oncologist for a valuation ofyou know for the t in the example of pancreatic cancer. Is You know, they'llcome and see me and they'll have a report or a read of their ct scan, butyou know I need to see the actual images and usually that delayseverything an entire visit. So, for instance, when you go to see yoursertion cologist, you know no matter where you had your ct scan or pet scanor whatever the imaging you have available. You want that on a disk, andyou want that in the hands of your surgeon because they look at it in avery different way than say a radiologist. Would we're looking at itin the sense of is this respectable, but where would our margins be andinformation like that that you don't always get from a report? So I thinkthat's that's one way, and then the...

...other is actually making sure they'recoming with the right scans is the right. The right protocole imaging. Soyou know for pancreatic cancer by the CCM. The national, Comprehensive CareNetwork has guidelines of what our best practices for a pancreas with thephases of it and the the thickness or the slices in which they cut that Ct.So each time you click the button you're only moving, you know about halfa million zero point: five millimeters at a time versus a normal s, t scan isanywhere in the neighborhood of three to five millimeters. So that's alsoreally important to make sure you don't just have the images imaging with you,but you get the right imaging done on it so to kind of arm our patient and tohelp them have the best experience when they have that consultation with you.We need to, of course examine the N CC end guidelines and then make sure wehave our pay our patients to have the actual, not a report, but a disk ofe.The images correct and I think, when patients come and see me that that'sall they want to know to start it's. It's can you take this out? That'squestion number one and then the how the the when and the war all thatfollows. But you know if I can't answer question number one. Everything elsebecomes a hypothetical question of. If this is good, we'll do this this andthis and it leaves a lot of uncertainty, which you know obviously- and you know,pancreatic cancer is a very aggressive cancer that has, unfortunately a veryhigh mortality rate associated with it, and it causes a lot of anxiety inpeople and coming to see someone and not being able to tell them what thenext steps are definitively. I think is really challenging exactly so. Withoutthese we're looking at publish, possibly extending the time totreatment right a week's months, possibly right, depending on when thepatient can come in again, absolutely yeah so again on patient treatment.Last time we talked, we talked about operability and how that what the whatis considered operable has changed so much for pancreatic and liver cancers.Can you tell us a little bit more about these companies changes or thesedevelopments sure so I'd say that the the definition of aoperability has really evolved. More so in the setting of pancreatic cancerthan liver cancer, but in pancreatic cancer. Historically, there werecertain elements of an granted cancer that if certain vessels were involvedin to a certain extent, how much involvement there was would be what you,what you would call a hard stop for a case, meaning you would not go forwardwith doing that operation. It was considered futile and it was consideredthat there was no survival benefit to doing something which is you know, froma surgical oncology standpoint. That's one of the driving factors behind everydecision we make is if there's no survival benefit. If the patientdoesn't get a you know, a significant advancement for or prolongation oftheir life at a high quality. Does it make sense to do something? Andhistorically, if certain vessels were involved, people would say this is notinoperable pancreatic cancer and almost certainly condemning them to to death,and what has has happened over the years and in part it was done more onthe international scene, as people began, repecting cancers that orpancratic cancer that people thought were not respectable and have actuallyshown very similar outcomes to the other patients who have respectablecancers. That aren't that different, and you know the Canadians, the UK. TheEuropeans have have shown that fairly definitively at this point and in theUnited States we've evolved here as far...

...as what our practice patterns are, ofwhat we consider receptable now. So there are and to be fair, if you have,if your medical oncologist has never had a a surgeon who takes thesepatients on, they may not know that and be doing practices that are consideredor which is unfortunately a disservice to those patients that they may havesomething. That is, in fact respectable. That again, someone practicing you knowtwenty years ago would say it's not respectable and back then that was theright answer. But today it's changed. A little bit and that's one of the thingswe've seen you know when I was in training, you'd, say the five yearssurvival from Ankra cancer. All comers was in the twenty percent neighborhood.Now it's about thirty percent, and you know you look at the medications andthe regiments for using there's, not a head, there's, not a ton of difference.What I believe is different today than twenty years ago, is we're being muchmore aggressive with who we take to the operating room. And again you see thatimproved. You know overall survival again, it's it doesn't benefiteverybody, but you have an overall improvement and survival which Ibelieve is related to that. So are you saying? Is it something?That's happened in the last ten years, the last five years. Are we lookingfurther back yeah? To be honest, it's really institution specific. You haveplaces in this country that are huge cancer centers that are very set intheir ways of how they do things and and have adopted new practices veryopenly, but you also have smaller centers that have been for lack ofbetter words. Boutique type places that do these operations and as a result ofthat they don't evolve, they've been practicing the same way. It may be oneor two surgeons there that do those operations, and you know if you weren'ttrained to do it, you're not going to do it unless, unless someone hasactually shown you how- and I can tell you- there are a number of H, P, bsurgeons who deal with pancreatic cancer, who are very uncomfortable,doing vascular resections. So how do you know if a surgeon has has receivedthat training? I would ask them. I think that start with that- and youknow the other things they've shown in pancreatic cancer and it's it'schallenging, because if you do more than fifteen of these operations a yearyou're considered a high volume center, not just a high volume surgeon, but ahigh volume center. So there are surgeons who are doing less than that.You know they may do five whip. A whipple is the the name of theoperation which takes the head of the pancreas, or you can do what's called adistal Pan cry attack to me. It's you. Take the tail always tell patientsthink of the Pan Cris like a fish. It's got a head body and tail, and you knowabout. Seventy percent of the cancers are in the head, the other thirty givertaker in the tail. If you do about fifteen of these a year again, you'reconsidered a high volume center. So if you have two surgeons at that center,and each of them are doing about seven giver, take that's not a lot and againyou have some very high volume centers that do about a hundred plus of these ayear. So I think that's important as far as where you go. Those are thingsas a patient. I would want to know is not just how many the the individualsurgeon does, but how many they do at that center they've shown in theliterature. The high volume centers actually have significantly improvedoutcomes, and it's as much as you know as a surgeon. I always wanted tobelieve those things were because of me, but it's actually, the nursing theyhave. The nurses are able to recognize when problems are happening, theyrespond more quickly or they have fewer episodes or events where you know quoteunquote: Failure to respond where something happens and people just letit go because they don't realize it it's a harbinger of something. Evenworse about to happen. That's one of...

...the things you'll as a patient or as afamily member certainly want to know is how much that individual surgeon doesand how much or how many of these operations that center does, and ifit's less than fifteen or twenty, I would be very careful about having itdone it wherever that is, and it's not to say those surgeons and centers maynot have excellent or be excellent at what they do. But you know by thenumbers alone. Those are those are concerning features that makes sense amore the more cases you see, the more you have more experience you have andthe better you get you develop your own best practices absolutely, and so wecovered nineteen has changed so much right and so many of us had a have hadto adjust the LY. We practice we've had to move to tell a medicine. We can'thave as many support staff or rather a family, of support for our patients inthe office as we used to what are the ways that the kind of the recentpandemic has affected your practice. I know you can't do virtual surgery, but how has it changed your your work, lifeyeah, so that the pandemic has really changed the face of medicine and insouth Florida. There was a period of time here where it was really bad,where the hospitals were flooded, with ovid patience and as a result of that,other patients did not want to come to come into the hospital, and you know Isaw in my practice, patients coming in with biopsy, proven or or highlysuspicious ct scan, suggestive of pancreatic or liver cancer that werecoming to see me later and later. Normally, when someone gets diagnosedwith something like this, you see them. You know they're, calling you as theyleave. You know the emergency room or the restaurant. I lit yeah ether, theywant that out, and you know the for the first time and in my practice I waswatching patients come in, who were getting diagnosed three to six monthsprior which, when you think of the median survival of these some of thesecancers, it is three to six months. So, when they're coming in having waitedthat long, it's it's. You are so far behind the eight ball. At that point,it's it's incredible and you know patients were more afraid of Ovid thanyou know, quite literally, a terminal disease process for almost everybodywho gets it. You know compared to you know, coved, which in Covin are veryserious and potentially lethal problem for many people, but it's still a aminority of the people who actually get it. The vast majority are totally youknow fine compared to you know I can't say the same about and granted canceror liver cancer, and so it was really a shock to watch patients coming in thatwere so delayed, and then you know with oncology where you have this multidisciplinary approach, it's true across the board. So, instead of someoneseeing me a day or a week after they see their medical oncologist, it's Ieverything gets backed up further and further so which again, usually thesurgeon is one of the not the last but one of the last people you see, usuallyin that pathway, getting worked up for a cancer, so it was. It was shocking.Honestly. I think there was a you know, a lot of delayed care for a number ofpeople, fortunately that that is subsiding in south Florida. I can'tspeak to the rest of the country, but I'm sure other you know other healthcare professionals and other surgeons deal with what I deal with saw verysimilar things, and it's there's an untold number of deaths that I'm surehave happened. Because of that I mean I can think of all the people who stoppedgetting screening colonoscopies and you know for every hundred colonoscopiessomeone does they find a cancer if all the sudden you're not doing themanymore, it doesn't mean you know colon cancer just stops. Those things arestill happening. So you know, there's there's an untold number of people whoare really adversely affected by Ovid,...

...without maybe even getting coved itself,but because of the environment it created. That was the Lazin treatmentand another delay Nan let or delay yeah. So what do you in so our patients whoare hesitant about taking the next steps intheir treatment because of coronaviruses? They don't want. Ofcourse no one would want to be sick, but what do you suggest that we say tothem and they say? Oh well, I don't want to go on for surgery. You know Idon't want to expose myself to corona virus. What? How should be? What shouldwe say to them? So I would start by saying that they should be vaccinated.I think that's important whether and it actually goes for family members aswell, that are going to be dealing with a critically ill or potentiallycritically ill person, who's, maybe had surgery or as a result of chemotherapyor radiation, is a Muno compromised. I would start with that alone of getvaccinated so that that that fear can can subside, and you know I wouldencourage them not to wait that pancreatic cancer has a much highermortality rate than coved, and you know waiting is it's like waiting with aticking time bomb inside of you, and you know you need you need enough timeon the clock to fix it. If you wait long enough it, it goes off and when itgoes off it's you know, you can't put it back together. At that point, Ithank you for that. Maybe some phrases there that we can use pass on to ourpatients to encourage them to continue and to kind of speed up their processes.So are there any other adjustments that you've had to make because ofCurrentius Yeah? One of the things I have done is when we actually getreferrals for patients with a new diagnosis of cancer. One of the thingsI've done is, I called the patients and encourage them to come in and be seen,and you know things that truthfully are not pleasant phone conversations tohave with people, but I think is necessary in order to get them to one to hear it, because sometimes thatthat's another piece that often happens is people will come into a medicaloncologist office, a Gast, runers or radiation on college or radiologists,interventional regality, and they may have a biopsy done and a lot of times.People come and see me and they haven't actually had their results from theirbiopsy told to them. Oh- and these are things that are usually you know,patient portals or my chart or any of these kind of electronic versions of ofour medical record that patients can access some. Some centers will holdthese from being published there, because if someone pulls it up and theysee a new cancer diagnosis, he them about. You can imagine that thatgenerates a lot of phone calls a lot of tansit. So there are some systems thatwill withhold that until the ordering physician releases it. So a lot oftimes you know someone may buy opsis mething and the patient has no ideawhat was found there and you know again, those are not conversations meant to behad over a telephone or but in the in the age of Ovid, when people are Refinoknow very hesitant to come in because they don't even know they have aserious problem. Yet that becomes you know something that I've adopted, whereI will call people and let them know that not necessarily what theirpathology shows, but that they need to be seen, and you know to go over whatwas found on on their biopsy. Whatever the procedure was, if there wereconcerning finding staring at a CT scan and have found that patients are fairlyresponsive to that when someone actually reaches out and and talks withthem about those things, those are the the big things. The other things from asurgical standpoint is any of our patients coming in for electiveoperations, they're all getting tested for Ovid beforehand- and you know ifsomeone tests positive there they're not disqualified from getting surgery,but other precautions are put into place. As far as what rroom, whatoperating rooms they go into and what...

...part of the hospital they go into sofortunate Broward is a very large hospital system and we had veryspecific parts of our operating rooms and our hospital itself that weredesignated specifically for patients with Ovid to keep patients who didn'thave covin. You know I separated from each other, but also being able toprovide the same level of care for both sets or both cohorts of patients.Exactly sounds like there's a lot of changes, but you've had to adjustment.You mentioned earlier vaccines. If you have a patient who is coming in, do youencourage them? You encourage them to get vacated, but is it a requirement oryeah? No, it's certainly not a requirement. I think it is a lot easier.Knowing someone has had a accint in this in the sense that a lotof things and I've seen vascular surgeons, talk about this, that you seecertain. There are certain. I don't want to say phenomenon, but there's alot about ovid. We don't know some people who get it. Are they more hypercoagulable or they do? They have certain other concomitant problems thatwe just you know, because it's so new, we don't realize it yet. So I think,knowing that patients are vaccinated, you can take a lot of those things offthe board. More factor that you don't have to yeahconsider, and I can tell you I can think in a number of patients that,when they start to do something that again, whether it's part of the courseor not when it when they start to get unusual findings or something that youknow, I've heard a lot of people say: Oh, it's probably ovid and there's nota lot of pure Ervier literature or evidence to support that. But at thesame time we have these findings that are unusual, that we can explain and wehave a new virus out there that we also. You know, we understand someone, but wedon't know a lot of the long term effects and things like that. So Ithink it's you know again, it's not mandatory. It's certainly, I think, formy end makes things a bit easier, but it's not mandatory, but I think from apopulation health standpoint, it's important to be vaccinated absolutelyand the vacation numbers are climbing, so more and more of your patients willbe coming to you already vaccinated yeah oncology is such a stressful field. Youare dealing with extremely ill patients. How do you manage your in stress? Oh so.Oncology is now stressful when you compared to transplant so transplantsat very strange oncology. For me, it's very relaxing, but no, I personally enjoy it very much. Iactually don't find it particularly stressful. I truly love what I do soare there stressful situations there are, and I find dealing with them headon the most common stressful situations usually come under the cloud ofcommunication with patients and families and there's a lot of anxietyand fear that go along with again a cancer diagnosis like an create cancer.Where you know, if you, Google, pancratic cancer, you don't see o now,O things. You know when People Google, the surgical procedures that I perform,you know they have a high morbidity and mortality associated with them and andthat scares people, and that that you know for my patience, is an incrediblystressful event. You know I view my job is to educate them and I think withineducation comes a certain. You know it helps to subside some of some of thatanxiety, certainly not all of it, and I think all patients are somewhatdifferent. But for me personally I don't get that stressed out and that'sprobably for the better or for the best of my patience. Absolutely if you cankeep your calm and keep your cool, you can communicate and share that calmwith your patients. They must be very...

...grateful to have such a calm coolcollected surgeon. You know you know I was. I was told in my training yearsthat when everyone else loses it, that's the most important time for youto stay. Cool people will often look in whether it's in the operating room orthe clinic or the impatient setting they they look to their physicians,whether it's a surgeon or not, but to set the tone and if you're stressed outor you're running around it transfers to the patients it transfers to thenurses, the rest of the team- and you know, ultimately, I think those thingslead to worse, potentially, worse outcomes and worse experience forpatients and their families, and you know as anyone who's gone through it. Acancer diagnosis, no matter how how the outcome is, is a stressful period oftime in their life. So I think it's important that you know they're at aplace where they're comfortable- and you know the team. There does not addto that stress if anything helps to to correct it. So thank you for thatadvice. This has been a really great conversation for any of our listenerswho want to reach up. You Know Foth, follow up questions what's the best wayfor them to do that. So can I leave my email? I can add it to. The show noteswill that work. That would be perfect. So I'm a my email, it's j, one Shaw atBroward Health Doto work. If you can add it into the notes and I'm happy torespond to emails. If you type in you know South Florida Transplant Center orSouth Florida transplant HPV, Sergical Gy Center, our group should pop up, butI'm more than happy to respond to emails directly with any patients,families or just independent folks out there who have some questions about pancratic cancer neuro under cinter ofthe pancreas liver cancer, liver transplant of Pan Cris transplant. Allthose things I'd be more than happy to discuss with any of your your viewers,Wol, that's very generous! Thank you. So much our audience will surely begrateful for that. I thank you for being a guest on the show. Thank youfor having me. This is great. I think it's great what you do and it'simportant to get. You know this type of education out there into the world.You've been listening to working in oncology to ensure that you never missan episode subscribe to the show in your favorite podcast player, if you'relistening an apple, podcast, we'd love for you to leave a quick rating of theshow just tap the number of stars. Do you think the podcast deserves? Thankyou so much for listening until next time. I.

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