Working In Oncology
Working In Oncology

Episode · 1 year ago

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


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:



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

You're listening to working in oncology, a podcast and video show that spotlights oncology practice staff and industry influencers who work behind the scenes to shape the future of oncology. The more knowledge the oncology community shares with each other, the more we all grow. Let's get into the show. Welcome to working in oncology. I'm your cohost, Alicia Evans. I'm joined here today by Josh Dr Josh Shaw. He's a transplant surgeon and hpb surgical oncologist at Broward Hell. Thank you very much for having me. Hi, Dr Shaw, I'm happy to have you here. Welcome to the show. I'm excited about our convertation. You were able to provide some really interesting insights into pancreatic and liver cancer and how what that looks like from a surgical perspective. Yeah, go ahead, no, sorry, that's okay. So, Dr Show, if you could just give us an information before we jump in a little bit about your background and what you do? Sure. So, as you said, I'm abdominal transplant surgeon. I focus primarily right now on liver and kidney transplant and living donation. On the oncology sign of what I do you ideal? Primarily with liver cancers, billiary cancers of the gall bladder and the bio ducts and then cancers of the pancreas as well. Okay, so I'll dominal. And so what brought you into oncology? What inspired you to on colleges an incredible field. It's current, it's always evolving and it's one of the few fields, similar to transplant, that really has a multi disciplinary approach. So it's not surgery is the end all, be all, but it is. It is truly a team approach with every other specialist who deals in oncology, whether it's medical oncology, radiation oncology and all of the, you know, ancillary and support teams that we have, working together to come up with what is the very best way to treat this patient. And sometimes that include surgery and and other times, importantly, it doesn't include surgery. So, you know, I think it's important to know the difference 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 as closely with our medical colleagues as we do in surgical oncology. And and transplant for that matter as well. So you're all working as a team for the patients, of course, but well being so often there's like a handoff, right. So you go from one specialty, medical oncology, to surgical and so patients you know they're doing that, that handoff. What are some ways, from a medical oncolog it's perspective, handing it off to you, that we could help patients kind of hit the ground running right and prevent any delays in treatment. Sure. So I think one of the biggest problems we see and surgical oncology is patients are often referred to a surgical oncologist for evaluation of you know, for the in the example of pancreatic cancer, is you know they'll come and see me and they'll have a report or a read of their ct scan, but you know I need to see the actual images and usually that delays everything an entire visit. So, for instance, when you go to see your surgical oncologist, you know, no matter where you had your ct scan or pet scan or whatever, the imaging you have available, you want that on a disc and you want that in the hands of your surgeon because they look at it in a very different way than say, a radiologist would. We're looking at it in the sense of is this resectable? But where would our margins be, and information like that that you don't always get from a report. So...

I think that's that's one way, and then the other is actually making sure they're coming with the right scans. Is the right the right protocoled imaging. So you know, for pancreatic cancer by the NCCN, the National Comprehensive Care Network, has guidelines of what are best practices for a pancreas ct with the the phases of it and the thickness or the slices and which they cut that Ct. So each time you click the button you're only move moving, you know, about half a million, zero point five millimeters at a time, versus a normal ct scan as anywhere in the neighborhood of three to five millimeters. So that's also really important to make sure you don't just have the images imaging with you, but you get the right imaging done audits, so to kind of arm our patients and to help them have the best experience when they have that consultation with you. We need to of course examine the NCCN guidelines and then make sure we have our paid our patients have of the actual not a report but a disk of the images. Correct you, and I think when patients come and see me, that's all I want to know to start. It's it's can you take this out? That's question number one, and then the how, the the when and the where, all that follows. But you know, if I can answer question number one, everything else becomes a hypothetical question of if, if, this is good, we'll do this, this and this, and it leaves a lot of uncertainty, which you know obviously. In you know, pancreatic cancer is a very aggressive cancer that has unfortunately a very high mortality rate associated with it and it causes a lot of anxiety and people and coming to see someone and not being able to tell them what the next steps are definitively, I think, is really challenging actually. So without these we're looking at probas possibly extending the time to treatment right, weeks months, possibly right, depending on when the patient can come in again in absolutely yeah. So again on patient treatment. Last time we talked we talked about operability and how that what the what is considered operable has changed so much for pancreatic and liver cancers. Can you tell us a little bit more about these these changes or these developments? Sure so. I'd say the definition of operability has really evolved, more so in the setting of pancreatic cancer than liver cancer, but in pancreatic cancer, historically there were certain elements of pancreatic cancer that, if certain vessels were involved into 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 forward with doing that operation. It was considered futile and it was considered that there was no survival benefit to doing something, which is from a surgical oncology standpoint, that's one of the driving factors behind every decision we make. Is If there's no survival benefit, if a patient doesn't get a, you know, a significant advancement or prolongation of their life at a high quality, doesn't make sense to do something. And historically, if certain vessels were involved, people would say this is a not inoperable pancreatic cancer and almost certainly condemning them to to to death. And what has has happened over the years and in part it was done more on the international scene as people began resecting cancers that or pancreatic cancer, that people thought were not reseptable and have actually shown very similar outcomes to the other patients who had resectable cancers. That aren't that different, and you know, the Canadians, the UK, the Europeans have have shown that fairly definitively at this point, and in the United States we've evolved here as far as what...

...our practice patterns are of what we consider receptable now. So there are and to be fair, if you have, if your medical oncologist has never had a surgeon who takes these patients on, they may not know that in be doing practices that are considered earlier, which is unfortunately a disservice to those patients, that they may have something that is in fact reseptable that again, someone practicing, you know twenty years ago would say is not reseptable, and back then that was the right answer, but today it's changed a little bit and that's one of the things we've seen. You know, when I was in training, you'd say the five years survival from pancreatic cancer all comers was in the twenty percent neighborhood. Now it's about thirty percent. And you look at the medications and the 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 much more aggressive with who we take to the operating room and again you see that improved. You know, overall survival. Again, it's it doesn't benefit everybody, but you have a an overall improvement and survival, which I believe is related to that. So are you saying is it something it's happened in the last ten years, the last five years. Are we looking for their back? Yeah, to be honest, it's really institution specific. You have places in this country that are are huge cancer centers that are very set in their ways of how they do things and and have adopted new practices very openly. But you also have smaller centers that I have been, for lack of better words, boutique type places that do these operations and as a result of that, they don't evolved. They've been practicing the same way. It maybe one or two surgeons there that do those operations and you know, if you weren't trained to do it. You're not going to do it unless, unleless, someone has actually shown you how. And I can tell you there are a number of HPV surgeons who deal with pancreatic cancer who are very uncomfortable doing vascular sections. So how do you know if a surgeon has had as received that training? I would ask them. I think I'd start with that. And you know the other things they've shown in pancreatic cancer and it's it's challenging because it if you do more than fifteen of these operations a year you're considered a high volume center, not just a high volume surgeon, but a high volume center. So there are surgeons who are doing less than that. You know, they may do five whip a whipple is the name of the operation which takes the head of the pancreas, or you can do what's called a distal pancreattack. To me it's you take the tail. I always tell patients think of the pancreas like a fish. It's got a head, body and tail. And you know about seventy percent of the cancers are in the head, the other thirty give or take, or in the tail. If you do about fifteen of these a year. Again, you're considered a high volume center. So if you have two surgeons at that center and each of them are doing about seven, give or take, that's not a lot. And again you have some very high volume centers that do about a hundred plus of these a year. So I think that's important as far as where you go. Those are things as a patient I would want to know is not just how many the individual surgeon does, but how many they do at that center. They've shown in the literature the high volume centers actually have significantly improved outcomes and it's as much as you know. As a surgeon, I always wanted to believe those things were because of me, but it's actually the nursing they have. The nurses are able to recognize when problems are happening, they respond more quickly or they have fewer episodes or events where, you know, quote unquote, failure to respond, where something happens and people just let it go because they don't realize it it's a harbinger of something even worse about to happen. So that's one of the things you'll as a patient or as...

...a family member, certainly want to know is how much that individual surgeon does and how much or how many of these operations that center does, and if it's less than fifteen or twenty, I would be very careful about having it done it wherever that is. And it's not to say those surgeons and centers may not have excellent or be excellent at what they do, but you know by the numbers alone, those are those are concerning features. That makes sense. Some more the more cases you see, the more you have, more experience you have and the better you get. You develop your own best practices. Absolutely, and so we covid nineteen is change so much right and so many of us had hat have had to adjust thely we practice. We've had to move to tell a medicine. We can't have as many support staff or whether family, a support for our patients in the office as we used to. What are the ways that a kind of the recent pandemic has affected your practice? I know you can't do virtual surgery, but how has it changed your work life? Yeah, so that the pandemic has really changed the face of medicine and in south Florida that was a period of time here where it was really bad, where the hospitals were flooded with covid patients and as a result of that, other patients did not want to come to come into the hospital. And you know, I saw in my practice patients coming in with biopsy proven or or highly suspicious ct scan suggestive of pancreatic or liver cancer that were coming to see me later and later. Normally, when someone gets diagnosed with something like this, you see them. You know, they're calling you as they leave, you know, the emergency room or their asking like yeah, there, there, they want that out. And you know, for the first time and in my practice, I was watching patients come in who were getting diagnosed three to six months prior, which, when you think of the median survival of these some of these cancers, it is three to six months. So when they're coming in having waited that 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 covid than you know, quite literally a terminal disease process for almost everybody who gets it, you know, compared to you know covid which in covids a very serious and potentially lethal problem for many people, but it's still a minority of the people who actually get it. The vast majority are totally fine compared to you know, I can't say the same about and grantic cancer or liver cancer, and so it was really a shock to watch patients coming in that were so delayed. And then, you know, with oncology, where you have this multidisciplinary approach, it's true across the board. So instead of someone seeing me a day or a week after they see their medical oncologist, it's everything gets backed up further and further. So it which, again usually the surgeon is one of the not the last, but one of the last people you see usually in 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 of people. Fortunately that that is subsiding in south Florida. I can't speak 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 very similar things and it's there's an untold number of deaths that I'm sure have happened because of that. I mean I can think of all the people who stopped getting screening colonoscopies. And you know, for every hundred colonoscopies someone does, they find a cancer. If all the sudden you're not doing them anymore, it doesn't mean, you know, colon cancer just stops. Those things are still happening. So you know there's there's an untold number of people who are really adversely affected by Covid, without maybe even getting covid itself,...

...but because of the environment it created those delays in treatment and another delay and and leather delay. Yeah, so what do you think? So our patients who are hesitant about taking the next steps in their treatment because of coronavirus. They don't want of course no one would want to be sick, but what do you suggest that we say to them that they say, oh well, I don't want to go on for surgery, you know, I don't want to expose myself to coronavirus. But what, how should be what should we say to them? So I would start by saying they should be vaccinated. I think that's important. Whether, and that actually goes for family members as well that are going to be dealing with a critically ill or potentially critically old person who's maybe had surgery or, as a result of chemotherapy or radiation, is immunocompromised. I would start with that alone, of get vaccinated so that that that fear can can subside. And, you know, I would encourage them not to wait. That pancreatic cancer has a much higher mortality rate than covid and you know, waiting is it's like waiting with a ticking time bomb inside of you and you know you need you need enough time on the clock to fix it. If you wait long enough it it goes off and when it goes off it's you know, you can't put it back together at that point. We thank you for that. Maybe some phrases there that we can use pass on to our patients 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 of coronavirus? Yeah, one of the things I have done is when we actually get referrals for patients with a new diagnosis of cancer, one of the things I've done is I called the patients and to encourage them to come in and be seen and, you know, things that truthfully, are not pleasant phone conversations to have with people, but I think is necessary in order to get them to want to hear it, because sometimes that that's another piece that that often happens is people will come into a medical oncologist off as a gastrunrologist or radiation on college or a radiologist Interventional Radiology, 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 their biopsy 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 our medical record that patients can access. A lot some some centers will will hold these from being published there because if someone pulls it up and they see a new cancer diagnosis that alb them about, you can imagine that that generates a lot of phone calls, a lot of anxiety. So there are some systems that will withhold that until the ordering physician releases it. So a lot of times, you know, someone may biopsy something and the patient has no idea what was found there and you know, again, those are not conversations meant to be had over a telephone. Or but in the in the age of Covid when people are refusing, you know, very hesitant to come in because they don't even know they have of serious problem yet, that becomes something that I've adopted where I will call people and let them know that not necessarily what their pathology shows, but that they need to be seen and, you know, to go over what was found on on their biopsy or whatever the procedure was if there were concerning findings during a ct scan, and have found that patients are fairly responsive to that when someone actually reaches out and and talks with them about those things. Those are the big things. The other things from a surgical standpoint is any of our patients coming in for elective operations, they're all getting tested for covid beforehand and, you know, if someone tests positive, they're they're not disqualified from getting surgery, but other precautions are put into place as far as what room, what operating rooms, they go into and what part of the... they go into. So, fortunate, roured is a very large hospital system and we had very specific parts of our operating rooms and our hospital itself that were designated specifically for patients with Covid to keep patients who didn't have covid, you know I, separated from each other, but also being able to provide the same level of care for for both sets are both cohorts of patients. Actually sounds like there's a lot of changes that you've had to adjustment. You mentioned earlier vaccines. If you have a patient who is coming in, do you encourage that? You encourage them to get vaccinated, but is it a requirement or yeah, no, it's certainly not a requirement. I think it is a lot easier knowing someone has had a vaccine in this in the sense that a lot of things, and I've seen vascular surgeons talk about this, that you see certain there are certain I don't want to say phenomenon, but there's a lot about covid we don't know. So people who get it, are they more hypercoagiable or they do? They have certain other com commit and problems that we 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 off the board, one more factor that you don't have to yeah, it'sider and I can tell you. I can think, and have a number of patients, that when they start to do something that, again, whether it's part of the course or not, when when they start to get unusual findings or something that you know, I've heard a lot of people say, Oh, it's probably covid and there's not a lot of pure reviewed literature or evidence to support that. But at the same time we have these findings that are unusual that we can explain and we have a new virus out there that we also you know, we understand someone but we don't know a lot of the long term effects and things like that. So I think it's you know, again, it's not mandatory. It's certainly, I think for my end, makes things a bit easier, but it's not mandatory. But I think from a population health standpoint it's important to be vaccinated. Absolutely end. The vacation numbers are climbing, so more and more of your patients will be coming to you already that scated. Yeah, oncology is such a stressful field. You are dealing with extremely ill patients. How do you manage your stress? Oh, so oncology is not stressful when you compared it to transplant. So transplants are very strongsful. Oncology for me is very relaxing. But no, I I I personally and enjoy it very much. I actually don't find it particularly stressful. I truly love what I do. So are there stressful situations? There are, and I find dealing with them head on. The most common stressful situations usually come under the cloud of communication with patients and families and there's a lot of anxiety and fear that go along with, again, a cancer diagnosis like pancreatic cancer, where, you know, if you Google pancreatic cancer, you don't see now you don't with things. You know, when People Google the the surgical procedures that I perform, you know they have a high morbidity and mortality associated with them and and that scares people and that that, you know, for my patients, is an incredibly stressful event. You know, I view my job as to educate them and I think with that education comes a certain you know, it helps to subside some of some of that anxiety. Certainly not all of it, and I think all patients are some went different. But for me personally, I don't get that stressed out and that's probably for the better or for the best of my patients. Absolutely, if you can keep your calm and keep your cool, you can keep unicate and share that calm with your patients. They must be very grateful to have such a calm, cool collected surgeon. Yeah,... know, I was. I was told in my training years that when everyone else loses it, that's the most important time for you to stay cool. People will often look in, whether it's in the operating room or the clinic or the inpatient setting. They they look to their physicians, whether it's a surgeon or not, but to set the tone and if you're stressed out or you're running around, it transfers to the patients, it transfers to the nurses, the rest of the team and you know, ultimately I think those things lead to worse, potentially worse outcomes and worse experience for patients and their families. And you know, as anyone who's gone through it, a cancer diagnosis, no matter how it how the outcome is, is a stressful period of time in their life. So I think it's important that you know they're at a place where they're comfortable and you know the team there does not add to that stress. If anything helps to to correct it. So I thank you for that advice. This has been a really great conversation. For any of our listeners who want to reach out, you know, foot follow up questions, what's the best way for them to do that? So can I leave my email? I can add it to the show notes. Will that work? That would be perfect. So I'm my email is. It's Jay one Shaw at Broward Health. dought to work if you can add it into the notes and I'm happy to respond to emails. If you type in, you know South Florida Transplant Center or self Florida transplant, HPV Surgical Oncology Center, our group should pop up, but I'm more than happy to respond to emails directly with any patients, families or just independent folks out there who have some questions about pancreatic cancer, neurunder corint tumors of the pancreas, liver cancer, liver transplant, pancres transplant, all those things I'd be more than happy to discuss with any of your your viewers. Well, that's very generous. Thank you so much. Our audience will surely be grateful for that. I thank you for being a guest on the show. Thank you for having me. This is great. I think it's great what you do and it's important 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 miss an episode, subscribe to the show in your favorite podcasts player. If you're listening in Apple PODCASTS, we'd love for you to leave a quick rating of the show. Just have the number of stars do you think the podcast deserves. Thank you so much for listening. Until next time,.

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