Cancer Care in the Community

April 19, 2021

Information

April 18, 2021

Yale Cancer Center

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email: canceranswers@yale.edu

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00:00Support for Yale Cancer Answers
00:02comes from AstraZeneca, dedicated
00:05to advancing options and providing
00:07hope for people living with cancer.
00:10More information at astrazeneca-us.com.
00:14Welcome to Yale Cancer Answers
00:16with your host doctor Anees Chagpar.
00:17Yale Cancer Answers
00:20features the latest information on
00:21cancer care by welcoming oncologists and
00:24specialists who are on the forefront of
00:26the battle to fight cancer. This week,
00:28it's a conversation about cancer care
00:30in the community with Doctor Anamika Katoch.
00:32Dr Katoch is assistant professor
00:34of clinical medicine and medical
00:36oncology at the Yale School of Medicine,
00:38where Doctor Chagpar is a
00:41professor of surgical oncology.
00:44Doctor Katoch, maybe you could start off by
00:47telling us a little bit about yourself and
00:49what it is that you do.
00:52So I'm a hematologist oncologist,
00:54and I work out of Smilow Waterbury.
00:56It's a small community setting we
00:59work out of a regional Cancer Center
01:01called the Harold Leever Cancer Center.
01:04So I'm a general community oncologist,
01:07and I see all kinds of cancer.
01:10The more common cancers,
01:11of course, are more common,
01:13so I tend to see those more than the others.
01:18But breast, lung, colon, lymphoma,
01:20and also some hematology patients.
01:22And so how common is cancer in
01:26the community?
01:27I mean when we think about
01:30cancers,
01:32very often we think about
01:35people going to large centers.
01:37New York, Boston,
01:39Houston, New Haven.
01:40But you're in a
01:42small Community Center.
01:44So how often does cancer present
01:47in those community centers?
01:49So it is surprising
01:51to see that cancer is very prevalent,
01:54and especially in the Waterbury area.
01:57I would say maybe because it
02:00has been an industrial town.
02:03And we do tend to see a lot of breast cancer.
02:06A lot of bladder cancer in this area as well.
02:11And yes,
02:12the bigger centers actually have
02:15the good fortune of having many
02:17good bigger centers around us.
02:19There's Memorial Sloan,
02:21Dana Farber.
02:23And certainly these are very useful and
02:25helpful for us when we have particularly
02:28tough situations where we need to
02:31get another opinion or some help.
02:34But I would say in the general Community,
02:37cancer is fairly
02:39prevalent and so many people,
02:42because cancer really doesn't discriminate
02:44based on where you live
02:47and many people may wonder,
02:51are there advantages and disadvantages
02:53to being treated closer to home
02:56versus going into a larger center?
02:58What would you say to people
03:01who are contemplating those
03:03decisions?
03:07It is important,
03:09especially for certain rare cancers
03:12to be seen at bigger centers that tend
03:15to see a lot more of those cancers.
03:19Sarcomas being one.
03:21They require a real multi
03:23disciplinary approach.
03:24You have to have surgeons who've
03:26done enough of those surgeries,
03:29trained radiation oncology team,
03:31trained chemotherapy
03:34professionals who've dealt
03:35enough of with that cancer.
03:38It is always patients preference
03:40to be treated close to home and
03:42nobody wants to drive 2 hours to get
03:44treatment because you know chemotherapy
03:47treatment is not just about chemotherapy,
03:49it's also about supportive
03:50care that goes with it.
03:52So we don't just see patients
03:54on day one and say OK,
03:56now we'll see you in three weeks.
03:58It doesn't work like that.
04:00So we see patients on day one,
04:02we're always available by phone.
04:04We are seeing them sometimes the very
04:07next day, sometimes within a week.
04:09Sometimes they need transfusion support.
04:11So it is a
04:12complicated and complex process,
04:14so patients preference is always
04:17to be treated in your home and I
04:20would say that we have very robust
04:23multidisciplinary teams for almost
04:25all cancers and we also recognize that
04:28some cancers do better when they are
04:30referred out to tertiary centers,
04:32one major example being acute leukemia.
04:37It is a cancer that requires
04:39a lot of resources.
04:41A lot of support,
04:42a lot of experience and
04:44people who have acute leukemias
04:46tend to do better when they're
04:48treated at tertiary care centers,
04:51so this is also recognizing
04:53what are your limitations.
04:55And what are the patients that
04:57you can best serve and which
04:59patients will do better if they are
05:01referred out? And so I guess the
05:04take home message there is that if
05:07a patient has a cancer that they can
05:10be seen at a Cancer Center in their
05:13community and that Community Center
05:16will have no hesitation about referring
05:17them out to a larger center if that's
05:20in the patients best interest.
05:22That is absolutely correct and a
05:24lot of times it is driven by physicians.
05:27Sometimes it's driven by patients,
05:28but I have to say that patients
05:30often feel uncomfortable telling
05:32their physicians that they
05:34want to get a second opinion and
05:37part of it will also depend upon
05:39your approach to the patient,
05:41and we're sort of very open about it.
05:43We understand
05:45that this is cancer.
05:46It can be a life changing diagnosis.
05:48So we we will often say to our patients,
05:51if you would like another opinion,
05:54please let me know
05:56and I will help you get one.
05:58So sometimes people do elect to get
06:00another opinion and lots of times
06:02people say no,
06:03what you're saying makes sense if
06:05they've already developed a
06:07sense of trust and confidence in you
06:10they will stay with you
06:12and be treated close to where they
06:15live and so are there particular
06:17cancers that are particularly amenable
06:19to being treated closer to home.
06:21So you mentioned that the rare cancers
06:23might be ones where you want to seek
06:26a second opinion, but are there
06:29certain cancers that
06:31you think, if you have
06:33for example, breast cancer or colon
06:36cancer that that those really can
06:38be treated closer to where you
06:40live that you don't necessarily
06:42need to go to a larger center.
06:46That is absolutely true.
06:47It of course depends upon
06:50the strength of your surgical
06:52staff and your surgical support,
06:54because a lot of these
06:56cancers do need surgery.
06:57So if you have a trained
07:00oncological surgeon on staff who
07:02is equipped to do these surgeries,
07:05then I think these cancers can
07:08be very well handled in the community.
07:12And what questions should
07:13patients be asking of their
07:15team of doctors if they are
07:17seen by a Community cancer program,
07:20what questions should they be asking in
07:22order to make the best informed decision
07:24as to where they should be treated?
07:28That's a good question,
07:29but can be a little bit tricky.
07:32I don't know if patients
07:34would entirely feel comfortable
07:35sometimes asking their physicians
07:37what their experiences
07:39in treating this cancer are.
07:40And I do get that question,
07:42but very occasionally,
07:43but I think it is important for
07:45patients to get involved in their
07:47care and ask these questions,
07:49and I think a lot of times people don't
07:52ask this question because they feel that
07:55they are going to offend the physician.
07:58Which sometimes may be true,
08:00but most times is not.
08:04So I think it's fair enough
08:06to say, Doctor,
08:08do you treat a lot of these cancers and
08:11it's sort of a ubiquitous question.
08:15How do patients generally do?
08:17Do you think I need a second opinion?
08:20So I think these are all fair
08:22questions to ask and say,
08:24do you work with the surgeon closely?
08:27Do you know if he's done many surgeries?
08:29Is it possible for me to speak
08:32to someone who has
08:34gone through this process?
08:36Also, just basic questions that might help
08:39keep patients well informed.
08:41And I think that that's so important
08:44that patients really do advocate
08:47for themselves and truthfully,
08:49many Community programs actually
08:51do have the infrastructure to be
08:54able to provide good quality care
08:56for the more common cancers.
08:59So you mentioned, for example,
09:01that you have a multidisciplinary
09:04team tell us more about how
09:06that works in the Community
09:08setting?
09:09I would say that our our care,
09:12even if I say so myself,
09:16We bring most of our cases to a
09:18multidisciplinary tumor conference.
09:19So if I were to pick, let's say,
09:22the most common cancer that we see in women,
09:25which is breast cancer.
09:27So once a woman gets a mammogram,
09:31gets a biopsy, or sees a surgeon,
09:35she is presented at a
09:37multidisciplinary tumor conference.
09:40For people who don't know what that is,
09:44it is basically a collection
09:47of many oncologists or any
09:49oncologists in the community.
09:52Radiation oncology, radiology, the breast
09:55surgeons themselves,
09:56social worker, nutritionists.
09:58So we all get together as a team
10:01and discuss the presentation of
10:03each sort of person's cancer,
10:06and then we decide
10:11to dealing with that situation.
10:14Being most of the time, it's standard,
10:17but things are changing.
10:18You know we were used to using,
10:22for example,
10:22chemotherapy in always the
10:24post surgical setting.
10:26But now we're moving to using
10:28treatment sometimes upfront
10:30before surgery so not everybody
10:32is a good candidate for that.
10:34We talk about
10:37the things like that.
10:38Other things that come up are genetics.
10:41This has also become a very
10:44important part of management for patients.
10:47You know 10% of the cancers
10:49that are diagnosed,
10:50especially breast cancer I'm
10:52talking about can be genetic,
10:54so we always talk about that.
10:57We have a genetic counselor
10:59as a part of the team who will
11:01be there and say, OK,
11:03I think this person needs to meet with me.
11:06We need to
11:07check her or family members.
11:09If there are
11:12financial issues.
11:14Social issues.
11:14We have a social worker who is
11:17present who can help
11:20guide patients through that process.
11:23We have a licensed nutritionist who can
11:25provide support as to healthy diets.
11:28Because this really becomes a very
11:30important part of what people feel
11:33that they have some control over it
11:35and it empowers them.
11:38And of course we know that obesity
11:41and cancer have a direct link so
11:44we always want to talk about
11:46maintaining a healthy lifestyle
11:48and a healthy body mass index.
11:51Once a case is discussed at
11:54the Multidisciplinary conference,
11:55we will then make recommendations.
11:58The patient gets established with
12:00medical oncologist or radiation oncologist,
12:03and it's really a very good
12:06collaborative approach.
12:08The other thing that we often
12:11talk about on the show is things like
12:14personalized medicine and genomics.
12:15So are those things available in
12:18Community settings or are those
12:20really only the purview of the
12:22larger academic centers?
12:24There has been so much progress in
12:26these things that they are now
12:29easily available to us as well.
12:33Our goal is always to be able to
12:37at least offer standard a standard of care,
12:41which means if you were to see
12:44an oncologist here or you went to the
12:47West Coast and used an oncologist there,
12:51the therapy recommended
12:53would be similar,
12:56if not identical,
12:57so that is called standardized
13:01care and it is based now
13:03on genomics, which do play a huge role
13:05in determining treatment for cancer,
13:08it has been a significant advance.
13:11In the treatment of breast cancer,
13:13when we look back we find that
13:16we were probably over treating a lot of
13:19the breast cancer patients with chemotherapy.
13:22Now we have tests that can actually
13:24determine benefit from chemotherapy,
13:26and these are based on genomic
13:28tests allowed for a lot of the
13:31cancers including lung cancer,
13:33colon cancer we are doing
13:35molecular testing we're
13:36identifying targets on these cells,
13:39which we know drive the growth
13:42of cancer cells,
13:43and then we can actually pick
13:46medications that would specifically
13:48block these drivers and that
13:51is sort of the tailor made approach
13:54for treating cancer.
13:56So it sounds like
13:58you know patients can get that
14:01same kind of genomic testing in
14:04that personalized therapies
14:06even staying closer to home.
14:08We're going to take a short break
14:11for a medical minute and come
14:14back and talk more about cancer
14:16care in the community with my
14:19guest Doctor Katoch.
14:21Support for Yale Cancer Answers comes from
14:23AstraZeneca, working to eliminate
14:25cancer as a cause of death.
14:28Learn more at astrazeneca-us.com.
14:31This is a medical minute
14:33about colorectal cancer.
14:34When detected early,
14:36colorectal cancer is easily treated
14:38and highly curable and as a result
14:41it's recommended that men and women
14:43over the age of 45 have regular
14:46colonoscopies to screen for the disease.
14:48Tumor gene analysis has helped
14:50improve management of colorectal
14:52cancer by identifying the patients
14:54most likely to benefit from
14:56chemotherapy and newer targeted agents,
14:58resulting in more patient
15:00specific treatments.
15:01More information is available
15:03at yalecancercenter.org.
15:04You're listening to Connecticut Public Radio.
15:11Welcome back to Yale Cancer Answers.
15:13We're discussing the care of
15:15cancer patients in the community
15:17and right before the break
15:20we were talking about some of the
15:23differences and the other thing that I
15:25was wondering about was clinical trials.
15:28So often on this show,
15:31we talk about the importance of
15:33clinical trials and how that's
15:35one of the ways to get tomorrow's
15:38therapies today in that patients
15:41often will get the best care by
15:43participating in clinical trials for
15:45which they are eligible and for which
15:48their Doctor thinks they would benefit from.
15:51Talk to us about whether clinical
15:53trials are available in the community setting.
15:56You bring up a great point,
15:59and it is true that we wouldn't
16:02be where we are today in cancer if
16:06we didn't encourage our patients
16:08to participate in clinical trials.
16:11As everyone knows, 2020 has
16:13been a particularly challenging year,
16:15and also for clinical trials it has been a very
16:18challenging year simply because
16:21clinical trials require
16:22very diligent follow-up,
16:23mostly for patient safety,
16:24and that we all know because of covid
16:27we've had to resort to
16:30virtual appointments and seeing
16:32patients may be a little bit
16:34less frequently than we normally would,
16:37so a lot of the clinical trials
16:39had to be put
16:41on hold, but usually we have a very
16:44robust collection of clinical trials
16:46for patients with breast cancer,
16:49colon, cancer, lung cancer,
16:51chronic leukemias,
16:52and myelomas.
16:53That brings up
16:55a great point. The fact that you're
16:57part of a network and can avail
17:00yourself of clinical trials that
17:03are available at larger centers.
17:06Maybe not all of the trials,
17:08but certainly a collaboration whereby
17:11patients can avail themselves
17:13of clinical trials,
17:14oftentimes closer to home, and if not,
17:17you can always send them to to a larger
17:20center where they can participate
17:23and that brings up my next question,
17:26which is in those cases where
17:29there is a particular nuances of the care
17:32or where a second opinion might be needed,
17:36is it possible for patients to
17:38seek a second opinion somewhere
17:40and still get treated
17:43closer to home?
17:44So for example getting the
17:47advice of an oncologist closer to home
17:50about what particular regimen to use,
17:52or how a radiation plan might be structured,
17:56but then still get their care closer to home?
17:59Absolutely yes,
18:01and this happens more
18:03frequently than one would think.
18:06And you know, sometimes I'll say to my
18:08patients when I'm torn between two options.
18:11And I'll say I would like you to see,
18:15so and so maybe at the Dana Farber Institute,
18:17maybe closer to home at Smilow.
18:19And then I always give them the
18:22option that if this is
18:26recommended and if it's not on a clinical
18:29trial and we are able to do it here,
18:31you are welcome to come here and
18:34we would love to treat you here
18:36if that is your preference,
18:38so this is,
18:39you know a very sort of open
18:41discussion with patients,
18:43and sometimes patients will finish
18:44their clinical trial and then will
18:47continue to follow with you as their
18:49primary oncologist.
18:51Ultimately it's about the patient.
18:52What is best for the patient,
18:54and I make sure that our patients
18:58know that and they're not feeling pressured
19:00and not feeling that their
19:02offending us in any way.
19:03It's important
19:05for patients and everybody listening
19:07to really understand that.
19:09You know this is a collaboration
19:11and it's a collaboration amongst
19:13physicians who are all trying to
19:15treat you in the best possible way.
19:18And so you're not going to offend
19:20anybody and for for the most part
19:23many of us actually do seek the opinions
19:26of our colleagues at multidisciplinary
19:28tumor conferences like you mentioned,
19:30as well as outside the institution
19:33and frequently you can get the
19:36same care then closer to home.
19:38If somebody has a better idea
19:40of how to treat something.
19:42Whereby those services
19:45are available in the community.
19:47You can still do so.
19:49Talk to me a little bit
19:51about kind of community support.
19:54You mentioned one of the
19:57disadvantages sometimes of going
19:59into a larger center is that you
20:02know frequently if care is required,
20:04say for example with radiation therapy,
20:07five days a week for many weeks
20:10that a 2 hour drive might not be
20:14the most feasible thing one would
20:16also imagine that just being
20:19in the community where you're at,
20:21being around loved ones and so
20:23on can sometimes be a little bit
20:26more comfortable for
20:27patients. Do you find that that's the case?
20:30So I would say that in cancer care
20:33that is of utmost importance.
20:35This is 1 diagnosis where
20:38just having the support of the
20:40people you love is so meaningful
20:43because it's not just a physical
20:45diagnosis. It's an emotional,
20:47psychological diagnosis that
20:50affects all the people around you.
20:52So it's really important to have that social
20:55support not only from your family,
20:58but also from where you are being
21:00treated so where we are
21:03for example, at the Yale Cancer Center
21:05we have a radiation oncology division,
21:07which is in the same building.
21:10So people who need radiation
21:11can come right there.
21:13If we are doing something which is a
21:16combination chemotherapy and radiation,
21:17we will
21:18try to make sure
21:20that their appointments
21:22can be coordinated that life really
21:24can be as simple as possible for them.
21:26Sometimes people don't have transport,
21:28so we have a social worker on site who will
21:31arrange for transport for people and
21:34we will tell our patients, our elderly
21:36patients who often rely on their childrenm
21:39but their children work,
21:41so it's not always possible for
21:43somebody to give you a ride each
21:45and every day back and forth.
21:47So we have that kind of support and
21:49we want our patients to know about it.
21:52We want them to use it.
21:54We also have support groups.
21:56We have a very robust and active
21:59breast Cancer Support group.
22:01Other support groups which are
22:03not as robust but are present.
22:05They meet once a month I think now
22:08with some of them have been
22:11meeting remotely but that women
22:14also find a very strong sense
22:16of community and support with
22:19those centers and I would
22:21think that the other
22:23place where
22:25optimizing and kind of using
22:28that social support is at end of life.
22:32In terms of palliative care.
22:34So our palliative care resource is
22:37available in the Community both on
22:40inpatient as well as there is
22:43such a thing as home palliative care
22:46where people can really
22:48take community all the way back to
22:52your own home and have the services
22:55that keep you comfortable at
22:57the end of life at home.
23:00You bring up an excellent,
23:03excellent question, so valuative care is
23:05a very important part of cancer care,
23:08and you know it includes pain control.
23:12It includes things that can
23:14occur like loss of appetite,
23:16loss of interest in life,
23:18so we actually offer a consultative
23:21service that is available through Yale.
23:24We can do it either virtually
23:27or we can do it
23:30in the office, we actually have consultative
23:33care services available on site,
23:36so that is outpatient and inpatient.
23:39Palliative care services are available
23:41through both hospitals.
23:43So both Waterbury Hospital and Saint
23:46Mary's Hospital offer palliative
23:49care services is an inpatient unit 4.
23:53A lot of patients want to be home.
23:56They want to
23:58be surrounded with the loved ones they
24:01want to be in familiar surroundings.
24:03So we have several Hospice agencies,
24:07who can make that possible
24:10and who do really do a very
24:13fabulous job of taking
24:16care of patients at the end of
24:19life, they trained to do that.
24:22They are compassionate,
24:23their empathetic and most patients
24:25are very pleased with their services.
24:30It's really important for cancer
24:32patients to get treated where
24:34they feel the most comfortable and
24:36being surrounded by loved ones,
24:39particularly at the end of life,
24:41is something that they may consider.
24:48You've mentioned a few times
24:50this whole crisis that
24:53we've been through with Covid,
24:55which in and of itself has restricted
24:58mobility in terms of going across
25:01state lines for certain states,
25:04travel and so on.
25:05Talk to us a little bit about
25:08how the covid epidemic affected
25:11cancer care in the community.
25:15Well, you know a lot of the screening
25:19procedures that people would go for,
25:21I think those have been the
25:24first ones to have gone
25:27away or have been put on hold.
25:30So screening mammograms,
25:31screening colonoscopies,
25:32those have been a challenge,
25:34so people have either put them off
25:37or have just been afraid to go out.
25:41And you know,
25:42we've resorted to some virtual visits.
25:45Which I would say patients are
25:47thankful that they're seeing a doctor,
25:49even if they're not coming into
25:51the office and patients who have
25:53been able to come to the office
25:54are just so delighted to be there,
25:57and they have often said to me
25:59that this is my first
26:01outing in the last three months.
26:03I cannot tell you how happy I am to be here,
26:06so it's sort of kind of funny to hear that.
26:13But a lot of people have delayed their
26:16care and we are beginning to see
26:20a little bit of an uptick
26:23now in patients presenting with slightly
26:25advanced cancers at this time because
26:28of the lack of screening, you
26:31think lack of screening and self delayed
26:34patient care, obviously,
26:36for reasons that are understandable.
26:39And so are you recommending that
26:42people get back into screening now?
26:44Do you think that we have gotten over
26:47the height of the pandemic such
26:50that people should really get back into
26:53doing those screening mammograms and
26:56colonoscopies?
26:56I think in the Community
26:58people are already back to it.
27:01You know our centers, they are
27:03asking everybody
27:05to wear masks, temperature checks.
27:07Most people now have been immunized.
27:10I would say at least 90%
27:12of my patient population,
27:14who I ask has either received the
27:17vaccine or is going to receive
27:19it in the next few days so I do
27:21get a sense that at least as far
27:24as medical care is concerned,
27:26that the Community is getting back to normal.
27:30And do you think that some of the things
27:33that we've kind of learned about medicine
27:36and how medicine can be delivered?
27:38For example, you know virtual visits
27:41and telemedicine really opened up
27:43a whole horizon for people for
27:46whom transportation was a big issue.
27:48Do you think that that's here to stay?
27:51That will continue to have Tele
27:54medicine visits into the future?
27:57Excellent
27:57question and I think that it
28:00is here to stay and it has made
28:03life simpler for a lot of people.
28:06But it has also brought
28:08along many challenges.
28:09The older patients
28:11cannot get the video connection.
28:13They are so frustrated
28:15by the end of the visit.
28:18But I would say the telephone
28:21visits go much smoother,
28:22especially if you're dealing with
28:25an older population or you
28:27know people who are just not
28:29comfortable doing it on the phone.
28:32Other than the technology challenge,
28:34I think it is here to stay.
28:36Doctor Anamika Katoch is an
28:38assistant professor of clinical
28:39medicine and medical oncology
28:41at the Yale School of Medicine.
28:43If you have questions,
28:44the address is canceranswers@yale.edu
28:46and past editions of the program
28:48are available in audio and written
28:50form at yalecancercenter.org.
28:52We hope you'll join us next week to
28:54learn more about the fight against
28:57cancer here on Connecticut Public Radio.