Narrator: Coming up on Mayo Clinic Q&A:
Dr. Rob McWilliams: If you delay screening, you might catch it at
a later stage where it could be life threatening or fatal.
Narrator: While COVID-19 continues to have our focus,
other health issues haven't gone away. Delay in a doctor's visit
now could lead to greater problems in the future. So, it's
important for individuals to continue caring for their
health, and that includes cancer screening.
Dr. Rob McWilliams: For many of the cancers that we screen for,
if you catch it early, it can be potentially curable and lead to
a normal lifespan.
Dr. Gazelka: Welcome, everyone to Mayo Clinic Q&A. I'm Dr.
Halena Gazelka. Thanks for joining us today. One of the
challenges of the COVID-19 pandemic has been that people
are delaying not only routine medical care, but also routine
cancer screening. Cancer diagnoses have actually
decreased during COVID-19. This has led experts to be concerned
that the delay in people receiving screening is causing
cancers to be diagnosed at a much later stage than they would
otherwise. And they are much more treatable at early stages,
obviously. So, what is Mayo Clinic doing for cancer care
during the COVID pandemic? Well, we have an expert to discuss
this with us today. here with us today is Dr. Rob McWilliams,
who's a medical oncologist at the Mayo Clinic in Rochester,
Minnesota. Thanks for being here Rob.
Dr. Rob McWilliams: Thanks for having me here Dr. Gazelka.
Dr. Gazelka: Well, it is great to have you here today. So, I
just started out by talking about cancer diagnoses and
cancer screening. What have you seen in your practice?
Dr. Rob McWilliams: Yeah, so definitely, when the pandemic
first hit last spring, we saw an abrupt decline in all types of
routine medical care, and that made sense. We were opening up
the hospitals for this anticipated huge wave of
patients that were requiring ventilators and ICU stays and
things like that. So, anything that was deemed elective was
postponed. And at that time, you know, we all thought it would be
for a few months, and now it's been dragging on. Since that
time as medical centers and Mayo Clinic specifically, we've
reopened, you know, we have seen the numbers increase, as far as
the patients who were able to get that type of screening,
however, and we've seen the same thing nationally. However, then
they really haven't caught up, and many suspect that there are
patients out there that are avoiding care or delaying care,
or they have other priorities. And so, the routine cancer
screening that we saw that was part of routine medical care
pre-pandemic, really hasn't caught up to where it was.
Dr. Gazelka: Rob, do you think that people are delaying care
because they are worried about contracting COVID-19, or the
risks of being in medical institutions, or that there's
just a lack of access to care now?
Dr. Rob McWilliams: I think it's a little bit of all of the
above. I mean, certainly, there are reasonable concerns that
when, especially when the pandemic first rolled out that
people didn't necessarily feel safe going to medical centers,
and you know, who didn't know that someone else in the lobby
might have COVID. And of course, measures are being taken now
that it is a much safer environment than it ever had
been before. So, I think there is some avoidance, but I think
also just in general, people are prioritizing other things. So,
you know, maybe financial circumstances have affected
their ability to access care. We know that underserved
communities and remote communities are having trouble
accessing care. And their limited resources have been
focused on the COVID pandemic because it has hit those
communities harder than it has other communities as well.
Dr. Gazelka: Rob, just off the top of my head, when I think
about screening for cancers, I think about certain types of
cancer that I know are routinely screened for like cervical
cancer with pap smears, breast cancer with mammograms,
colorectal cancer with colonoscopies, and Cologuard
tests, etc. Are those some of the cancers that we're talking
about with screening? Are there other cancers that we should be
concerned people are not screening for as well?
Dr. Rob McWilliams: Yeah, I think all of the above and the
schedules for those different cancers do vary. As far as
screening, sometimes a colonoscopy is recommended at
this time every 10 years. So, putting it off a year may not be
that big of a deal for most people. But then there are other
cancers, prostate cancer, lung cancer, which are screened at
more frequent intervals. And so, all these large, more common
cancers do add up and if we look at the general population, and
if we are seeing higher numbers of cancer diagnoses in the next
year or two at later stages, that'll be evidence that we had
a significant impact, which we unfortunately expect to see.
Dr. Gazelka: I'm curious too Rob, if this represents just a
delay in medical usage overall, that people are not going in and
getting their yearly exams, because a lot of the things that
you and I have mentioned, are topics that would be discussed
with a primary care provider perhaps when someone went in for
their yearly exam.
Dr. Rob McWilliams: Yeah, I think you know people early on
in the pandemic, we said postpone elective care. And I
think a lot of people unfortunately view cancer
screening as part of elective care. Well, it's really not that
elective, it can be moved for a few months here and there, but
we know that it's important. We know that as we've looked at
cancer mortality rates over time, that large scale screening
and preventive measures have really had a substantial impact
on cancer mortality in our population. So unfortunately,
when people don't get that screening performed, you lose
that impact.
Dr. Gazelka: Rob, you mentioned, the impact on society. When you
talk about delaying cancer screening, what are the risks
that are long term, specifically to individuals who may be at
risk, and then for our population overall?
Dr. Rob McWilliams: Yeah, I think patients are going to be
diagnosed at later stages. And for many of the cancers that we
screen for, if you catch it early, it could be potentially
curable and lead to a normal lifespan. And if you delay
screening, you might catch it at a later stage where it could be
life threatening or fatal. And so, I think for an individual
that impact on their own mortality is substantial.
Dr. Gazelka: Rob, we've been talking about screening, but I'm
kind of curious about your own practice. When patients have
been diagnosed with cancer, have you seen people delaying even
getting treatment for their cancers during the pandemic?
Dr. Rob McWilliams: There are a couple aspects of that. One is,
there are patients who are having symptoms and are delaying
necessarily a workup for that, that eventually leads to a
diagnosis of cancer. And we're seeing signs of that as well,
just navigating the healthcare system during the pandemic has
been more challenging overall. But patients who were already
diagnosed with cancer, by and large, most of our treatments,
we've been able to continue chemotherapy and radiation
therapy, really never missed a beat necessarily, although
patients who travel for care did find some barriers there. For
surgical procedures and operations there was a very
brief pause here at Mayo Clinic for trying to, you know during
that March and April time window of trying to empty out the
hospital, and things like that, but that very rapidly resurged
and really just became sort of a part of normal practice again,
and we caught up so. So, I think for, you know there are
some patients where say there's a screening interval, we'd say,
well you need to have CT scans every three or four months, or
maybe, and the national guidelines say we can go up to
six months and we might go longer into that just to help
with that backlog and that rush of patients. But I think in
general, most patients who are on treatment, we've strongly
recommended that they follow through with their cancer care
as planned. When we look at how cancer patients do, we knew
early on in the pandemic that cancer patients were higher risk
for complications of COVID than other patients. What we found
over time, and we worry that to just be on chemotherapy or be on
immune therapy would really compound people's risk. But what
we've seen over time is that it's really certain populations
of cancer patients that are at a really high risk for
complications such as bone marrow transplant patients or
leukemia patients where that immune system has really
profoundly decreased. The patients with more common solid
tumors, breast cancer, colon cancer, they seem to do fairly
well, even if they get infected with COVID. So, overall, we have
not seen reason to delay necessary therapy for cancer.
Dr. Gazelka: I'm glad that you addressed that topic, Rob,
because I would imagine that it's very frightening. It was
frightening for all of us when we saw the number of people ill
and the number of deaths, and we watch this continuously on
television and on the internet. And then to think about cancer
treatment. And we often think of people as being immune
compromised or have less ability to fight infections, but it must
be quite variable based on the treatment that they're
receiving, and even the type of tumor, etc. And so, obviously a
good topic to discuss with one's oncologist.
Dr. Rob McWilliams: Absolutely. Many of our treatments these
days actually boost immune immunity rather than decrease
it. So, a very complex relationship with infectious
disease but worth the discussion with your treating physician or
provider.
Dr. Gazelka: That's a really interesting point, because I
don't really think of cancer treatments as boosting immunity.
Dr. Rob McWilliams: Yeah, it's been a paradigm shift over the
last several years, and it's really improved outcomes for our
patients. But it's not a natural thought process for most of our
patients, either.
Dr. Gazelka: Rob, what are we doing at the Mayo Clinic to make
it safe for patients to come here for their cancer care? And
what should individuals be looking for when they're needing
to pursue cancer care during the pandemic?
Dr. Rob McWilliams: Well, we've been dealing with this for a
year, and so we think we've been managing it pretty well. You
know, when a patient comes to any of our campuses, there's
distancing, there's hand sanitizer widely available.
Providers and patients are masked. Most health care workers
at this point have been vaccinated, and an increasing
number of our patients have been vaccinated. So, you know, I
suspect that being at one of our medical facilities is probably
the safest it's ever been. I mean, you used to be able to go
to the doctor maybe you could catch a flu or a cold. And now
with all the measures in place, you know, it could possibly be
the safest it's ever been. So, we are very cognizant of that.
We've seen very low rates of any transmission at medical
facilities, but by and large, the vast majority of our
patients who get affected with COVID are acquired in their
communities.
Dr. Gazelka: Rob, you made a comment a little bit ago about
vaccines. And, I was wondering if I could ask you about
patients being vaccinated for COVID while they're undergoing
cancer therapies, is that permissible? And does that put
them at risk? Or does it make the vaccines less durable or
efficacious I guess?
Dr. Rob McWilliams: Yeah. So, patients on active treatment for
cancer, were excluded from most of the vaccine studies. And so,
we got together with other cancer centers, through the
National Comprehensive Cancer Network, which Mayo Clinic is a
part, and got our experts together with infectious disease
experts and put together some guidelines for vaccination on
patients who have cancer. And by and large, we felt that the mRNA
vaccines that are currently out there are safe for all cancer
patients to receive. They shouldn't be an increased risk
for complications for the vaccines. And, we knew that it
would be really challenging for patients to coordinate the
timing of the vaccine with the timing of their treatment. And,
you know, you get an email or a phone call from your doctor
saying your vaccine is at two o'clock today, come get it, you
know. And so, we wanted to make the recommendations as broad as
possible. By and large, we said everybody should get a vaccine
when it's available to them. There's a small population of
people who just had a bone marrow transplant, or another
type of immune therapy called CAR T, where we really don't
think they're going to have a robust immune response, even if
they get it. So, we say, three months outside of that window
for that treatment, that they should delay vaccination, but
for the vast majority of patients, either on
chemotherapy, on radiation, or who just had surgery, when they
get that vaccine offered to them, they should go ahead and
get it.
Dr. Gazelka: I think that's a good thing to hear that patients
should continue to get their vaccinations during most cancer
therapies, because it's true that people are concerned. If I
give up my vaccine, they're going to give it to someone
else, because there's a limited supply. So, that's good
reassurance.
Dr. Rob McWilliams: Yeah, absolutely. We knew we knew that
would be the case. And the more rules you make around
vaccination, the more potential wasted doses and challenges
there are for patients. And so, we wanted to make that as broad
as possible. We may have learned over time that, you know, timing
with regard to when someone's on chemotherapy, or when in their
cycle, that it may be more advantageous than others, but at
this point, we don't have that information. And rather than
make more specific recommendations, we've said, you
know what, everybody should just get their vaccination when they
can, and then we'll study it later.
Dr. Gazelka: Rob, I have marveled at so many changes
during the COVID-19 pandemic, for instance, you and I talking
to each other over computer today in zoom, rather than being
face to face as we might have been a year ago. The other thing
that we have seen, another huge increase that we have seen even
here at Mayo Clinic is the use of video and telehealth visits.
Are you using those in cancer care? And do you find them
helpful for patients and for you as a physician?
Dr. Rob McWilliams: Yeah, the pandemic has been devastating in
a lot of ways. One of the silver linings has been the
acceleration of the use of telehealth and video visits
specifically. We have definitely used this much more
than we ever have in the past. And it's been a learning curve
for providers and for patients. But, I think well received on
both ends. A lot of times, we have patients that you know, may
need a quick second opinion, and we're about to start therapy
locally, in a video visit can answer their questions so they
can, in a very timely manner proceed to what they're going to
have done anyway. There are patients where we might have
genetic testing results or some other delayed results that may
take a while rather than waiting around in town to have a face to
face discussion. we can let them return to their communities in
their homes and then have a video visit later. It's more
personal than a phone call. And you can you can read those
nonverbal cues better. But it is much more convenient for
patients to be able to meet them where they're at.
Dr. Gazelka: What you just said made me think of another
question. A lot of people obviously travel to Mayo Clinic,
to our sites from great distances. And so, it's not
convenient to come here regularly necessarily. Do most
of the patients that you care for with cancer come here for
all of their therapy, or is it primarily that you are seeing
them and giving recommendations or confirming what a home
oncologist might have told them?
Dr. Rob McWilliams: We do all of the above. So, we have a mix, we
have some patients who come here for everything, and we have some
patients who come here just for a second opinion one time or key
points in their care. One thing we've, you know, we do a lot of
clinical trials in our Medical Oncology Group. And one of the
things that the National Cancer Institute, who governs the
management of a lot of these trials has allowed, is to allow
for more virtual visits and distant visits. It used to be
that so many things had to be done in the facility that's
doing the research trial, and now, that's liberalized a bit so
more of our experimental studies and investigational trials can
reach out to broader populations of patients for that reason. So
again, we are being as nimble and trying to bring care to as
many patients as we can, based on what we can access today.
Dr. Gazelka: That sounds like a great silver lining to the
pandemic, Rob, that you're able to offer clinical trials and
treatments to patients who otherwise might not have been
able to come here and have them.
Dr. Rob McWilliams: Yeah, it has been and I think we're still
learning along that regard as well. But I think, you know,
aspects of this are definitely here to stay. And it's our job
as, as clinicians to figure out how to utilize these
technologies and move the field forward and meet the needs of
our patients in the future as well, even when the pandemic has
subsided.
Dr. Gazelka: One of the things that patients often tell me in
my own practice is how very surprised they are that I'm
willing to be in touch with their physician at home or to
talk through things with their care team at home, or to send my
clinic notes, or to even participate in their care while
they're receiving care at home. And so, I think that's really
reassuring to patients, that they can have the continued care
and that we will interact with the other providers caring for
them.
Dr. Rob McWilliams: Yeah, I think patients are more in
communication with Mayo Clinic than ever before. And this has
really enabled that, I think. Even patients that weren't that
technology savvy, a year ago have learned by necessity, and
that's allowed us to do more and more creative things. So, it's
been a silver lining.
Dr. Gazelka: That's great. Thanks so much, Rob. Any last
words of advice or wisdom that you'd like to share today?
Dr. Rob McWilliams: Yeah, one thing that we have started
seeing for people who are lucky enough to receive the vaccines
for COVID. Sometimes that robust immune response can be pretty
strong. So, sometimes, if you get it in the shoulder, your
lymph nodes under your arm might be increased in size, that can
affect screening studies, such as mammograms and some of the
assessments that are done for breast cancer screening. So,
just to make people aware if they do call for a screening
study, they may be asked when their vaccine was if they've had
it, and they may ask to have some timing for that screening
study to allow for that natural immune reaction to subside
before they get the screening, otherwise, there's some chance
of a false positive. So just for people to be aware, it's not a
deal breaker, but it's one of those things that we want to be
aware of.
Dr. Gazelka: Well, that's very interesting, not something that
I had thought of.
Dr. Rob McWilliams: Well, we have definitely seen our share
of patients who we get imaging studies, PET scans or CT scans,
and boy, they have swollen lymph nodes, and you ask did they get
a COVID vaccine? Yeah, which arm did you get it? And it's in the
arm where the lymph nodes light up. So, by and large, we have
learned through experience so, you know, certainly the vaccines
are causing robust responses that we can see on radiology
studies.
Dr. Gazelka: How fascinating. Thanks for being here today,
Rob.
Dr. Rob McWilliams: Thank you.
Dr. Gazelka: Our thanks to Dr. Rob McWilliams, medical
oncologist at Mayo Clinic in Rochester. As he's told you
today, don't delay your cancer screening and cancer treatment
is still ongoing during COVID-19. I hope that you
learned something today. I know that I did. And we wish all of
you a wonderful day.
Narrator: Mayo Clinic Q&A is a production of the Mayo Clinic
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