Episode 070: Cancer, COVID and Coping: A discussion with Dr Christopher Steer

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In this episode of Simplify Cancer Podcast, we talk about better ways of dealing with cancer during the pandemic, coping with uncertainty, and reducing the risk of severe infection.

This is particularly crucial in the time of COVID-19 pandemic. Our special guest is Dr Christopher Steer, a medical oncologist who specialises in helping older adults with cancer, and here is what we cover in our discussion today:

• Balancing your risk of infection with need for anti-cancer therapy
• Separating myth from fact on boosting your immune system
• Finding the better care for older adults
• Where to turn to for expect advice in this uncertain time
• The missing link of psychological care through cancer
• and much, much more!

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Full episode transcript (PDF)

Episode Transcript:

Joe:                             As a medical oncologist, I know that you are deeply involved in cancer treatment, in follow-ups, in research, in clinical trials, Christopher, what impact have you seen with the pandemic so far?

Christopher:            We have a large number of patients from regional Australia coming to receive standard chemotherapy and immunotherapy and radiation and follow-up in our centre.  Of course, patients need to travel to have their treatment to our centre.  That is the first issue.

As you may also be aware, patients with cancer tend to be older.  The average age of patients with cancer in Australia is 67 years at first diagnosis.  That means a significant number of our patients are older.  Here we have a large number of patients older, having to travel to our centre for treatment.

I would say rightly so, that because our patients are going to be at risk of more severe infection should they contract the virus.  We need to remember that we’re all at risk of contracting the virus and the only thing that we can do to prevent infection and not be infected by it is not to be infected with it.  The only thing that we can do is practice social distancing and good hygiene.  Good hand hygiene and other practices that we’re all well aware of now.  There is no prophylactic treatment.  There’s no treatment once we get it.  We need to remember that the only thing that we can do is practice good physical distancing and hygiene.  What does that mean for our patients coming to the cancer centre?  They need to visit us as a centre and that would be mean coming in contact potentially with other people.

Certainly, for the patients with treatment, that’s unavoidable.  We don’t currently have a service where they can have treatment at home.  For the patients who aren’t on treatment, of course, we have pivoted to tele-health as much as possible.  We’re providing telephone and video consultations for our patients as much as possible.  As a regional cancer centre, as a medical oncology unit, we are quite used to doing this already.  Tele-health is a core part of my business model if you like.  Tele-health is a core part of my care.  I conduct it with my patients regularly.  What can we do for our patients?  We can stop them coming in to seeing us.  If they do need to come in for treatment, of course, we need to change our management here.  How are our patients feeling?  They are in the majority fearful of this infection, rightfully so.  Most of them are doing the right thing by staying at home, if possible.

Joe:                             Absolutely, Christopher.  There are so many challenges that the pandemic brings, as you say, how people are taking it in terms of their attitudes, in terms of the risk and in terms of how you treat them.  There is also, Christopher, so much that we hear about Covid-19 in the news, what is your take and what does someone who’s potentially going through cancer treatment and going through follow-ups, what do you think they absolutely need to know about the disease right now?

Christopher:            Unfortunately, as we are seeing an increased number of patients with Covid-19, mainly in Victoria, the thing that our patients need to know in this regional cancer setting is the likelihood of them having infection is low, but it needs to be thought of.  If they are worried, they should get tested.  If they have any symptoms, they should get tested.  If they are in contact with someone who has it, obviously, they need to go into two weeks of quarantine.  For patients who example on treatment, we need to be aware that often treatment does cause immunosuppression, that means lower immune systems.  We think, we’re not entirely sure, but we think that this may lead patients to be at increased risk of severe infection.  What we’re mainly concerned about for our patients is what is the risk for severe infection?

We know that tends to be older adults.  We know that mainly men are more of a concern.  More men than women develop severe infection.  We know that if you have core morbidities, such as diabetes, high blood pressure, heart issues, you’re more at risk of an infection.  We think that immunosuppression and having cancer itself is something that puts you at high risk.  Therefore, we are very cautious with our patients.  However, the fear of the severe infection should not put us off adequate, appropriate anti-cancer therapy.  I think still in the current situation that people are more likely to run into trouble with some of their cancer sometimes than from a severe covid-19.  As with everything, it is a balance.

We need to weigh up what the risks and benefits of the treatment are in this new environment with every patient that we see.  It is important to individualise care.  One of my mantras in dealing with my older patients is, adequate assessment yields appropriate care.  For our older adults, we know that a geriatric assessment leads to a better and adequate care and supportive care.  I think in this new pandemic, in this new environment, it’s very important to adequately assess our patients to individualise our care and make the decisions together.

Joe:                             Yes, that makes so much sense, Christopher.  I love how you put it into perspective that while there is a great risk and with restrictions potentially changing depending on where you live, we should always be safe and mindful of what we’re doing and practicing everything that government and our health departments are recommending.  It’s so important to put it into perspective and to find that right balance between minimising the risk but yet, at the same time, getting the proper care that you need when it comes to cancer.

Christopher:            That’s right.  Our public health experts are giving us the right advice.  Following that advice is important.  Unfortunately, the new lockdowns and border closures are important parts of managing this condition.  When patients are on what is often the most difficult journey of their life, they do not need yet another obstacle.  I think it’s important to know that a, you need to follow the advice of the experts, and that I would support the public health initiatives being taken in place.  Also, that as specialists, as cancer care specialists, as cancer care teams, people like us at our teams at the cancer centre are here for our patients.  If you’re in doubt, ask, call, but don’t just stay at home and wonder.  Get advice if you’re worried.  Ask questions.  It’s very important.  We will try as much as we can to be here for you.

Joe:                             Absolutely, Christopher, that makes so much sense.  What types of questions would you encourage patients to ask you or their own specialist in this time?

Christopher:            Often, the most difficult time for our patients, as you’re aware, is their first visit.  You’ve been diagnosed with cancer, the surgeon, the general practitioner has made the diagnosis and the patients come to the oncologist in the cancer centre for answers, reassurance and treatment.  The first visit is so important.  It’s where the relationship is established.  It’s where the plan is made.  It’s where the patients find out really what the problems are hopefully.  That is the most important time.  My patients need to come into my office.  Hopefully with somebody else.  The first thing I would say rather than what questions to ask would be, make sure there’s someone with you, if possible, who can help you ask the questions but more importantly, remember what the answers are.  I’ve had one patient today say, well, you should have someone to join you to help ask the questions and listen to the answers and then another person to write them down.

The team, now, we have a team to care for you, but often it is the team of the family or the spouse or friends.  Sometimes a neighbour.  Someone who’s there for you as part of your team.  If you’re a patient coming for the first appointment.  I can’t stress it more often.  My heart sinks when I got to the waiting room, I call a name and one person walks on their own to my office and they don’t have someone with them in support.  That happens for many reasons.  Sometimes there is nobody to support the patients.  Often down this very difficult journey, you need help and support, and I would say it’s really important to have someone with you.  Yes, they can ask questions, they can listen to the questions and write it down.  Write down your questions before you come in, if possible.  There are a number of different sites.  The Cancer Council provides a good list of questions for your oncologist before you come in.  What kinds of questions should you ask?

Of course, what cancer do I have?  What is the stage?  What are the treatments?  Really, it comes down to what my answers are.  What are our options?  What are our options for treatment and care?  Usually, I would go through those including ones which people might think are possible, for example, surgery, even when the situation is not operable.  You need to say, yes, we would like to do surgery, but for this reason, we can’t.  Things like that.  Go through every option that the patient might think about and then hopefully they will leave the appointment with an informed opinion about the way forward, a proper plan.  Then someone who’s also witnessed that, and they can talk to them on their way home afterwards.  That’s what I see as some of the vital things that happen at that really important first appointment.

Joe:                             It’s just such a critical thing that you raise, Christopher.  I remember when I went to see my oncologist for the first-time getting treatment, I have almost no recollection of the first conversation whatsoever.  I was just happy that I did have my wife and my mum with me to be there and support me.  Also, just figure out what we need to do next.  I’m really glad that you’re bringing this up.  Christopher, is there anything that you think at this time, as well, that people want to be asking yourself or the specialist with respect to follow-up appointments or treatment with the pandemic?  How does tele-health work?  How does all of that fit in?

Christopher:            People often ask, what can I do?  What can I do to help the treatment?  What can I do to stop the cancer coming back?  Certainly, one of the things that I say to my patients in advising them about whether or not they should have treatment at all.  First of all, follow the experts and have the treatment if that’s the best thing for you.  Then if you are on treatment, or even just in follow-up, what can you do in this pandemic to help yourself and avoid the infection and avoid the seriousness?  Of course, follow the advice of the experts as we’ve said.  Physical distancing, meaning staying away from people.  Hand hygiene.  Other things, when there are areas of high community transmission and masks may well be something that we would be recommending.

Currently, it’s not standard and there’s a lot of debate about that.  If you apply masks with, and this is cloth masks, not the full-on respirators, but cloth masks with physical distancing.  Then there are some studies to suggest that that is something extra that you can do to first of all stop you from getting the infection, but if you do have it, if you’re unfortunate to have it, then you can stop it from passing onto others.  There is evidence that masks help, but only in certain circumstances.  They’re currently not recommended in general hospitals, for example, here in the regions, in our cancer centre where there is no community transmission.  There are simple physical things.  Unfortunately, there are no drugs you can take.  People say, could I do anything to boost my immune system?

Well, exercise, diet, get plenty of sleep.  These are simple lifestyle things that you should be able to do to boost your immune system.  I do not think that there is any evidence that there is a medication, unfortunately, so-called natural remedies as something you can take to boost your immune system.  There has never been any trials or science to show that is possible.  Simply lifestyle factors, such as good exercise and sleep and having a good diet would come under the heading of doing everything you can.

Joe:                             Yes, absolutely, that makes perfect sense, Christopher.  I really like how you speak plainly to it and I think this is what we all need to hear.  What are some of the things that I guess older people need to consider as they adjust to life after cancer diagnosis?

Christopher:            Our older adults and for this we’re talking about often patients over the age of 70 years, let’s say, for example, are at risk of developing cancer and then once they develop cancer, often due to the presence of core morbidities and other issues, risk from the complications of the treatments and are at risk of having more problems with just the cancer itself in many ways.  Despite that, as I say, if we assess outpatients adequately and adequately manage their core morbidities and give appropriate supportive care, I do not think that older adults should be denied appropriate treatment, even curative treatment.  A difficult treatment if they’re fit enough.  We should not treat our patients on the basis of age alone at any time.  Yes, people who are over the age of 85/90 are often frail, but not always.  Frailty as a concept is something we could talk about at length and fits into the assessment scenario.

In general, our older adults need to be treated with respect and treated appropriately.  Now, what can our older adults with caner actually do to help themselves through their journey?  First of all, they have some support, ask for help if needed.  There’s so many supportive medicines and things that we can give to try to get through the treatment toxicity, such as good anti-sickness medicines, as you’re well aware.  Medicine sometimes for the bowel problems that people sometimes get on anti-sickness medicine.  There are things we can give to help them through the journey and though the side-effects. We can give things; we can do things to help our older patients through their journey.

Then, of course, there are the teams.  There are supportive care teams.  Nurses, the allied health social workers, the teams of people often in the cancer centres who are there just to help our older patients.  There are regular GP visits, for example.  There’s keeping everyone in the loop and keeping the supportive care team together.  Then what can you do for yourself as an older adult?  Well, keep active, keep healthy.  Keep exercising.  Now, that is difficult in times of social distancing, and physical distancing, but keeping active is crucial.  At the same time, of course, in this pandemic, unfortunately, keeping away from other people as much as possible is difficult.  Here we have a number of challenges, but there are certainly many things we can do.  Where can you go for advice?  Well, as I say, the cancer council helpline is something we would recommend, but there will be a local cancer care coordinators, often oncology nurses, your doctors, and your GPs who’ll be able to provide you with good solid scientific advice to help you on your journey.

Joe:                             Yes, absolutely, Christopher.  I think it speaks to a lot is finding the courage to speak up and ask questions.  I remember from my own experience that it really mirrors exactly what you are talking about, that there is a lot of potential side-effects, which can be managed or helped when you ask the right questions of the oncology nurse and you try to understand what’s happening or when you maybe try to ring up your specialist and say, hey, what’s going on here, so you’re able to really understand what is happening.  That takes away a lot of the worry, a lot of the fear.  Whether you are in active treatment or maybe you’re living with cancer or perhaps even when hopefully you’ve passed active treatment and you’re in the survivorship stage.  Do you notice that that gives people a greater sense of control over their lives or to restore some of that calm, do you think?

Christopher:            That is such an important issue.  I think the sense of control.  Patients who sit in my office talking to me, they are often faced with something for the first time in their lives, they cannot control.  The cancer is often something that you can’t just wish it away and you can’t control it without help.  Sometimes even without treatments, they prove to be uncontrollable.  That is a very important concept, which we do need to recognize.  I think it goes back to what we might have said earlier about what patients feel they can do and against the cancer or more so for themselves to help feel like they might bring some control back into their lives.  Be it exercising and feeling better and getting fitter enough to have that treatment.  Simple things like that.  Something which will give them more control over this journey that they’re on.  I think that is a vital thing.  Other experts can help them bring that control and even help them through look at what’s important for them would be psychosocial support that the experts in the cancer centres can give.

Now, unfortunately, our wellness centre here at the hospital is closed.  Now, this is an important organisation formed by the patients with volunteers but through community support, they’ve been able to fund, for example, a full-time psychologist, who is so busy helping each individual patient through their journey from a psychological perspective.  The concept of psychology and that effort of support is so important.  Our community has recognised this.  Unfortunately, our health service is unable to fund it fully and so, through amazing donations from our local community, the organisation that runs a wellness centre is able to fund a full-time psychologist.  We really need two in our centre.

Of course, with the pandemic, the problem is that face-to-face visits are somewhat difficult, but our psychologists have also pivoted to tele-health and that has been very effective and she continues her really important work in our region to look after the mental health of our patients as they go through their journey.   It’s very important.

Joe:                             Absolutely, Christopher.  I couldn’t agree more.  I remember when I was in my oncologists’ office and he laid out different treatment options.  He said, we can go with chemotherapy, we can go with radiation.  Here are all of the pros and cons.  Have a think about what you want and then you can decide.  I was like, how do you expect me to decide?  I’m just some guy.  You’re the professional.  They took me a while to really come back to understand how empowering that is for the person who is dealing with cancer themselves to make decisions because I think it gives you some measure of control and it speaks to what you’re talking about, to what matters to you.  What is important to you and to your life?

Christopher:            That’s right.  These decisions are important, but as you rightly say in your own circumstance, they can be overwhelming.  If possible, I try and give my patients a framework in which to base their decisions on.  Listen to them carefully, try and determine what matters most.  Equally, they often provide more options.  It’s a really complex decision and I come back to the first consultation issue that we raised in the beginning.  Sometimes the things that matter most to the daughter of the patient is different from what matters most to the mother who is the one facing the decisions.  You have to factor in these complexities in the family relationships and the different people in the room when you’re guiding people through these difficult decisions.

That can be overwhelming but are really important because we’re talking often about people with incurable conditions who are going to be certainly my patients for the rest of their lives.  I need to get to know them and help them through these at times overwhelming decisions.  These are in ordinary times very difficult to make.  Here we are in Covid-19 pandemic when we’ve got to work out whether our treatment puts the patients at more risk of severe disease.  Yes.  My other thing that I say about older patients with cancer is, these things take time.  I cannot rush these kinds of decisions.  Sometimes you need more than one visit.  It takes time to assess our patients adequately, give them the options, listen to them and then finally find the right treatment path for the individual who’s with you.

Joe:                             Christopher, what about the cancer survivors?  Are they at a greater risk of being impacted by Covid-19?  What is the greatest impact or consideration there?

Christopher:            Joe, how do you define a cancer survivor?

Joe:                             Cancer survivor, I would define it as anyone who has finished active treatment.

Christopher:            Yes, so there are a few definitions around this, which is why I ask because some people think that a cancer survivor, your survivorship journey starts when you’re first diagnosed.  You’re a cancer survivor from day one, very important to have your flu vaccination, so you don’t get another infection to put you more at risk of the issues with Covid-19.  That comes back to doing everything you can for yourself.

Then as you go out and your immune system is picking up and you’re seeing the doctors less, really.  Often, the situation is you’re back to relative normal from a Covid-19 severity perspective unless those things you’ve got you can’t control.  Like, you’re older, you’re a bloke, you’ve got other core morbidities, any of that stuff happens.  Then yes, you need to stay away from the risk of getting it as much as possible.  Then we have visiting the hospital less and using telehealth to stay at home and have your care.  We’re here for you, even after you’ve finished your active treatment, make sure if you have a problem and a question that you seek help either through the GP or directly with our clinic.  If you have a question, don’t be scared of it because we’re here to help.

Joe:                             Absolutely.  Christopher, how important is it to get tested for coronavirus if you do feel unwell?

Christopher:            Yes, well, the current advice in the Australian context is that testing is vitally important.  That testing is available.  Testing does not cause significant side-effects in the self, if you like, it is uncomfortable.  It is a very long cotton bud, if you like shoved to the back of your nose to get those important cells at the back of the throat, which harbour the virus if they’re there.  You’ve got to get an appropriate sample.  It’s not comfortable.  However, it’s important to have the tests.  The current advice would appear to be that if you have any symptoms at all concerned, then have the Covid-19 test.  It’s vitally important.  Don’t come to hospital if you feel sick.  That sounds weird, doesn’t it?

Joe:                             Yes.

Christopher:            Ring first.  Don’t just share it around.  Think about it.  We’re going to have to think about this very carefully now.  I take part in a survey every Monday morning.  It’s a flu survey.  It’s an influenza symptoms survey.  I’d have to check the actual address because in my mind, I don’t have it.  Every Monday morning, I get asked a series of questions and there are 70,000/80,000 people who are involved in this survey every Monday morning.  It asks whether you have a sore throat, temperature, cough.  It’s usually used for influenza monitoring.  You can see in previous years; the influenza has been quite high.  This year, with all of the physical distancing, the rates of the normal influenza are really low and the rate of the symptoms around Australia and New Zealand are really low.

It shows the power of physical distancing to avoid these kinds of symptoms and these kinds of illnesses.  I think the other side of that is, when is business as usual and we all go to work with a bit of a sniffle, with a bit of a cough or feeling unwell.  Business as usual says, you’ll be right.  Well, we show that it’s very easy to pass on these kinds of respiratory illnesses to each other.  The rates of infections are quite high.  That’s part of what we’re used to.  Maybe that’s going to change in the post-pandemic era.  Who knows?

Joe:                             Yes, that might be one positive thing that comes out of this, is how do we manage it going forward?  Christopher, what are some of the best ways, I know we kind of touched on some of that already, but what are some of the best ways to keep yourself in good shape during the pandemic, especially if you’re an older person who’s living with cancer?

Christopher:            Once again, Joe, I think we need to think about this in a physical fitness and in mental fitness.  How do you stay in shape physically and mentally?  Such a great question.  Like cancer care, it’s individual.  It depends on who you are, how fit you are already, and what you like and what type of person you are and what kind of support you have, where you live?  These kinds of things still of course need to be factored in.  I find it interesting that in these studies of exercise in patients with cancer, often it’s the patients who are the frailest who benefit the most.  They’ve got the most to gain.  It’s the most interesting when we look at these studies of exercise in people before a big operation, for example.  In studies of pre-habilitaion rather than rehabilitation.  We find that it’s the patients who are almost most at risk that have the most advantage.

Another thing, don’t just assume that if you’re frail you don’t benefit from it.  Even simple exercise, such as strengthening the core muscles, for example.  I think activity is good, certainly not being active is better.  I think how you keep in good shape, clearly staying physically active, eating the right things, getting enough sleep, that’s important.  Then mentally, as we touched on, it is going to be hard on everyone.  Some of these catchphrases, like we’re all in it together, well, they’re okay to be said, but really when it comes down to it, there’s an awful lot of loneliness out there, ordinarily.  There’s an awful lot of people now having to stay alone, unsupported and fearful of any physical interaction.  This is an awful and interesting new time that we find ourselves in.

Mental health and support of people mentally through as many avenues as we can is vital.  There’s probably a lot of trials looking at this.  I know psych oncology is a really important area that we touched on already.  Psycho-oncology in the Covid pandemic becomes so much more important as we all battle through this individually with or without our support.  We need to be agile but also remember that we will sure be able to continue care for our patients as much as possible with as much continuity as possible and given the care that they need despite these challenges.

Joe:                             Thank you so much, Christopher.  Thank you for your time.  Thank you for just what you do in the world in supporting cancer patients and cancer survivors in such a difficult time.

Christopher:            Thank you, Joe.  Pleasure to be here.