“The Traveling Oncologist” Bridges Gaps In Rural Healthcare Access: Dr. Robert Hoyer, UCHealth Hematology and Oncology

Lindsey Smith

Hi, I'm Lindsey Smith, welcoming you to Raise the Line from Elsevier, an ongoing exploration about how to improve health and healthcare.

A nationwide study released in March by researchers at the American Cancer Society showed that rural communities now have higher death rates from cancer than urban areas, a reversal of the situation that prevailed in the U.S. fifty years ago. Among the key drivers of this turnaround is limited access to care.

That is not news to our guest today, Dr. Robert Hoyer, who has gained national attention as "The Traveling Oncologist" for his devotion to providing care to cancer patients in a large section of Colorado where no cancer specialists are based, saving patients the time, stress and cost of long trips to get the care they need.

Dr. Hoyer is Medical Director of Oncology at UCHealth Hematology and Oncology in Colorado Springs and a specialist in gastrointestinal and lung cancers. In addition to his clinical work, he spends his time focused on educating people about healthy living and cancer prevention.

Thanks so much for joining us today, Dr. Hoyer.

Rob Hoyer

Thank you for having me.

Lindsey Smith

So let's start at the very beginning. Can you tell us what first drew you to medicine and then specifically oncology?

Rob Hoyer

So I've always been interested in science as a, a young child. I liked, you know, Mr. Wizard and different science experiments and different things like that. I always, always really loved science. That was kind of my thing growing up: science fairs, model rockets, all those types of things.

And so I went to Georgetown University and majored in biology, and while I was there, I kind of really got to know a couple of professors. I did some research with Carolyn Hurley, who's a researcher in HLA immunogenetics, and also John Marshall, who's a clinician in oncology, specifically colon cancer specialist. Got to work with them and also an oncologist, Dr. Smith, in the community in Washington, DC.

And I really, I really like that combination of patient care and science. And putting that together, that's what really got me interested in both medicine and oncology specifically. And I've always really been interested in immunology, both for cancer prevention and for treatment. And it's been really great riding that wave over the past twenty years in practice.

Lindsey Smith

That's a great story, and I liked what you said there about loving science at an early age. So let's come back to oncology. You've carved out a very specific focus. Can you tell us why GI and lung cancer specifically and what drew you to those areas? And what do you, what do you find most compelling about working in those subspecialties?

Rob Hoyer

So both of those conditions, when I was in my fellowship, really we were struggling. I, I would think, would be a, a good, a good way to describe it. GI cancers, you know, were, for, you know, for many years it was 5-fluorouracil-based chemotherapy, was really all we had. We had, yes, we had oxaliplatin, irinotecan, but, you know, a f— a few monoclonal antibodies, but it was really very, very slow going.

Still a major issue with pancreas cancer. And, you know, we're, we're now seeing a little bit of hope now with, with, with the RAS inhibition for that disease, but still, you know, we're still, we still have a long way to go for pancreas cancer treatment. Lung cancer also was, was similar. It, back in, you know, go back to 2008 when I was finishing up my fellowship, we were just learning about EGFR mutation and ALK translocation. And now those are, you know, those are everyday topics that, you know, oncologists talk about just, you know, just, of course you're going to do sequencing to look for EGFR and ALK and other targetable mutations, but back then that was, that was not the case. That was, that was new. And we were treating everyone with platinum-based chemotherapy.

So I really thought these are two areas that have a lot of potential to really change how we, how we treat patients in medical oncol— in, in, in medical oncology and oncology in general. And, and that, that, I think that paradigm has come about over the past, you know, fifteen, ten to fifteen years. We've seen targeted therapy, immunotherapy, and still a long way to go, but we're making progress. And I really feel that the, those are two areas that, that, that really needed a lot of attention. The research funding came in. We saw those, you know, had those big advances, and the, and there, then, then you see the, the, the cure — increase in cures, better survivals, and yeah, that's what we're, we're here to do, is to help improve both quality and length of patients' lives.

Lindsey Smith

Absolutely, and I, I think it's really interesting that you chose those subspecialties because those areas needed more attention and that they had so much potential. You've clearly found your niche since then, and you took it somewhere where most physicians maybe wouldn't. So you've been making these monthly road trips into remote southeastern Colorado for about fifteen years now. Can you tell us how that started, and why is there such a gap in cancer care in that part of the state?

Rob Hoyer

So I'll back up a little bit. In 2008 I finished my fellowship at Mayo Clinic in Rochester, Minnesota, and then started in Colorado Springs later that year and started practicing oncology on the, what we call the, in Colorado, Front Range. You know, you're familiar with, but our listeners might not. That's the Front Range of the mountains that, that run the, the Rocky Mountains that run north-south in Colorado. And that's really where I, I'd say probably 90 percent of the medical care is, maybe 85 percent, is concentrated on that Front Range.

So I started practicing and just jumped into the c— community oncology and was there a few years. I think I was in twenty, 2010, late 2010, when I was kind of, I, I would say the term "voluntold," that I would be going to Lamar. And I said, "Where is that?" And I, I had seen patients from Lamar, but I, I was busy. I never really looked up, you know, where it is, or Alamos or La Junta or these areas. I, I, I just didn't know. And so started going out there and initially one day a month, and it was taking over a practice that another physician was retiring from. And my, my nurse practitioner and I went out and started working out there, and yeah, that's, it's been, it's been a great, rewarding experience since then, but a lot of, a lot of changes and a lot of differences, a lot of changes over time, and also differences with how we practice in Colorado Springs, and happy to talk about those too.

Lindsey Smith

So to play that back a little bit, you had to look at a map to find out where some of these remote southeastern Colorado cities were, and now you've been doing this for over fifteen years. That's a real commitment. So let's kind of talk about what these trips actually look like. Can you describe what life on the road is like, and what does a typical visit look like?

Rob Hoyer

So typically my nurse practitioner and I, along with a medical assistant and, and a, either a scheduler or a second medical assistant, will travel to, first to Trinidad, usually on a Monday morning. We travel out to Trinidad, which is about two hours south driving from Colorado Springs. And then we have a clinic there at Mt. San Rafael Hospital, and that's a general heme-onc clinic.

And then we, Tuesday morning we'll travel to Lamar, and that'll be a clinic from Tuesday midmorning to Friday afternoon, usually, what, 12:30, one o'clock. And then we'll return from Lamar to the Springs is typically how the, how the rotation will go. And that happens once a month. Over the years it's changed. We've sometimes had a nurse practitioner going every two weeks, and I, I would go every two weeks. We, we've found that it's better to be practicing together. Just, patients, we can have more real-time support for patients. I can jump in if there, if there's a question or a concern. I can, it's just more interactive, and it just seems to work better if we go together.

So that, so we, so we, so Rose Gates and I, she's my nurse practitioner, she's... Of note, she, she retired from her practice in Colorado Springs a few years ago, decided she just loved seeing patients and wanted to keep doing it. And so she decided to come back, and we're so grateful that she's back in practice part-time with me in Trinidad and Lamar. And she also sees patients in Colorado Springs as well.

Lindsey Smith

That's awesome. And I appreciate you shining light on what access to care kind of means in practice. I'm sure that your patients are grateful for you and your team coming on these road trips and the commitment of you continuing to show up for them. So at the top, I mentioned the data on cancer outcomes outside major cities is really sobering. Beyond extraordinary efforts like yours and what you and your team are doing, what can realistically be done to improve this situation at scale?

Rob Hoyer

So I, I, I would make two comments. This is a complex issue. Obviously, this has developed over, you know, there's, there's demographic factors, socioeconomic factors, you know, lots of different things that are playing a role here. So, but I wanted to comment on one and sp— specifically that I think is very doable, like, tomorrow Congress can do, which is make telemedicine a permanent part of Medicare benefits for, so for Medicare, Medicare beneficiaries. And then what'll happen is all the commercial plans will also follow suit once that happens. So right now we're seeing this, you know, post-COVID, telemedicine was, benefits were extended, then they were in question, and then they were extended again and then they just, a couple, just within the last year, same thing happened again. The funding is coming, which is, which we appreciate. And that's, I think, very important.

But the problem is that w— when, when the playing field is uncertain, hospitals, clinics may be hesitant to deploy resources toward these technologies if they're not sure that they're going to be covered in the future. And so I, I think making this a permanent benef— benefit of Medicare is, makes a lot of sense. Now, not all visits can be done via telemedicine. I recognize that. However, there's been a huge push to increase broadband internet throughout the country for the past twenty-plus years. What, what better usage of the broadband internet than to do real-time telemedicine consultation? And so I, I think this is a very doable thing that Congress can do, that they, they have to appropriate the funds permanently for this technology. But post-COVID, telemedicine is here to stay. It's, it was, it was in, in practice before COVID, of course, but Medicare didn't cover it. And so come COVID, the switch was flipped and all of us started doing telemedicine visits for, you know, 80 to 90 percent, or even sometimes on some days it was 100 percent of my clinic was telemedicine during COVID. And so it really is a great way to help with access.

And the second thing I'll comment on briefly is I really think there needs to be some type of, some mechanism for, whether it's, whether it's young, young oncologists or individuals who have, have significant student loans, or to, to help to be able to practice in... well, maybe you could, you could edit this a little, sorry, you could edit this a little bit, but sorry, I lost my train of thought a little bit. But bringing doctors into rural areas, for example, oncologists, bringing them in and encouraging student loan repayments or other mechanisms for, to compensate them for that time that they're spending away from their practice, away from their families, I think would be a very helpful strategy. And so we have student loan repayment for rural healthcare providers. Why not have that for specialists? And not just oncology, but you could do it for other specialties too. And encourage folks to come out, you know, one day a month or two days a month and have a, a rural practice. I think it's, it's very rewarding. It's wonderful to meet, to work with the patients and also to be compensated for that, I think, is also helpful in that, providing that community service, and is, it's, it really does help with access and also, I think, would help to support rural hospitals and also rural infusion centers, which we have concerningly seen a lot of those infusion centers have closed over the past, you know, five, ten years. That's a really concerning thing, when, because oncology, we know it's not just the, the, the clinical visits, it's those infusions, and those can be every week, every two weeks, and those are a, a huge part of the care as well.

Lindsey Smith

It sounds like there's no single solution here, but a few ideas that you mentioned were making telemedicine a permanent benefit for Medicare, improving the funding and technology coverage, and a mechanism for young oncologists to practice in remote areas and compensate them for their time. I think those are all really great ideas. Interestingly, your own focus has been shifting toward getting ahead of the problem entirely, because in recent years you've made a significant change to how you spend your time. You've pulled back on direct patient care to focus more on lifestyle factors and their role in cancer. Can you tell us a little bit more about that?

Rob Hoyer

Yeah, thanks. So I, I think many physicians go through this when they, you know, when we see patients and just think back, wow, you know, what if someone had really, you know, done some education or taken five minutes to talk about blood pressure control or, you know, ha— stopping smoking or wha— what have you. And so this is a focus that, something I'm very interested in with oncology. And there's a, we, we know that up to, up to 70 to, up, even up to 90 percent in some, in some stats of cancers are ha— impact— are influenced by lifestyle factors. And so lifestyle plays a huge role in many, in the, in the origin of cancer for many individuals. Not, not 100 percent, of course, but it's a big factor. And also the WHO estimates about up to 50 percent of c— cancer cases are preventable. I mean, this is a, this is a big deal. It's a big deal.

And of course the, the obvious ones: smoking, drinking and poor diet. But, you know, my mission is to help educate about some of those other, other factors too. For example, metabolic health. So obesity and diabetes are huge, huge factors in terms of cancer risk. Sleep: poor sleep, less than six hours of sleep a night, is associated with increased cancer risk. And so there's a variety of factors here that are really, I'd say, not in the mainstream in terms of general awareness or knowledge that, that really can impact individuals.

So a couple years ago, and my friend and I, we started a podcast called Two Docs Talk, and we've, since that was, have had guests and also content from both, both of our backgrounds. My, my friend's gastroenterologist, Dr. Shafi, and he, he contributed a lot about GI health and cancer risk and prevention. So we've, we've since sunsetted that podcast. However, I'm now working on a different project called Prevital Health. And this is a, the first, to my knowledge, the first cancer prevention app, and something that I really hope to roll out. It is actually live now. The site is prevital.health, and, but if the listeners want to go on, they can look, they can, it's also, it's all, it's in testing right now. So this is not, not HIPAA certified or anything like that yet. It's got to go through a lot more phases, but it's, it's in beta mode right now.

And so prevital.health, and users can enter the, the code. It's Prevital, capital P, Free. So PrevitalFree, all one word, with a capital P and a capital F. They can log into the Pro features and get some of the access to the AI tools that are part of this app. I, I really think there's something here. You know, I'm, and, and so I, I have not formed the, the company yet, but I hope to make Prevital a public benefit corporation and to roll this out to as many people that, that are interested in it. Because if, if we can really impact lifestyle choices ten, twenty years before the, the cancer is diagnosed, I, I really feel we can have a meaningful impact on both length and quality of life and potentially either prevent the cancer entirely or at least diagnose it at an early, earlier stage.

Lindsey Smith

That app seems very interesting, and we're gonna, we're gonna dig into that in just a second, and we'll be sure to link the links you shared in our show notes. So the more time you spent treating cancer, the more convinced you became that prevention was where maybe the real leverage was. And so let's talk, and let's talk about the app that you are creating. You are working on a cancer prevention tool that tracks lifestyle and cancer-specific risk factors over time. What's the vision? Yeah, go ahead.

Rob Hoyer

Yeah, so... Yeah, no, please, please.

Lindsey Smith

What's the vision for that, and how would it work exactly?

Rob Hoyer

So the idea is that it's a, it's an, it's a real-time app that offers both that assessment of cancer risk as well as, as well as basic recommendations. These are, there's, for, first and foremost, this is not medical advice. The app is not giving advice about, you know, medical, about treating, for example, blood pressure, or "Do this and you'll prevent risk of cancer." No, it's not doing anything like that. It's, it's a wellness tracking tool. And it's based on generally available knowledge about cancer risk. For example, eating fruits and vegetables. We know that those are a, sh— strongly associated with reduced cancer risk. So the idea is five or more servings of fruit and, fruit and vegetables per day, tracking that. So the, the app allows users to input their, their diet into the app or take a picture of their, what they eat, and then the, the AI will then convert that into fruit and vegetable intake. Reducing red meat, so trying to get red meat down as low as possible, because that is also associated with cancer risk. And the other one is fiber. So fiber, so the AI can estimate all this automatically. And then looking at other lifestyle factors too.

So alcohol, sleep, stress management. I think a big one, I, I s— strongly suspect a big one, is circadian disruption in our modern world. A lot of folks are on their phones more than four, six, eight-plus hours a day, especially young people. I mean, this is, this is, this is a huge change in how we spend our time, looking at these phones hours and hours a day. And even before bed, circadian disruption, a big factor. So the app goes through all that, and so there's daily check-ins, and it gives recommendations for how to try to increase, for example, increase, reducing screen time, increasing time spent in nature or with meditation or, and whatnot. And so it gives a stepwise approach. Once the user has those basics covered, it then goes a little bit more, more detail. You can get into more advanced things. For example, continuous glucose monitoring, or CGM, try to get, to look at metabolic health. Looking at, you know, for example, water that we use, rever— using a reverse osmosis or a Berkey product to filter water to try to reduce contaminants in the water, things like that. Not all of these are strongly associated with cancer risk reduction, but we suspect, we suspect that they have impact. So once the, once the user can get, gets those basics, they can go into these more advanced techniques as well.

The app is largely a AI-based, and so it uses a lot of different tech to both look at the, look at diet, lifestyle. It also looks at, there's a questionnaire at the beginning. It looks at health history, and then it can combine all that together and, and generate real-time recommendations for, about lifestyle. And it's, I think, a really powerful way. I was thinking it when I was designing it, like, why hasn't this been done yet? And I think it's just because there hasn't been really these tools to really... Now we have such access to these tools to both, to look at, okay, here, the, here are the ri— here are your specific personalized risk factors. Here's a couple of things to work on. For someone else it might be, here's, here, this other person's respect. They may be different. And so they're probably different, in fact. No two people are alike.

And so I, I really feel that this is something that, you know, it, it, it basically is in addition to what you're, see, working with your doctor and help, all the other regular health screening that you're doing with your doctor, cancer screening, mammogram and colonoscopy and whatnot. Absolutely, it's not meant to replace any of that, but to supplement it, and really feel that this can have a significant impact on people's lives.

Lindsey Smith

That you're thinking about this more upstream, and so this tool is not focused on treating the disease, but designed more so as a personalized wellness tracking tool with the intention of trying to catch it before it starts. So you mentioned AI in your tool, and so I want to kind of come back to that. You've made a bold prediction that AI and other advances could lead to a cure for cancer by the late 2030s. What's driving that optimism?

Rob Hoyer

Correct.

So there's a couple of things here. The biggest one, and if you look at the, the cost of computing power per one U— U.S. dollar adjusted for inflation, you see this dramatic increase in, you know, the, in computing power relative to cost. And so it, it's not, it's, it's, it's a... It's such a exp— it's an exponential curve. Initially, in the, in the fifties and sixties, it was there, but it was, you know, you know, infinitesimal compared to what we have today. And what we will have five years from now, ten years from now, and when you put together the, these exponential technologies, AI, quantum, I, I very much think it's, it's extremely likely that we'll have a, a cure for most cancers by, by then. And, you know, things like, you know, sci-fi stuff like nanotechnology. These are all things that are s— we know today are, you know, in Star Trek-type stuff. But that little secret is Star Trek's real. It's coming. It's gonna be coming, you know, very, very soon, actually, the next decade, fifteen years. And that's a big, big deal.

And I think it's, you know, even more important to be cognizant of our health today, because, you know, we're gonna have, yes, we'll have better treatments, but, you know, we, let's, we, we, that's not, we, we have a little ways to go before we, we get there as well. We have to be able to survive to, and, and live and thrive until the, you know, the 2030s, to, to be able to see those technologies. I think these technologies are gonna have a dramatic im— increase in, in human lifespan. I think we're gonna see a, you know, the, the hundreds will be, will be normal, I think, in, in the coming decades. To see folks live into their nineties and hundreds will be routine. And so huge s— changes in society and other, other aspects of life.

But yeah, I think the, you know, I, I'm an optimist at, at heart, and I, I really feel that there is, we're, we're gonna see some, you know, huge improvements. I, I believe, I believe in humanity, and I think we, we can do this, both in terms of improving access to care and also, you know, the, the, the other part of this is that we have, you know, we have great technology, but a lot of patients are not being able to access that. And so we have to be able to... It's, it's, it's not just about having the technology, but also the access to that technology, which is so critical.

Lindsey Smith

Absolutely, and that's a hopeful note that you just shared with us, and science and technology is certainly moving very fast. So in our audience, we have many students and early career health professionals listening in. What's your advice to them about building a career in medicine and meeting the challenges of this moment?

Rob Hoyer

Biggest thing is keep learning, and is, that's, and your goal as a healthcare provider or physician is not to dictate but to educate, and that's, those would be, be my two biggest pieces of advice, and, you know, recognizing that probably most of what you're learning today is either wrong or it will be outdated in six months. Just recognize that. Take it as fact. That's, that's it. It's, it's, it's, it's gonna change. You ca— you always have to keep asking questions and learning and working with patients.

I, I feel that when we, when we give patients the, the tools and educate and give them the tools, you know, they make really good decisions, and, you know, it's empowering patients to be able to, to be able to both access the care and then continue with those, their, their treatments, and then, and then live, and the, the, those, those cancer survivors who can live and then educate others in, in the process, I think is really important. But yeah, I really, I think we have to have a very transparent relationship with our patients and let them know that we don't know everything, that every, that we're still learning a, a lot, and this is something that medicine is an ongoing, lifelong learning. So...

Lindsey Smith

That's wonderful advice about being a lifelong learner, and I know our listeners will appreciate that. Is there anything that I didn't ask you today that I should have?

Rob Hoyer

I, I think we covered everything. I, I know I, I, I do think one of the aspects I would just add is that when I went to Lamar back fifteen years ago, it really opened my eyes, the situation in rural healthcare. I, I was, I ha— I'd always trained it at Georgetown and Mayo, and so, you know, was used to working in these hulking medical centers, and I really enjoyed it. I love, you know, love the medical center setting. It's a great center of learning and collaboration, and the patients are the focus. It's wonderful. But when you get out of those medical centers into these rural communities, it really opens your, opened my eyes. I, I, I had, I, I was shocked at how different it was.

And these little, these rural hospitals are really, really struggling. And both for providers, physicians and nurses and techs, and for example, sometimes they have the, these rural hospitals will have an MRI machine or a mammogram machine, but they don't have a tech to operate it. I, it just, you know, that just struck me as, like, what? You don't have a tech? You have the mach— you have the equipment. You don't have a technician to operate the machine. And, you know, I, so really we, we need to, I, rethink how we look at healthcare in the, in the, in the U.S.

We can do this as a country. We've done some amazing thing. We've done many amazing things in America over the past, you know, no, now 250 years. This is our, our great nation, is, you know, I think, will continue to be really a, a leader in many fields, but we need to, we need to figure this out. Like how, like, we have, there's millions of people with really, really poor access to healthcare. And this is, I think, the, the responsibility of, for all of us, including our elected officials, to figure out a way to, to help improve this.

Lindsey Smith

Access to healthcare is an ongoing challenge that we must figure out together. One thread running through everything that you've shared today is that medicine at its best is about showing up for people, whether that's driving hours into remote areas in Colorado or building a tool to prevent cancer before it starts. Dr. Hoyer, thank you so much for being with us today and for the work that you do every single day.

Rob Hoyer

Thank you so much for having me.

Lindsey Smith

And that does it for today's episode. Dr. Hoyer, what you're doing for patients in underserved areas in Colorado is a reminder that access to care isn't just a policy issue, it's a human one. Thank you for being on the front lines of that fight.

To our listeners, thank you for tuning in to Raise the Line from Elsevier. If this episode resonated with you, please share it and subscribe wherever you get your podcasts.

I'm Lindsey Smith. Thanks for checking out today's show. Remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.