States across the U.S. are beginning to re-open and life is taking on a ‘new normal’ as people venture more and more outside of their houses. For breast cancer patients, now is a time to be extra vigilant about your health, regardless of whether you’re going to the pharmacy to refill a prescription or to the doctor for an in-person check-up.
Susan G. Komen’s recent Facebook Live examined ways patients can protect their health during these times and whether non-symptomatic women should resume getting their annual mammograms. Dr. George Sledge, one of Komen’s Chief Scientific Advisors, and Dr. Lisa Carey, a Komen Scientific Advisory Board Member, shared what their respective institutions are doing to protect patients who are coming into their facilities and how they’ve been able to care for their patients during the COVID-19 pandemic.
Sledge is a medical oncologist, a Professor of Medicine and Pathology and the Chief of the Division of Oncology in the Department of Medicine at Stanford University. Carey is also a medical oncologist, a Professor of Medicine, an Alliance Breast Committee Co-Chair and the Deputy Director of Clinical Sciences at University of North Carolina Lineberger Comprehensive Cancer Center.
Their conversation was moderated by Sandy Finestone, a breast cancer survivor and member of Komen’s Advocates in Science Steering Committee and Komen’s Scientific Advisory Board. Below are excerpts from that discussion.
What does ‘re-opening’ look like at your respective institutions? Are in-person appointments increasing?
Dr. Carey: North Carolina was blessed with having a relatively flat curve, and they actually just started allowing some expansion, but it’s a pretty slow change. From a hospital standpoint, we instituted a number of changes in the way patients entered into the hospital. We cut down by more than half the number of people, patients themselves, who are being seen, and we cut back very, very much on the number of visitors that patients could bring with them or have visit them. The registration processes were all changed. The checkout processes were all changed.
Additionally, about half of the patients that I interacted with today, I did virtually and about half I did in person. I do think that those proportions may increase a bit, but I think there’s a lot of value to virtual visits for certain type of patients, and I think we will likely continue to have virtual visits as a much larger component of what we do going forward.
Dr. Sledge: The six-county area around the Bay Area [in California] was actually the first area in the United States to shut down, and we remain in a shelter-in- place mode for most people who live there, though we’re collectively starting to gradually reopen some businesses. From a hospital standpoint, we never stopped doing cancer surgery, but we certainly did stop doing routine screening mammography for patients coming in. These have now been deferred several months. We are starting to reopen our screening mammogram and breast imaging facilities. In addition, we’ve tried very hard – if a patient doesn’t need to come in, this would typically be a patient who is a routine follow-up patient, to do virtual teleconferencing with patients. We have always continued to see patients who are receiving pre-operative chemotherapy, for instance, or where we need to do an in-person tumor measurement. Many of those difficult discussions that oncologists have with patients have been done in person as well. But, certainly, we’ve seen a significant shift towards videoconferencing for our patients.
Can patients be confident that it is safe to have in-person appointments?
Dr. Sledge: I think most hospitals today are probably some of the safest places on the planet in that we have an enormous amount of testing going on inside the hospital. Of course, hospitals are very good at cleaning surfaces. It’s what we’ve always done, although we’re certainly doing it even more so now.We’re going to great lengths to try and make sure that those who take care of you are not likely to give you the infection and that the surfaces that you’ll come in contact with are uninfected because they’ve been regularly cleaned. I think hospitals and outpatient facilities associated with those hospitals, such as mammography units, are some of the safest places around today.
Dr. Carey: These kinds of administrative and operational structures and engineering of how people interact with each other are actually the first line of defense, and hospitals have been doing that for a long time. PPE – the masks – that is the last line. So, what you want is a place that minimizes the risk before you get to the point of gloves, handwashing, and PPE. The other thing is, this isn’t going away, so it’s not as if we have to get through the next few weeks. The reality is, these need to be sustainable and longstanding ways of interacting with our patients. I do think that, for the most part, these are pretty successful, and I think your risk of infection is higher at the grocery store than at the hospital.
Presumably breast cancer patients will start to venture out more, whether they are leaving their house to go to the pharmacy or back to work. So, what should they pay attention to or be vigilant about?
Dr. Sledge: Being vigilant is appropriate social distancing. This crisis is not over. Going to your local tavern with 300 other people is still not a good idea, despite what you may see on certain networks. Being careful in that regard is certainly going to continue to be important for a very long time. Avoiding large get-togethers and wearing masks where appropriate – I think these things are important. At the same time, we have to realize that as much normalcy as we can have in our lives is an absolutely good and appropriate thing.
Susan G. Komen issued a statement in March, suggesting non-symptomatic (no sign of breast cancer) individuals delay routine breast screening this spring to mitigate risk to COVID-19 and allow health care workers to focus on managing the pandemic. Should these individuals continue to delay their routine screenings?
Dr. Carey: We shut down all screening efforts of all kinds at my own institution and at others because early on it wasn’t clear whether there was going to be a massive amount of infections, such that it would overwhelm the health resources. I do think that it is perfectly reasonable for a woman who feels well and is due for her mammogram next month, to do it next month and not put it off a few months. I don’t think there’s any danger to that and I don’t think she should become overly anxious about it. I also don’t think she should say, “I’m going to stop having mammograms.”
Dr. Sledge: In terms of general health measures, screening mammograms saves lives. If you have not had a mammogram and you’re overdue, you should sign up for one.
Are there dangers if a woman notices something abnormal in her breast and puts off seeing a doctor?
Dr. Sledge: We actually are seeing far fewer new cancer patients right now than at any time in recent years. I think this is partly due to screening. I think this is partially due to patients who are having symptoms who are avoiding the health care system because of concerns of infection. Certainly, if you have a symptom, if a woman, for instance, has noticed a breast lump and is concerned about coming to a hospital because of risk of infection, I think this is clearly the case where the risk of infection is far less than the risk of dying of a cancer left untreated.
Delayed long enough, a stage I breast cancer can become a stage II cancer. A stage II cancer can become a stage III cancer, and any of them, in theory, could become a stage IV cancer. Brief delays are probably of not much significance – prolonged delays certainly are. We don’t want to lose the gains we’ve made in treating this disease.
Learn more about what you should do if you notice a change in your breast.
How are surgeries for newly diagnosed breast cancer patients being handled?
Dr. Sledge: In our institution, we never stopped doing surgeries for patients with invasive cancers. We’ve considered that important and gone forward with it. We have delayed surgeries for some patients with ductal carcinoma in situ (DCIS), where someone had a core biopsy and had a DCIS, but for an invasive cancer we’ve always gone ahead with surgery. In many cases, we’ve gone ahead with systemic adjuvant or neoadjuvant therapies for those patients.
Dr. Carey: Even at the peak of our concern, surgeries were urgent, priority, and elective and there were some nuances within those, but anycancer-directed surgery, outside of cosmetic stuff, was considered priority. They never stopped.
Do you see elective surgeries slowly being incorporated into your normal routines?
Dr. Sledge: This is going to vary center-by-center, and region-by-region. There are still places in this country where the health care systems are still relatively overwhelmed and, because of that, people have had to make hard decisions. Fortunately for most of the country, we’ve been able to continue with elective surgeries, and I think increasingly we’ll be able to do so.
Which patients are considered immune compromised, and what advice can you give these individuals as they leave the house?
Dr. Carey: I think outside of cytotoxic chemotherapy and, to some degree, CDK4/6 inhibitors and some of our other treatments, I think a patient who has just gone through surgery and endocrine therapy (hormone therapy) for example – I don’t consider them to be particularly immunosuppressed. Our patients should continue to be vigilant about how they interact with the health care system, with the grocery story, with everything else.
There’s a little bit of data that has come out about how cancer patients who were patients within large metropolitan hospitals fared, compared to the rest of the population. All cancer patients, in general, didn’t seem to be at a particular risk of getting COVID-19 or of having a significant complication of COVID-19, just by virtue of having a history of cancer. On the other hand, there were some groups that did appear to have an increased risk of complications of COVID-19, and by that we mean needing to be intubated or dying of it. Again, it wasn’t everybody and I think there are a lot of nuances here.
Dr. Sledge: Many of the agents we use, many of the chemotherapy drugs we use, CDK4/6 inhibitors we use, their principle effect on the immune system is to affect what are known as the neutrophils. These are the white blood cells that fight bacteria, and they probably in many cases, if not most cases, have a lesser effect on lymphocytes, the white blood cells that fight viral infections like COVID-19. So, we’re still not just quite clear yet how much risk a patient is at even if they’re receiving chemotherapy. I think we all suspect that they’re at somewhat increased risk – how much? I think it’s hard to say.
Should I be concerned about immune risk if I’m undergoing radiation treatment? Should I be alarmed or using extra caution due to treatment?
Dr. Sledge: Radiation therapy certainly affects circulating lymphocytes. Patients who get radiation therapy get some reduction in their circulating lymphocytes, though generally not to a dangerous range. During the current pandemic, everyone should be careful, wash their hands, practice social distancing and use the appropriate masking if they’re going to be in a social situation.
Dr. Carey: Whether the personal risk of catching this virus is increased [while undergoing radiation treatment] – I think time will tell. However, a patient coming into hospital to get radiation therapy is touching doorknobs, using elevators, coming in contact with hematologic malignancy patients, etc. These factors may, in fact, create a greater risk of a poor outcome. So, I think there’s a duality to this which is not just the risk to oneself, but are they frequently in contact with others who might be at an increased risk of having a problem?
Should newly diagnosed MBC patients be cautionary about their immune system?
Dr. Sledge: I suspect many patients – especially advanced metastatic disease patients – are going to be at least modestly immunosuppressed. They may have had prior radiation therapy, which I explained earlier could affect lymphocytes, they may have had multiple prior regiments, their cancer itself may be having some immunosuppressive effects. My suspicion is that they are probably somewhat in a higher risk population, so I think it’s reasonable to think in terms of them being a little bit more precautionary.
Are there any new or different questions you’re asking your patients during these COVID-19 days that perhaps you did not consider previously?
Dr. Sledge: One change that I’ve noticed is that the goals of care and end-of-life care conversations have taken on a very different tone, compared to the pre-COVID era. I think those conversations have become franker and more open both on my part and on my patients. I think those conversations have certainly changed; now they were always there, and we always tried to be good about those things, but the reality is that this is certainly brought it to the floor, both for the patients and for the physicians.
What positives have you seen come out of all of this?
Dr. Carey: One of the striking things that happened was that the modeling for the disease, the trajectory of the disease, and the institution of the safeguards was a highly collaborative effort. Institutes and services were all working together, they were sharing resources, and scientists were collaborating on research.
Dr. Sledge: In the past, many of our studies had end points that were looking for fairly minor differences in terms of outcomes that were statistically significant but clinically not particularly important- fairly brief improvements in progression-free survival, for instance, for patients with metastatic breast cancer. I think the recognition that there are real trade-offs in terms of how many touches the metastatic cancer patient has with the healthcare system has led many of us to say, “Maybe we should be redesigning these clinical trials to look for much more significant improvements in terms of outcome before willing to declare a victory with the new drug.”
And the importance of science and medicine has never been clearer than it is now. Research cures cancer, research will cure COVID-19!