Breast surgery and treatment changes during the coronavirus outbreak

As people across the country deal with the outbreak of COVID-19, the disease caused by the new coronavirus, we’re here to help you find the information and support you need. Every week, we’re speaking to experts from our medical advisory committee about ways people with breast cancer may be affected by COVID-19 and efforts to prevent its spread.

Living Beyond Breast Cancer CEO Jean A. Sachs, MSS, MLSP, spoke with breast surgical oncologist Monique Gary, DO, MSc, FACS, about how new recommendations can affect breast surgeries and testing. They discuss ways doctors are adapting treatment for early-stage breast cancer during the outbreak, from postponing checkups and some reconstructive surgeries to holding video appointments and giving chemotherapy before surgery. Watch, listen, or read the transcript below.

Monique Gary, DO, MSc, FACS
Dr. Gary is a board-certified, fellowship-trained breast surgical oncologist and medical director of the Grand View Health/Penn Cancer Network in Sellersville, Pennsylvania. She has served as director of the breast program there since its accreditation in 2015. She is the founder of the Cancer Genetic Risk and Prevention Program at Grand View Health, which provides genetic counseling and high risk management for those with a strong family history of cancer and those with known hereditary cancer syndromes. Dr. Gary would love to hear from you: Follow her on Facebook, Instagram, and Twitter.

Jean A. Sachs, MSS, MLSP

Chief Executive Officer, Living Beyond Breast Cancer

Jean began her work with LBBC in 1996 when she became the organization’s first executive director; she was named CEO in 2008. Jean brings a lifetime of women’s advocacy experience to her role as CEO. She lives LBBC’s mission everyday by speaking with newly diagnosed women about their needs and gaps in support. Read more.

 

Jean Sachs (00:00):

Hello everyone, it's Jean Sachs. I am the CEO of Living Beyond Breast Cancer and today is April 1. We are in the middle of our third week of fully understanding the implications of COVID-19, and for many people, their regular routine has really been altered.

We've been doing many things at Living Beyond Breast Cancer and one is, a couple times a week, we've had the privilege of talking to some of the members of our medical advisory committee, doctors and other healthcare professionals from around the country who have generously given us, some of their time to answer your questions and help you navigate [breast cancer care in this time].

I'm very pleased that today I have Dr. Monique Gary with me. Dr. Gary is a breast surgical oncologist and the director of the breast program at Grand View Hospital, which is part of the Penn Cancer Network.

So welcome Dr. Gary, and again, thank you for joining us.

Monique Gary (01:02):

Thank you so much for having me. It's a pleasure to join you today.

Jean Sachs (01:05):

We've had the privilege of having Dr. Gary speak at some Living Beyond Breast Cancer programs in the past, and not only is she intelligent and compassionate, she also has a really wonderful sense of humor, an incredible way of connecting with patients, so I know you're going to be very helpful to our audience.

We know many things have changed in the world, but we also know many things have changed in cancer care and for us specifically [in] breast cancer care. Let's start at the basics. Tell us, are women getting mammograms today?

Monique Gary (01:42):

Yes and no. Women are not currently getting screening mammograms. The recommendation at this time is, because it's not urgent if it's for surveillance or for annual follow-up, those women should forgo that screening for a few months. But if a woman needs diagnostic imaging, she is still able to get that in most places. There are some regional differences depending on the status of the hospital, for example, in Seattle and in New York City. There may be some challenges there, but pretty much across the country, women can still get diagnostic imaging.

Jean Sachs (02:16):

OK. So, if they feel a lump that's a diagnostic image, but anyone coming in just for their annual would be asked to wait.

Monique Gary (02:25):

Exactly. Yeah. I feel it's better to not put those patients at risk at this time.

Jean Sachs (02:30):

That's great to know.

If someone was in the middle of getting her full workup for a diagnosis before this all happened, what would happen? Would she still be getting a biopsy and other screening? How is that working?

Monique Gary (02:47):

Yes, women can still get their biopsies. I have a number of patients right now who are newly diagnosed or who are in the process of being diagnosed. At our institution, biopsies are still happening every day. I can still get things like diagnostic MRIs to help guide decision making and help perform staging. PET scans are still being performed in many institutions. So the work continues. Yes.

Jean Sachs (03:13):

If there is a woman out there, and I'm sure there are many who are in the middle of this, what can they expect? And what is different than it would have been a couple of weeks ago?

Monique Gary (03:23):

I think women can expect a couple things. One, their imaging might not happen at a hospital. Their biopsy might happen at an outpatient imaging center as opposed to a main facility. [And] they might find that their visits, at least their initial visits with their doctors and providers might be virtual visits.We have begun to utilize telemedicine very heavily. I've counseled three patients today, and increasingly so we'll utilize the virtual platform as we're able to.

I think patients should also expect that their care is going to continue, but that the treatment algorithm, the guidelines and the pathways that manage how physicians take care of patients with cancer, that algorithm has been turned on its head completely.

Jean Sachs (04:07):

I know that you're learning right along with the patients. Right?

Monique Gary (04:11):

It's true. And I think each society, whether it's surgical or medical or radiation. we all had some idea and concepts about what we should do for patients during this time. But it really was thanks to the society, the American Society Of Breast Surgeons, and President Jill Dietz [MD, FACS] who put together an expert panel of physicians from the medical oncology world, from the radiation oncology world, from breast imaging, and really got together and came up with a consensus statement for how we think breast patients should be managed from diagnosis through to their treatment through surgery, through medicine, through radiation.

We're all starting to get on the same page across the country regarding how patients might be treated. And it does differ some from the NCCN [National Comprehensive Cancer Network] and some of the other standard guidelines that patients have used as a resource historically.

Jean Sachs (05:02):

Well, thank you. I'm so happy people stepped in and I'm sure that it happened really, really quickly with a lot of coordination, so we're very grateful for that.

I know for many women who are newly diagnosed they like to get a second opinion. Is that happening? Is that possible? Is that something you're not encouraging right now?

Monique Gary (05:23):

I think it's always encouraged for patients to be well-informed and I encourage patients, when they have additional questions or when they want to understand their treatment a little bit better. If they need a second opinion, that's something they should do for their personal peace of mind.

It is still possible with a cancer diagnosis to get a second opinion. The timing and the manner [of] that second opinion could be varied because there are differences regionally as well as nationally regarding how we're treating certain breast cancers. I'll give you an example. Certain [cancers] that are triple-negative, they have no receptors, therefore they couldn't be placed on a hormone-blocking pill. Many of those patients now are going directly to chemotherapy before their surgery as a bridge to surgery. Even those with slightly earlier disease are now being downstaged and we're bridging and buying time to keep patients out of the operating room and away from viral particles. The goal really is to do the safest thing for patients. Sometimes that's surgery and sometimes it may be going on a pill, like a hormone blocker like a letrozole or a tamoxifen at a time when we might have previously done surgery on some of these patients, there's some subtle differences there

Jean Sachs (06:37):

That's important for everyone to know, that if you're Googling best practices for a certain subtype, it may be different during this particular time period.

Let's talk about surgery because I know you spend a lot of time in the operating room. Some of the questions we're getting are people [asking] are lumpectomies and mastectomies happening? And are women still getting the choice of a mastectomy or lumpectomy?

Monique Gary (07:06):

So the answer, the short answer is yes. Yes, they are still happening. There are again, regional differences, depending upon what level of alertness your hospital is having regarding COVID-19. As we see this virus spread through the country, we may find that regionally we may be doing less surgery on even early disease, like in New York and in Seattle and other places, but in general, a woman still can get a lumpectomy, she can still get a mastectomy.

There is a current moratorium on certain types of reconstruction. For example, autologous reconstruction, where we take the patient's own tissues, muscles and fat from the abdomen, the tummy tucks, things like that are not being performed at this time. The recommendation is that we should consider very heavily not performing contralateral procedures for symmetry, contralateral meaning the opposite breast. If a woman was getting a lumpectomy and wanted reductions or asymmetry-matching procedures, in some places in the country those are being delayed. So, the cancer will be removed, but other cosmetic procedures might be delayed.

Jean Sachs (08:12):

We've been hearing that and I'm glad you touched on that because that was part of my questions as well. And we will cover plastic surgery in depth with a plastic surgeon in the coming days.
For the woman going in for surgery, I know things have changed in hospital protocol and how many visitors [are allowed] and those kinds of things. Can you give us a sense of, what is it like to go in as a patient today for surgery?

Monique Gary (08:37):

I think it's scary all the time, and right now it's no different because most of my patients will come with several family members. It's a good time for family to rally around and some of my patients have the family tee shirts that they have all ordered together or special things that they like. They like to pray before surgery, things like that. And some of those practices are definitely being challenged right now because hospital policies prohibit more than one visitor. In some instances, no visitors are allowed. It calls upon the physicians and the nurses and the staff to make sure that we step in and fill the gap. We honor our patient's wishes, whether it is a prayer or …
I always ask my patients right before we take them back and [I] say, “I have one more really important question for you. It’s the most important question anyone has asked you all day.” And they're terrified. Then I say, “What kind of music do you like?” And they're instantly at ease and we play the music that they like as they go off to sleep.
It's a good time for us to step in and let our humanity shine because cancer is scary, whether COVID-19 is around or not. Cancer patients have known this fear and this isolation and fear of infection and worry about contracting something that's something cancer patients live with every day. I think it's important to make sure that we support our patients at this time.

Jean Sachs (09:58):

That's wonderful to hear because I know there's a lot of anxiety and then having to go into the hospital without your family knowing they'll be right by your side as soon as they can be.
What about follow up care? I know a lot of, well almost all, patients go home with drains and I know they can often be managed at home, but what is the protocol for follow-up visits once someone is discharged?

Monique Gary (10:22):

Once a patient is discharged, at least from my practice, once they're done with surgery, if they have drains, we make sure that a home-care nurse or a visiting nurse will come out to them, and that has not changed yet. It'll be interesting to see if, as things progress, we need to perhaps curtail home visits by nurses, but as of right now a nurse will still come out to help teach the family how to manage drains and to do an immediate post-op check.
If the patient does not have drains, which many of my lumpectomy patients don't, then they're discharged with follow-up instructions to notify me for fever over 101.5 [degrees] redness, bleeding, other things like that.

Then there will be a follow-up appointment. That follow-up appointment right now is a combination of virtual appointments and in-person appointments. As much as possible, I like to see my patients postoperatively to check their wounds and incisions.

But we are trying to be very flexible about bringing patients into the hospital and into the clinic setting because, as this virus spreads, we're finding that maybe up to 50 percent of the people who are spreading it are asymptomatic. All healthcare providers are in some ways assuming that, we may be at risk of spreading it. We want to limit our patient's interactions with us as well for safety. So, a combination of in-person and virtual visits as the situation dictates.

Jean Sachs (11:44):

That really leads in nicely to my next question. We’re asked this a lot right now: If you have had surgery and no chemotherapy, are you any more immune compromised then the general population?

Monique Gary (11:57):

It's a great question. The short answer is yes, you are. Because surgery creates an inflammatory response in the body. All of the things that help us to heal are the things that respond to injuries that surgery is. It damages cells, chemotherapy damages cells, radiation is cell damage. There is always an element in what we do that will compromise a person's immune system, but not to the degree of a person who is, for example, undergoing active chemotherapy. But in the average patient, even a cancer patient, their immune system will restore. It will help to overcome any challenges that you're facing.

Jean Sachs (12:36):

I think everybody wants to know these days, “Am I immune suppressed?” and I think we're learning we sometimes don't even know if we are or not.

Monique Gary (12:44):

That's true.

Jean Sachs (12:45):

You touched on the breast reconstruction question, but do you want to give a little more about what's changed? Because it's changed pretty recently.

Monique Gary (12:53):

Sure, absolutely. I can tell you, in the last 3 weeks I've had to call patients and change their entire treatment plan around. They had initially wanted to have the deep surgery or deep inferior epigastric perforator [DIEP Flap], the fat from their belly placed into the breast at the time of their mastectomies. They were booked for these surgeries and they've met their plastic surgeons and they've discussed and we signed consents, and now we realize that we cannot, one, keep a patient in the operating room for that length of time, but two, utilize resources like an intensive care unit where those patients have to go after surgery for 1 hour, monitoring.

The ICU is not a safe place right now. So in those patients, we are currently placing tissue expanders, which are our space holders that can be filled with air or fluid and it helps the breast to keep the shape. It helps to keep the skin from contracting too much and we will go back and do their flap reconstruction at a later time.

Jean Sachs (13:49)

How are your patients reacting to that change?

Monique Gary (13:53)

A combination of frustration and fear and also understanding, because they want to be safe too. They don't want to be in the hospital and they want to do the best thing and many of them just want their cancer gone. When they understand that the primary goal is to do the safe thing for them, which is to remove the cancer where possible and, we can do the rest later and that yes, insurance does cover it, yes, we will make sure that all of their needs are addressed leading up to that surgery, but we've got to get rid of the cancer. I have a hashtag going on social media right now. It says #CancerDoesntQuarantine.

Jean Sachs (14:33):

That's great. I think I am going to follow you.

I just want to thank you. I'm realizing as I talk to more and more doctors, I really do think this is a time where we have to trust our doctors. We have to trust all these societies and professional organizations who are thinking through best practices in a very unusual time. If women are facing a delay or a change, they have to believe that this was very carefully thought out. And those people that really need to move forward are being moved forward. Is that how you see it?

Monique Gary (15:10):

Absolutely. I'm seeing heightened anxiety among patients and so I spend a lot of time working with patients through that anxiety because a cancer diagnosis in and of itself bears so much anxiety. Now if your radiation, for example, is delayed, you've come through your surgery and you're all done and well, what about my radiation? Why can't I start? Why is it being delayed? Or, I finished my chemotherapy. Can my surgery still proceed? So [there’s] a lot of counseling, a lot of time with patients.

I'm seeing also an indomitable courage. This is a time when women are able to really look within themselves and to manage some of the things I think that will help them to have a full and holistic picture of what wellness looks like beyond breast cancer, as you say, living beyond breast cancer looks like.

I tell my patients more than ever to listen to their bodies. You have got to listen to your body. You've got to eat good food and get good rest. There are so many resources available online right now for meditation, for yoga, [for] cooking classes.

Everything is virtual. In that virtual connectivity, in that virtual world, there's less physical interaction, but there's a lot more resources for patients. Tapping into those things, I encourage my patients to try to find something positive. I spoke to three patients today and I said tell me what you're looking forward to. Let's start to think about, when this is over, what are you looking forward to? And then everybody said vacations, they all want to go somewhere. And I asked them, well what brings you joy? Trying to focus on those positive things.

And the last thing I would tell patients is to speak up if there is something that you need, if there's something that you don't understand, there will be people available. We still have our nurse navigators, we still have our social workers available. All of the physical supports that were available to patients are still available either physically or virtually or a combination of both. It's not the time to suffer in silence. If you don't understand, talk to your doctor in whatever form you can. Reach out to organizations like [Living Beyond Breast Cancer] if there are things that you need, you don't have to go through this alone. I hope every patient taps into that and lets that resonate that. Even though we're all isolated, you don't have to go through it alone.

Jean Sachs (17:20):

That is such great advice and every one of your patients is so lucky to have you watching out for them and helping them through this.

Monique Gary (17:30):

Thank you so much.

Jean Sachs (17:31):

Thank you so much for your time. And I want to thank everybody for listening. Please share this. We really want people to get information that is relevant and up-to-date and we realize it might be different next week and we might have to bring Dr. Gary back to tell us what's happening next and we'll be committed to doing that.

Please remember that Living Beyond Breast Cancer is here all the time. At LBBC.ORG we have several new closed Facebook pages. Go on and we'll join you in that group. There's some amazing conversations going on in real time. You can post your question or what you experienced and you'll have a very supportive community. We also have a helpline, and again, we're continuing to create resources, so stay with us and we'll stay with you. Stay safe. And again, thank you so much, Dr. Gary.