Coronavirus and breast cancer: where we are now

COVID-19, the disease caused by the new coronavirus, is spreading across the U.S., and everyone has been dealing with interruptions to daily life and health care. Living Beyond Breast Cancer CEO Jean Sachs, MSS, MLSP, spoke with medical oncologist Harold J. Burstein, MD, PhD, about how precautions against COVID-19 are affecting hospitals and health care as of early April. They discuss how those measures are altering breast cancer treatment and the science that supports those changes. Watch, listen, or read the transcript below.

We’re here to support you and help you understand how COVID-19 and social distancing affect can affect breast cancer care. Keep up with our COVID-19 resources page, and join our Facebook groups – Breast Cancer Support: All Ages, All Stages and Breast Cancer Support for Young Women – to share knowledge and support with others affected by breast cancer.

Harold J. Burstein, MD, PhD
Dr. Burstein is associate professor of medicine at Harvard Medical School. He practices medical oncology at Dana-Farber Cancer Institute and serves as staff physician, medicine, at Brigham and Women’s Hospital. His research interests include new treatments for early-stage and metastatic breast cancer.

 

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 (00:01):

Hi, everyone. It's Jean Sachs, the CEO of Living Beyond Breast Cancer. I am here today with Dr. Harold Burstein from the Dana-Farber Cancer Institute and Brigham and Women's Hospital. He has been extremely generous to give us a few minutes of his time to just update us on his thoughts of where we are in the trajectory of this pandemic that we're all facing, and particularly how it may be impacting those living with breast cancer.

Harold Burstein (00:34):

Hi, and thanks for asking me to speak with you today. Obviously a very timely and urgent subject. These are really unprecedented times in medical care and breast cancer. Patients and researchers and doctors, like everyone else, are trying to figure out how their own disease, how their own patients, how their own clinics can best respond to deliver the care we want to our patients right now while also being very mindful that the healthcare system broadly is being overwhelmed by the needs of patients who are sick with the coronavirus, and intensive care units in particular are being strained. And there are limits on the availability of personal protective equipment and other things that clinical teams need to optimally take care of patients. So we're all looking at our standard practices and trying to figure out the best ways to care for breast cancer patients amid this global pandemic.

I can share a little bit with you about what our center in particular is doing. In outline, it is a set of changes that, most major cancer centers are adopting. And in fact there has been a very nice guideline development process jointly led between the NCCN, the National Comprehensive Cancer Network, the American Society of Breast Surgeons, the American College of Radiology, the Committee On Cancer, the National Accreditation Program for Breast Cancer and they have posted some very preliminary guidance online. There's a full document and guidance, it's now been submitted for publication. People can begin to get a shape or a feel for what the shape of this is going to look like nationally.

The first thing is that for the general public and for women with a personal history of breast cancer, we have stopped all screening mammography or breast imaging in women who do not have breast health concerns that are immediately pressing.

This is a big change, obviously, at the public health level and for women in the routine follow-up of breast cancer. [Susan G.] Komen and other advocacy groups have supported this posture. It's become a national recommendation from the radiologists, from the advocacy groups and others.

The reason for doing this is that it's very safe to defer screening breast imaging by a 6 or 12 months in women who did not have new breast findings or breast lumps or breast symptoms. And, it's important for American women in particular to know that around the world, the standard of care for a mammogram imaging is usually every year or every 2 years. It's really only in the United States that there has been this very big push for annual screening. And so medical experts feel very comfortable saying at this time it's very reasonable to stop screening mammograms for 6 to 12 months.

We are asking our patients to defer imaging for that breadth of time. And this also applies to women who've had a personal history of breast cancer but are scheduled for their annual breast imaging. I think patients can really feel very comfortable that that's a reasonable thing to do.

Obviously if they notice changes in the breast then they should bring that to the attention of their team, and we are still imaging women who have new lumps, bumps, findings. But if you're not having those things, you should feel very comfortable rebooking the mammograms for the fall or winter of the coming year.

The second challenge has been, how do we put together a multidisciplinary treatment team, particularly at a time when there's real worry that we don't want to put too much burden on hospitals. Specifically things like operating rooms, recovery rooms, intensive care units.

Our group, like many others and as endorsed in these emerging national guidelines, is not offering immediate breast surgery to many patients. Instead, what we are recommending is systemic therapy or neoadjuvant or preoperative therapy to many women with all subtypes of breast cancer.

This is a very well-established treatment program. The role for chemotherapy or anti-HER2 drugs or hormonal therapies are all studied in dozens of trials going back decades. Women should be very comforted to know that in multiple randomized trials, the actual sequencing of treatments, whether it's surgery first and then chemotherapy and then radiation and then hormonal treatments, or chemotherapy or hormonal therapy first for a while then surgery then radiation then continuing on those lead to exactly the same long-term results.

Even in the strictly adjuvant setting where your questions might be “should I get chemo now or should I get radiation now?” there've been studies that have looked at this, and in the long term it's all the same, whichever sequence you use.

As the COVID-19 epidemic makes different demands on different hospitals in different parts of the country at different times you may be advised that we think it's important to do the chemotherapy or hormonal therapy upfront and to defer surgery by 6 or 12 months even. Or we might say you still need to have surgery, but we're going to do a different sequence of the radiation and chemotherapy. And for the vast majority of cases, there really is very high level evidence that that is perfectly safe from a long-term breast cancer health point of view.

Now, to try and minimize the side effects of treatment, because we don't want patients to go into the emergency room, we don't want them to be vulnerable to infection at this time, we're doing some tweaks to our supportive care programs. We're using more, growth factor support to make sure that the patients are not neutropenic. We are, in some instances, modifying doses or delaying certain drugs to avoid neutropenic fever or other immunosuppressive treatments at specific times. For the most part we're doing that in ways that hopefully do not compromise on the long-term outcomes for our patients.

We're also looking at ways of stretching the intervals between treatments or evaluations. For many women who are on chronic or long-term maintenance drugs, we're stretching out the intervals of treatment. For many drugs that's perfectly safe to do. For women who have advanced cancer, we are cutting down on some of the frequency of the imaging studies or maybe stretching the interval between scans and things like that so that there is less consumption of healthcare resources and fewer visits to the clinic by patients, if that's appropriate, whenever possible.

We're trying to use oral treatments that can be picked up at the local pharmacy and taken safely at home to reduce the number of times patients have to get out of their house or come to the healthcare center.

These are all very rational, and in large part, incredibly safe options for patients.

I just want to emphasize that as you talk to your team, they may propose something that seems a little different from the textbook. You do this first then you do this second and this third. But almost always in the breast cancer space, there's really good evidence for the usefulness and the effectiveness of these approaches.

In breast cancer in particular, we can have our cake and eat it too. We can do things to adjust the program while still making sure that the long-term results are excellent. I know from talking to my friends who were on the leukemia service that they don't have that luxury. If you have someone who's got acute leukemia, they have to be treated now and so they're doing it, but they're worried about the risks that come with that at a time of a global infection epidemic.

Jean Sachs (08:20):

Thank you. This is, that is very comprehensive and really helpful and answers many of the questions that we're getting, thank you so much. Do you have any insight of how long we're going to be in this situation?

Harold Burstein (08:32):

I am not a public health specialist. I read the papers and I listen to the news reports, as I'm sure everybody is doing. We're in early April right now, the feeling is that in the Northeast, New York obviously has been hit hard. Boston has a growing number of cases. The next couple of weeks, they are feeling, are going to be the peak. Everybody is doing all they can to defer anything elective, anything that can be kept out of the healthcare system for the short term, so that all the resources that are necessary, all the personnel, all the equipment, can be available to help care for sick patients who have COVID-19.

But that's going to vary around the country at different times as the exposures continue. I would stay tuned both nationally to what's happening but also to your own local environment, because there's a lot of variation in where the disease burden is in different parts of the country right now. I've been on some conference calls and obviously the folks in New York, they're waist deep in it right now, and they're only focusing on that. There are other parts of the country where they've hardly seen any cases, and it's much more business-as-usual, though they're watching very carefully to see what happens in their communities.

Jean Sachs (09:49):

That's really good advice and good insights. Thank you again, Dr. Burstein for your insights and for your compassion and to everyone watching. Please stay connected with Living Beyond Breast Cancer. Visit our website LBBC.ORG for updates and ways to connect with the breast cancer community. Take care everyone.