How the coronavirus affects early-stage breast cancer treatment

As a newly diagnosed person, you may have a lot of questions about how to get the best treatment for breast cancer while protecting yourself from COVID-19, the disease caused by the new coronavirus. While the standard advice to protect yourself from COVID-19 is to stay home, breast cancer treatment requires going to medical centers and taking medicines that may make you more vulnerable to COVID-19 complications.

Everyone in the healthcare community, from your doctors, nurses, and support staff, to researchers and professional organizations, is working on plans that balance the treatment you need for breast cancer and methods to protect you and those treating you from COVID-19.

Professional organizations such as the American Society of Clinical Oncology, the American Society of Breast Surgeons, and the National Comprehensive Cancer Network have developed recommendations for treatment during the COVID-19 outbreak. These recommendations are based on well-established evidence from clinical trial treatments. They provide guidance on how doctors can give treatment while limiting time at medical centers, protecting against the spread of the coronavirus in the centers and conserving important resources for COVID-19 treatment. (Here's a message directly to you from the National Accreditation Program for Breast Centers.)

Your most important relationship will continue to be with your medical team. They know your particular diagnosis, the level of COVID-19 infections in your area, and other conditions that affect their recommendations for your treatment. As the situation changes over the coming months, they will know how new recommendations could impact you locally. If you have questions or concerns about your treatment, it is still possible to get a second opinion.

Throughout this crisis, LBBC will continue to provide you with trusted information and a community of support. We invite you to our Facebook communities — Breast cancer support for young women and Breast cancer support, all stages all ages — to connect with others and to share support and information.

Surgery

Surgeries are often thought of as the first step for breast cancer treatment, but this is not always the case, even without COVID-19. Treatment for many breast cancers now starts with chemotherapy or targeted therapy. Today, more cases are going in this order as doctors and medical centers delay surgeries until the peak of the COVID-19 outbreak has passed. Surgeries require several trips to medical appointments and the hospital and can have complications that require hospital admission. All those interactions with the facility put you at risk of contracting the coronavirus and require protective equipment that might be needed to handle the surge of people with COVID-19.

In HER2-positive breast cancer and triple-negative breast cancer, neoadjuvant treatment — chemotherapy and targeted therapies given before surgery — is already common, and it is likely to be recommended to more people now to delay surgery and avoid the worst of the COVID-19 outbreak.

For hormone receptor-positive breast cancer, treatment before surgery is less common under normal circumstances, but evidence shows it is safe and effective to give hormonal therapy for up to a year before surgery.

Some surgeries will likely go ahead because a delay can lower the effectiveness of treatment or because of an immediate concern such as pain. People who are completing preoperative chemotherapy will also likely get surgery as scheduled.

Many decisions are up to your medical team. Where some areas of the country have to delay all but the most immediately dangerous procedures while dealing with high rates of COVID-19, others are able to carry on operations as usual.

For more information on breast surgery and COVID-19, watch our interview with breast surgical oncologist Monique Gary, DO, MSc, FACS.

Radiation

Radiation therapy is likely to continue as planned in most parts of the country, but there are considerations that may lead your healthcare providers to consider a different course of treatment.

Some doctors may recommend hypofractionated radiation. Standard radiation requires you report for treatment 5 days a week for 3 to 6 weeks. Hypofractionated radiation delivers more radiation per visit. This allows for fewer in-person appointments, one of the keys to COVID-19 prevention.

In areas hardest hit by a surge of COVID-19 cases, radiation could be delayed. The type and stage of breast cancer can affect if and how long radiation can be delayed. Hormone receptor-positive breast cancers may be delayed a few months without raising the risk for recurrence.

Ask your healthcare providers what they recommend for your case and the reasons why.

To learn more about the impact of the coronavirus on radiation therapy treatment, watch our interview with radiation oncologist Nicole Simone, MD.

Chemotherapy and targeted therapies

In early-stage breast cancer, targeted therapies and chemotherapy often go hand-in-hand. They are an important part of treatment. They are not likely to be delayed during the COVID-19 outbreak, and if you already started a treatment you will remain on that treatment.

People who are newly diagnosed may see their treatment shaped by efforts to prevent COVID-19, such as when chemotherapy or targeted therapy comes in your treatment plan, what medicines are recommended, and how often you get treatment. The main change is to accommodate delays to surgery, by recommending more people with triple-negative or HER2-positive breast cancer get chemotherapy first. But the course of chemotherapy may also be changed to better protect you from possible exposure to COVID-19.

Doctors may also be able to recommend a schedule that involves fewer visits to the treatment center, depending on the type of chemotherapy appropriate for your diagnosis. People with stage 1 or 2 HER2-positive breast cancer can receive ado-trastuzumab emtansine (Kadcyla), an antibody-drug conjugate that links a chemotherapy medicine to an antibody, instead of treatment that includes chemotherapy and the targeted therapy trastuzumab (Herceptin). Ado-trastuzumab emtansine is less likely to affect certain immune cells in your blood and requires fewer infusions.

People who already started treatment will, in most cases, carry out the treatment plan they developed with their doctor. There is very limited evidence to support changing treatment once started. Some treatments, such as trastuzumab and chemotherapy, can be stopped early with results comparable to the full course of treatment, if your cancer center is particularly affected by COVID-19 cases.

Chemotherapy can affect the immune system, which makes people on chemotherapy vulnerable to diseases like COVID-19. While treatment may go on, know that healthcare centers are doing everything possible to prevent the exposure and spread of COVID-19. If you have concerns, ask your doctor what measures your treatment center is taking and how you can best prepare yourself before starting treatment.

For more information, visit ASCO’s page, Patient care during COVID-19.

Reconstruction

Many reconstructive surgeries are delayed due to the coronavirus outbreak, but certain procedures are moving ahead. Most delayed procedures won’t affect your final outcome. These include:

• Revisions to correct earlier surgeries.
• Surgeries for symmetry, to have the other breast match one that was operated on.
• Removing expanders to replace with permanent implants.

Delays mean more time with your concerns, but nothing is expected to change in the coming months that would affect the safety or outcome of the surgery when it is done.

People with complications from a past operation that remain painful or damaging may still be able to have surgeries to fix those problems.

Reconstruction surgeries that use your own tissue are being delayed because they require more resources, including time in the intensive care unit, that may be needed for people with COVID-19 as well as increase your risk of exposure to that disease.

In many places, immediate reconstruction is not offered right now. It will still be offered to some people who are getting radiation after surgery. Ask your medical team if delaying reconstruction could limit your future options.

For more information on breast reconstruction and COVID-19, watch our interview reconstructive surgeon Clara N. Lee, MD.

Extended hormonal therapy

People who completed treatment with surgery and chemotherapy and are taking hormonal therapy — either tamoxifen or an aromatase inhibitor — for 5 or more years should see no changes to treatment. Doctors emphasize that hormonal therapy does not make you more vulnerable to infection or more likely to have serious effects if you get COVID-19. You should continue to take hormonal therapy as your doctor recommended.

To limit trips to the pharmacy, consider having your medicines delivered to you and ask for a 90-day prescription.

People with upcoming appointments may have that appointment delayed or changed to a telemedicine appointment. Mammograms and other scheduled screenings have been delayed, even for people with a history of breast cancer. It’s safe to go longer between mammograms. If you notice a lump or other concerning change in your breast, report it to your doctor, but if you have no changes to report, you can feel confident that a delay to your screening mammogram does not affect your risk.

Fertility preservation

Some cancer treatments can cause infertility. We recommend any young person starting breast cancer treatment speak to their doctors about that possibility and talk to a specialist about options to protect your fertility.

During the COVID-19 outbreak, many fertility services are being postponed to protect people from possible exposure to the virus. While expert recommendations allow for urgent needs, such as women preparing to start chemotherapy, it may be harder to find an office open and able to provide care.

If you have any concerns for the effects of treatment on your fertility, or haven’t yet thought about fertility, start by speaking to your doctor. During the COVID-19 outbreak, the Oncofertility Consortium is offering assistance to help you find care.

Questions to ask your medical team

Many of the treatment decisions and changes to care influenced by the COVID-19 outbreak depend on the how your local community is affected, the policies of your healthcare center, and your diagnosis. The best way to understand the decisions for your care is open communication with your doctor. If you have concerns or want to learn more, you should feel comfortable asking for more information.

We’ve provided some questions that may be on your mind. These common concerns can help get the conversation started. We encourage you to raise your own questions about your treatment plan and the effects of the COVID-19 outbreak.

• What measures is the treatment center taking to prevent the spread of COVID-19?Are there ways to approach my treatment that limit the amount of times I have to come to the medical center? How might that affect my side effects and outcome?
• Would my treatment plan be affected if our area experiences high rates of COVID-19 in coming months?
• Why did/didn’t you change my treatment plan in response to COVID-19 protections?