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COVID-19 Outbreak: Breast Cancer Coronavirus Questions Answered

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Published on March 27, 2020

Key Takeaways

  • It may be safe to delay radiation or surgery by several months. Talk with your doctor about whether a treatment can safely be postponed.
  • If the goal of treatment is cure, talk with your doctor about the risks and benefits of proceeding with the curative therapy and the risk of a serious outcome if you get infected.
  • No supplement or vitamin has been shown to reduce the risk of infection from COVID-19, but in general good nutrition, physical activity, adequate sleep and reducing stress can help boost the immune system.

A global pandemic, massive shutdowns, quarantine restrictions, social distancing, and breast cancer patients want to know, "How will the coronavirus affect my care? Will my treatment be delayed? Should I still go to appointments? Are people with breast cancer at higher risk for infection?"

Leading expert Dr. Julie Gralow, from the Seattle Cancer Care Alliance, takes questions from the breast cancer community regarding COVID-19 to help patients—from newly diagnosed to survivors—navigate their care in a distressing time. Watch as she discusses treatment, screening, testing, immunity and more.

Dr. Gralow also separates the myths from the facts about coronavirus, shares reliable sources of information and what preventative measures to take to help minimize the risk of exposure and transmission. Watch to learn from a breast cancer expert.

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Transcript | COVID-19 Outbreak: Breast Cancer Coronavirus Questions Answered

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Recorded March 25, 2020

Andrea Hutton:
Hello, welcome to our coronavirus updates from Patient Power. I am Andrea Hutton, and I am the Director of Production and Web Publishing for Patient Power. I am also a breast cancer patient and advocate. Thank you so much for joining us today for a live webinar, and we're so pleased today to have with us Dr. Julie Gralow.

Dr. Gralow is the Director of Medical Breast Oncology at the University of Washington and Seattle Cancer Care Alliance as well as being involved as the Director of Oncology at Fred Hutch in Seattle, Washington. Dr. Gralow, thank you so much for joining us today in such a busy time and a scary time for breast cancer patients.

Dr. Gralow:
Well thanks for having me here, Andrea. It is indeed a very distressing, disturbing time, and it seems like we're getting new information hourly, so it’s always good to provide information. Knowledge is power. We need to sort out the myths from the facts.

Andrea Hutton:
Absolutely, and to that end also, I want to encourage everyone who's watching today, if you have questions, please use your chat function, the Q&A function at the bottom of your screen, and you can send in questions. We've fielded some questions in advance as well, so we can cover what patients are really concerned about today. So, to start with, I think the biggest question is, are breast cancer patients at higher risk for infection from the coronavirus?

Dr. Gralow:
Well, Andrea, the best we know is that cancer patients in general and breast cancer patients specifically do not have a higher risk of being infected by the COVID-19 virus. So, the chance of getting infected with it is the same as the general population.

Andrea Hutton:
So, I keep hearing though that cancer patients are at higher risk. Can you break that down for me? What am I hearing, and what's different?

Dr. Gralow:
Right. So, the key is what are they at risk for? If a cancer patient does acquire the COVID-19 virus, if they get infected with it, we have seen some data mostly out of China and Italy, that they have a higher risk of a serious infection, of the need to be hospitalized or to be put on a ventilator, or sadly even to die.

Out of some studies in China, and these are tiny studies, one major study that's been published is only 18 cancer patients, but the patients diagnosed with cancer proven to have the virus had about a 5 to 6 percent chance of a serious event if they were infected, as opposed to the general population, which might be closer to 3 percent or something like that. That's a mix of all kinds of cancers—some on treatment, some not, some survivors not on anything, some metastatic patients, some who are 80 years old, and their main risk was their age—not their cancer. But I think the key here is cancer patients are at higher risk if they get infected, of having a serious outcome.

Andrea Hutton:
Does that include survivors as well? So, for example, like I'm on an oral treatment, but I'm not having infusion or chemotherapy, and then there are people who are survivors who are no longer in any therapy. Are they at higher risk for complications, or is there a baseline after you finish treatment? How do you know what category you're in?

Dr. Gralow:
Great question—one I'm getting multiple times a day from my patients. If you're just on endocrine treatment, an anti-estrogen like tamoxifen (Nolvadex or Soltamox), like one of the aromatase inhibitors, but you're otherwise all done with your surgery. If you had radiation, if you had surgery, we don't think that the endocrine agents have any real risk of immunocompromised, and a very good source of information is the American Society of Clinical Oncology’s, Cancer.Net.

They've got a couple great COVID-19 sheets, and they very specifically state that to date there is no evidence that breast cancer survivors that are done with their primary treatment, including those who are still on their anti-estrogen treatment, have any increased risk of the serious events if they get a COVID-19 infection. So that should be reassuring. Now those same patients can have other risks based on their age, whether they have diabetes or heart disease or lung disease. But the cancer piece of it for the majority of survivors who were done with their treatment or only on anti-estrogen treatment have the same risk as the general population if they develop the infection.

Andrea Hutton:
So, then we're also getting a lot of questions about starting treatment or going to the hospital for treatment. As a patient, how would I assess the risk if I'm newly diagnosed? Or I'm in radiation treatment, I have to go every day. It's super scary to imagine going to the hospital. What's your advice to patients about that? What are you guys doing in Seattle, and how are you handling that for your patients?

Dr. Gralow:
So, let's break that down into treatment for early stage disease versus the treatment of a metastatic recurrence, because I think we have some different recommendations there, and this is actively evolving. So, the key here is two things. One, to try to keep you out of the clinic or the hospital, to decrease your risk. And two, to preserve resources such as masks and gowns and gloves to keep the operating rooms free in case we need to turn them into ICU beds, because they all have ventilators. Every surgery uses a lot of masks and gowns and gloves. So, here's what we're doing at the University of Washington right now for our patients who have early stage nonmetastatic breast cancer, and this is evolving hourly. We've actually just implemented yesterday a strategy of trying to delay their surgery in the majority of our patients, where it makes sense, where it's safe, where we don't think we will be impacting their rate of cure.

So we have agreed, as a group, and we're still refining our guidelines, that if it is reasonable to start chemotherapy before surgery, so we already know we're going to recommend chemotherapy, and we don't need the information from surgery to decide what regimen we're going to use, what drugs we're going to use, then our preference is to start the preoperative chemotherapy if you're HER2-positive with the HER2 drugs—and try to delay the surgery, which would be four to six months later.

Now you might say, "Oh, but doesn't starting chemo put the patient at an increased risk?" Yes, it does. It does put them at some increased risk. What we're trying to balance is keeping you out of a hospital setting and an operating room, because most of the COVID-19 patients are coming to the hospital versus the clinics usually. We're also trying to preserve the resources in the OR space for the greater good.

But you're a patient with cancer and you're like, "What about me? Are you putting me at increased risk?" Well, from a cure standpoint, we've shown time and time again that the order of surgery and chemo makes little difference. Actually, unless you have a lot of positive nodes, and then giving chemo first does make a difference as opposed to surgery first.

And we're trying to do everything we can to keep the clinics safe, and we're trying to minimize the number of appointments that would be needed if you're starting on chemotherapy. Don't come in on days when you don't need to. We're not allowing, for example, any visitors in our chemo infusion room right now except for the very frailest patients who really need somebody.

If you're coming in for a clinic visit right now at the Seattle Cancer Care Alliance—to the clinic visit itself, which is not the infusion room—you can bring one person, you can't bring anybody under the age of 16. And that person has to go through the same screening that everybody does that enters the building. You can't have had an exposure; you can't have symptoms. So, we're trying to minimize the risk, and frankly I get daily updates on how many patients across our multiple sites that we give chemo, how many healthcare providers have tested positive for COVID-19. And we are actively testing symptomatic people right now. Our cancer patients and our healthcare providers, and the numbers remain across about our five sites in the very low single digits. And most of those people have not been in the building for quite a while at the point at which they're tested.

So, I believe we're doing a terrific job of keeping symptomatic patients who could be spreading the virus and symptomatic healthcare workers who could be spending virus out of the infusion room. So, I am fully supportive of delaying surgeries by starting preoperative therapy.

Now what about pre-operative endocrine therapy? That's something that we don't normally do. So, if you have an estrogen receptor-positive, HER2-negative cancer, what about starting one of these anti-estrogens like tamoxifen, like the aromatase inhibitors first? If you're premenopausal, maybe shutting down your ovaries and giving one those drugs. And we are going that route. We're having the discussion with the patient, we're having the discussion with the surgeon and the medical oncologist, but that is going to be our strategy now moving forward. So if we can delay your surgery by three to six months safely and monitoring you regularly and making sure that the tumor isn't growing and it's actually responding, then we want to try to do that. So that was a long answer, but that's evolving. That's what we've just implemented yesterday really is to try to keep as many patients as possible with early stage breast cancer out of the operating room right now, delay their surgery by three to six months.

In some cases, it's probably safe to delay radiation by several months as well. You asked about radiation coming in every day. Although I would say our radiation facility is doing the same screening that we are for our chemo infusion room, and we're really trying to keep it safe, and we've had very low rates of infection and positivity. Actually, I'm not sure we've had any where we've documented any kind of transmission within our building, everybody we can account for that they had some kind of likely community contact.

Andrea Hutton:
So, we're getting some great questions. So, thank you all so much for sending them in. And there are a lot around the different kinds of treatments and whether different kinds of treatments have increased risks in this particular setting. And you talked about radiation and endocrine therapy. What about trastuzumab (Herceptin)? Those kinds of different kinds of treatments, is there a difference for—I mean, I know like Herceptin, if there are risks for your heart, does that put you at an increased risk category and how can patients talk to their doctors? Is it telemedicine? How should they be asking these questions right now?

Dr. Gralow:
Yeah. I think we're in a strategy where for all non-essential visits, we're trying to do it by telehealth, and we've had a lot of exemptions made really quickly over the last couple weeks about who we can credential, who we can provide them to. It used to be you couldn't do any out-of-state telehealth unless you had a license in that state, but we believe that as long as you're an established patient that we're probably not at great risk if we do this in this kind of pandemic situation.

The HER-targeted therapies, we don't really think that Herceptin, trastuzumab, pertuzumab (Perjeta) cause any major immunocompromise. You've asked about the heart risk. You should continue to have your heart monitored. The risk of any substantial heart toxicity with these drugs is really minimal. We can see it coming on if you stop the drugs. Generally, we see a rebound, so we would...

…what the American Society of Clinical Oncology says and what I endorse is, at the present time, we do not see a need or have a recommendation for not going ahead with chemotherapy and the targeted therapies, particularly if we're going for curative intent, meaning you're an early stage breast cancer patient and our goal is cure. We think that proceeding with the curative therapies is more important when you do a risk benefit, than the small increased risk of a serious outcome if you got infected.

It's an evolving time. We're trying to do a lot by telehealth. You cannot get an infusion by telehealth, although there have been some comments. If there's an oral medicine you could do instead of an IV, maybe you should consider that. If you need lab tests in between visits, could you go someplace small locally and do it there instead? Here we are in Seattle. I have patients come from five states and all over. Do they really need to travel and be exposed? No. If it's just a blood draw, if it's just a CT scan, sometimes let's try to do it closer to home and limit your risks.

Andrea Hutton:
And to that end, we have a great question about providing in-home care. So, like the subcutaneous injections and things—is there any movement to have some of those things done more in home as opposed to having to come to the clinic?

Dr. Gralow:
Right. Herceptin is now approved and can be used subcutaneously. If you're already coming in to get IV chemo with it, then you're not saving a visit. Right now, could there be the potential that when you go off the chemo part and you're just on the Herceptin alone, that you could convert to the subcutaneous and maybe do it at home? I would say having a home healthcare provider come out into your home, it is not necessarily that much safer than coming into an infusion room. You don't know who that person is.

If I'm asking for that, we don't control the home healthcare providers, right? I mean, we are all trying to be super safe and nobody wants to be risky, but I do have, interestingly, a phone call tomorrow with our colleagues at Genentech who make Herceptin talking about exactly this kind of thing though. I mean, could we somehow even teach patients how to give this themselves and dispense it? That we haven't sorted out yet.

I'm not recommending that, but we do let people get white cell growth factors and give it to themselves at home, for example. And when it's subcutaneous, it's not much different. I probably worry more about an intramuscular injection. So, in the metastatic setting, we use a drug for fulvestrant or Faslodex that has to go deeper into the muscle, and some of the shots to shut down your ovaries if you're premenopausal, have to go into the muscle.

I think that is much more critical how we deliver it. And that might not be for home, but we're looking, we're actively looking. I think that's a great question. Can we take some of these subcutaneous medications and maybe allow patients to give them themselves or to be given in a different setting where you're not coming into a big infusion room—but maybe giving it to you, and you can get it at your little local clinic or something?

Andrea Hutton:
We're also getting some questions about the screening process for patients who are coming into the clinic. Does every, and do you know whether this is happening across the country, not just in Seattle, does every patient who's coming into a clinic get screened before they come in?

Dr. Gralow:
Good question. So, here's what we're doing, and I can't speak to every single place but, first of all, everybody with an in-person visit is getting a call the day before, they're getting informed of our policy about visitors. We are screening for symptoms and exposures, right? We're asking, "Have you been in contact with anybody who is known to be COVID-19 positive? Has the visitor you're planning on bringing?"

So, it's both exposures and symptoms, and we're asking about symptoms. And we're telling you, "If you have any symptoms, we don't want you in the building." Now, there are some patients who we might need to somehow bring it, but we work out a separate thing for that, and they get gowned and masked and gloved and everything. But we know ahead of time that we're going to be bringing them in, because it's critical that they have to physically be there.

Then when you arrive in clinic, we've locked all of our doors except one for entry. You can still get out with a fire, but for entry, and you can only come in one way. And everybody, the healthcare providers, the staff, the patients, and the visitors have to be personally screened, running a list of questions, okay?

And then, you get a sticker with the day of the week that says, "I've been screened." And as long as you keep that sticker on, you're free to enter the building and go up and down between floors. If we pick up symptoms or a history of exposure, then we're probably going to, in that case, we bring you to another room. We will test you if you have symptoms, actually. And we're probably not going to let you come in for your appointment. We'll arrange a telehealth visit if we can.

We don't have enough space. I wish we could isolate those patients, put them in a room downstairs, and we would do telehealth from upstairs, but we don't have space right now. But we're talking about things like that.

Andrea Hutton:
And we also have a question about the difference between early-stagers and the need for their treatment right now versus metastatic patients who are in ongoing treatment. Should there be a break in treatment for metastatic patients right now? Who's at higher risk? Who should be coming in, who should be waiting?

Dr. Gralow:
Well, I would think, this is my educated opinion as opposed to data from China and Italy, that the metastatic patients who might already have some compromise of their lungs or their liver from their cancer to start with, and then we're giving them some immunosuppressive therapies like chemo and immunotherapy. I would think these patients would be the highest risk, as opposed to our early stage patients who started out healthier, in terms of all their organ function.

So, the American Society of Clinical Oncology has issued some guidelines for us and said for a patient with metastatic disease such as metastatic breast cancer who is in a deep remission, okay? So, somebody who, the last several scans haven't shown any active disease you're stable, consider actually I would call it a drug holiday for a while, for three or four months.

Watch what happens. Keep them out of the infusion room. But monitor, because there the risk/benefit of coming in and getting your infusion when you have no active disease versus the exposure there versus the benefit of the drug and the harm in discontinuing it for a few months until we see where this pandemic is going, that might play out more favorably.

Just this morning I had a patient in her early 80s actually who was asking about this, and I advised that, "Let's wait three months, stop all of your current therapy and do another scan in three months, and make sure you still have no evidence of active disease, and we'll go from there."

So, one, I think her age was a big risk factor. She was in her 80s. And two, her cancer's not active right now. She does have a history of having some metastatic spots, but it's well-controlled and with careful monitoring, if I then just restart the same therapy if it starts growing, I can get it under control again, most likely.

Andrea Hutton:
So, as a follow-up question to that, if someone's in the middle of their treatment plan, and maybe hasn't had a scan, didn't know this was happening, so didn't have the scan before the virus came to the U.S., what do we do then? How does a patient decide whether it's worth the risk to keep coming in or wait a few months?

Dr. Gralow:
So, if we're talking about the metastatic setting still, I would, first of all, for everything I'm saying, “I would say you are a unique person, and you have other health issues potentially besides cancer.” So, I think it's really critical to talk with your healthcare team about your specific situation and the specific risks of where your cancer is, what the treatment you're on is and all of your other health conditions, as well as your age, et cetera. So, my first comment is you really need to talk with your healthcare team and help them help you weigh the risks and benefits.

Also, I think patient preferences have to come into play here, especially in the metastatic setting. I think we need to know what the patient's goals are and how they're viewing the risks and benefits. And there may be some patients of mine who I think my preference would be they keep getting therapy, but they're very nervous, or they have high risk because maybe somebody else living in the house is going out and working. They're an essential employee or whatever. And if the patient chooses to say, "Let's give it two months off," I'm okay with that. I mean I need that interaction to understand the patient's priorities and personal situation as well.

Andrea Hutton:
Also, since we only have a few minutes left, I would love to know about what patients can do to enhance their own immune system. I mean, if our immune systems are suppressed from chemotherapy or other treatments or just life in general at the moment, what can we do to protect ourselves?

Dr. Gralow:
Well, I think something that can help all of us and that we should probably be doing all the time, but especially in these stressful times of his pandemic would be to—there are some things you can do to overall generally improve your immune system, and those would include healthy lifestyles, good nutrition, physical activity, trying to reduce stress and getting sleep. All of those things have been proven to just generally boost our immune system a bit. There's no supplement, no vitamin that has been shown to in excess doses beyond our normal diet to reduce the risk of infection from COVID-19.

And then I think, what can you do? I mean, the key here really is avoiding exposure. And we know that COVID-19 is transmitted through droplets. Okay. And it's a lower respiratory tract infection. So those droplets have to get in through your nose or your mouth to get down to your lower respiratory tract. So interestingly, blood transfusions, we haven't shown that those increase risks, and we wouldn't think that they would increase risk. The virus has to come in through droplets, get in through your nose, get in through your mouth. So, if you have to cough or sneeze, if you see someone coughing or sneezing, cover it either with a tissue, in your elbow. Don't touch things that you don't need to touch. Wash your hands frequently, 20 seconds, as they say, it's two Happy Birthday to You songs versus if you don't have soap and water, hand sanitizer, that's at least 60 percent alcohol I think would be important, but avoid exposure.

Don't go out if you don't have to. If you do go out social distancing at least 6 feet. And that doesn't mean social isolation. And I think that's a really key point, because I think we all need the contact virtually, but let's not do it physically. Okay, so let's support ourselves, talk to our friends and family, but try to do it virtually. And if you have family members who you're living with who are going out, they have to abide by all of these things too, because they could be bringing it into your home. So really encouraging anybody who's coming into your house, even if you're staying home, if they're going out, they can put you at risk. So, talk to them. We don't have any specific guidance on mask use right now. That's evolving. We have a mask shortage, but we really don't have evidence that putting on a mask is going to protect the population. If you have symptoms, don't expose others.

And in many sites, we are testing all of our cancer patients. In Seattle, we're doing it through, you have to call, you have to fill out a survey, and then we arrange a drive-through at a specific time. I know every site can't do this. But if you do have symptoms, consider getting tested. And if you're on treatment, minimize your time in the clinic or the hospital, and work with your team on how to do that and try not to travel. If you travel for your visits, we've had a lot of relaxations on clinical trials for example, which used to mandate that you come and get your blood work and have your clinic visit and your CT scans at the institution where you're enrolled. But now we're really relaxing that, and even the National Cancer Institute is saying they'll give waivers, so you could do this locally and still stay on trial.

We're even talking about being able to ship oral clinical trial drugs to patients. So, we're trying to minimize the need to come into a big busy cancer center. So, there are things you can do, and you can stay educated, and you can educate others and kind of understand what the myths are and try to burst those myths and tell people, "No, that's just not supported." The has a good website, the WHO, the CDC, Centers for Disease Control has a good website on myths versus facts. So, inform others, inform yourself, but know that this is evolving and everything I've said today at this point, some of this may be outdated in a couple of days.

Andrea Hutton:
Well, Dr. Gralow, thank you so much for joining us, and we will definitely be doing more of those, perhaps another one next week, because as you say, today is March 25th and who knows what will happen on March the 26th or 27th with this disease. So, thank you so much for joining us. Everyone, thank you so much for sending in your questions. If we didn't get to them today, we will be keeping track of them and hopefully answering them the next go-round, so you can sign up at patientpower.info so that you can always stay up to date with everything that we are doing. And, Dr. Gralow, thank you so much again for joining us. And as you said, knowledge is power. Thank you.

Dr. Gralow:
Stay safe. Wash your hands.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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