COVID-19 and breast cancer care in the southern U.S.
Since the initial outbreak of COVID-19 in the U.S., the burden of high rates of new infections has shifted. States like New York and New Jersey that had a lot of cases in March and April have seen new infections go down, while many states with few cases in those early months have seen COVID-19 infection rates, hospitalizations, and now deaths rise in recent months.
Debu Tripathy, MD, is an oncologist at University of Texas MD Anderson Cancer Center in Houston. Texas has been one of the states hit hardest in recent months, with hospitals in some cities running near capacity. Living Beyond Breast Cancer CEO Jean Sachs, MSS, MLSP, spoke to Dr. Tripathy about how his institution has used lessons from the past 4 months to inform breast cancer care as cases in the area have risen.
As the outbreak continues, LBBC is here for you with information on the disease, its effect on breast cancer, and resources for coping with the shutdown and with all the effects of the pandemic on our COVID-19 resources page.
Debu Tripathy, MD
Chair, department of breast medical oncology, University of Texas MD Anderson Cancer Center
Dr. Tripathy is professor of medicine and chair, department of breast medical oncology at the University of Texas MD Anderson Cancer Center. Dr. Tripathy has published numerous original lab and clinical research articles in breast cancer and serves on several editorial boards, study sections, and societies. He is editor-in-chief of CURE Magazine. Read more.
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):
Hi everyone. It's Jean Sachs. I'm the CEO of Living Beyond Breast Cancer. And first and foremost, I hope everybody is doing well, and staying safe today. We are talking with Dr. Tripathy, who's a professor of medicine and department chair of breast medical oncology at the University of Texas MD Anderson Cancer Center. Thank you for joining us.
Debu Tripathy (00:26):
Thank you for having me, pleasure to be here today.
Jean Sachs (00:28):
We appreciate it.
Since the beginning of the COVID-19 pandemic, Living Beyond Breast Cancer has been working really hard to keep our community updated on how breast cancer care is changing things they should be aware of. We talked a lot to our friends and colleagues in the Northeast in the late spring. But now we thought it was really important that we focus on the southern half of the United States, since things are changing there.
Of course we want to first say how grateful we are for all the healthcare providers, including you everything you're doing to, to keep us safe. How are you doing?
Debu Tripathy (01:11):
In some ways we're as busy as ever. We're having to reinvent a lot of things that we do, so at the same time that we're probably not seeing as many patients, as we aren’t delivering as many services, we have been using our time to develop new systems, to take care of our patients remotely to lessen traffic to make sure our key operating word here is safety: the safety of our patients, the safety of our staff because they are mutually codependent on each other. As we have found as our community rate has gone up, obviously the number of our patients and our staff that have gotten sick has gone up, so it's a new challenge every day.
But at the same time, I feel like it's forced us to, re-examine a lot of our regular procedures that we do: whether it's how we check patients in or how we return phone calls or get labs from an outside testing facility, which is very common, and interpreted that quickly and get back to our patients. So the fact that we're having to do this more often has made us more efficient at this. I'd say the key word here is learning. We have to learn from everything we do.
Jean Sachs (02:28):
Let's break it down a little bit for patients. I know when things were surging in the Northeast, some surgeries were canceled, you weren't allowed to bring anyone in for chemotherapy, and when possible telemedicine was happening. So tell us what you are seeing in the Houston area and at your own hospital.
Debu Tripathy (02:49):
We had to go through the same step way back in late March, early April. We were asked to shut down our surgery operations, mostly to make sure that all of the medical capacity was available for patients needed [during] the surge, especially with what was going on in the Northeast. And while we didn't reach that level of having hospitals filled and reaching our capacity, we knew that we had to prepare for it, because we didn't know what was around the corner.
So us, along with many other organizations, we're in close communication with each other about how do we manage specific medical situations. Particularly with breast cancers that have been newly diagnosed, most cases are first treated with surgery. And if we're not going to be using our surgical capacity, particularly the operating rooms and the need for ventilators, how are we going to treat these patients?
We actually developed an algorithm and other organizations have to, and we've actually published them, and [there are] a lot of similarities between what the different hospitals are doing. When possible we're using medical therapy first, that's actually something we have done in the past with other cases. For example, when we know people are going to need chemotherapy after their surgery, we can give it before their surgery to shrink the tumor, and sometimes that allows us to do less aggressive surgery. That's something we had already adopted, we just use that approach more often in patients. And the same thing with hormonal therapy, sometimes we can use that before surgery or to delay surgery.
We try to identify which patients would be safely treated that way based on clinical trials that have already been run, comparing treatment before and after surgery and showing that the long-term outcomes are the same. There were some situations where we had good data and felt confident to do that, so we did change those practices.
And then finally, we got a brief window where it looked like we were over the surge — late April, early May and things were going down. So we started opening up our surgery again, and we got super busy because there were a lot of patients whose treatment had been delayed. Then we got into our second wave, which we're in right now. But we've managed to keep our surgical capacity open because what we also learned along the way is how to minimize traffic, how to screen patients, there were certain people we wouldn't allow into the hospital, anybody who had an illness or felt sick. And then we started testing patients too, new patients before they came here, or we'd ask patients to quarantine if they were coming from out of state.
So, with a variety of steps that we took, we've been able to maintain our activity high but still keep our infection rate down and also make sure that we have a margin for a surge, if it happens, that we have enough operating room capacity, that we have enough ICU beds and ventilators, they're essentially kept free in case we need them.
Jean Sachs (06:01):
It's really encouraging to hear that as we move into the second wave that there's been enough learnings that surgeries can continue. I know for some patients there's been a lot of concern if they were expecting surgery first, and then they're told they're having chemotherapy, or even being told to wait. Are you finding a lot of anxiety? How are patients reacting?
Debu Tripathy (06:31):
Absolutely. And I think it's natural to expect that.
We all know that when you have a treatment plan that's laid out or that's by the textbook and all of a sudden it's being changed, it is a little nerve wracking and we completely understand that. We really explain things with all the facts as best we know them and we walk patients through the process that we went through when we were thinking about that and how to set it up. That gives them some comfort that this wasn't something that we're just saying, well, we have to delay your surgery, but rather we looked at the situations and we felt it was safe. We actually looked at trials that had been done in that setting, and that gave people an extra measure of comfort.
Jean Sachs (07:13):
That's great. We've been trying to reassure the community that all these decisions really are being made with a lot of thought.
For your patients that are coming in for chemotherapy now, two questions. One is: Are they allowed to bring anyone with them for that long day getting therapy? And also, what are you telling them to do to stay safe since they are immune compromised?
Debu Tripathy (07:38):
In terms of visitors, we were allowing patients to have limited visitors initially, but when the community rate, especially in Houston, went up, we had to stop that because we were up to 1 in 30 patients that are asymptomatic and may be carriers, so we had to really eliminate all visitors.
We have very strict rules. Patients who really need assistance or who have any cognitive issues where they need someone with them to help with decision making and those things [are allowed], but for the most part, we're asking people not to bring visitors. But we definitely encourage and facilitate their ability to speak remotely, to go on FaceTime, and with the physicians, with the whole medical team, and even other people calling in, we have three-, four-way calls sometimes. We make sure people are connected that way.
It's not uncommon for the MD Anderson parking lot to be full with cars, waiting with their loved ones with our iPads open. We actually have designated places where they can wait and park their car. So that's how we've done it. Same for our patients that are in the hospital. We have really not been allowing visitors. We have a small pediatric area where, of course, we do allow parents or a caregiver to come, but everyone else really has to use remote contact.
Jean Sachs (09:03):
Right. It's like when we used to all sit in the cell parking lot of an airport when we were waiting to pick someone up, but you're not doing so much anymore.
Are you giving those patients that are on chemotherapy that does compromise their immune system, any special instruction? Particularly in Houston where community risk is so high?
Debu Tripathy (09:26):
Yes. We don't know precisely who is at really high risk. If you look at cancer patients, as a whole there clearly are statistics that show that the rate of infection is higher and the severity of infection is higher. However, we don't have enough data to break it down between breast cancer and some of the more serious cancers that are treated with more aggressive treatments like leukemias and lymphomas, where there is a higher degree of immune suppression. So we have to assume that the risk is higher and we tell patients to follow the same safety practices everyone should follow, but to have maybe a lower threshold for being tested or for coming in for medical attention.
We started to pay a little more attention to blood counts. We always have a threshold at which point we might lower the chemotherapy dose. A lot of our oral therapies that we use now, some of the newer biological therapies also can lower counts. Every now and then we have to delay or lower the dose. And we've tightened those thresholds a little bit just to avoid any potential problems, but we just don't have enough data yet to be precise and to personalize all of these things to minimize risk.
Jean Sachs (10:39):
Right. In the Northeast, we've been wearing masks since for a while, but are you finding that the community in Houston is starting to adhere to these public health?
Debu Tripathy (10:55):
Yes. I have sort of a biased exposure because I'm spending a lot of my time in the hospital, and of course we have all along been wearing masks and everybody that comes in has been very compliant. We've really had no issues with people that don't want to do that. Everybody understands, so it's just really been a nonissue.
I know that in the community and nonmedical situations, in restaurants and things like that, there may be some opposition. We just haven't seen that. I think everybody's saying, look, why expose ourselves to risk? I think when people are in a medical facility, it's a little bit …
Jean Sachs (11:30):
Yeah, I think this is. I think medical facilities have felt very, very safe, actually among the safest places to be.
Have you had any of your breast cancer patients diagnosed with COVID-19?
Debu Tripathy (11:42):
Yes, we sure have. We're seeing it just like a regular community illness. We'll have a patient who's doing well, everything has been going fine, and then they come down with a terrible fever. We see them in the room, get them tested right away. And so we're seeing it amongst our patients. We're seeing it amongst patients that are doing well. We see it around among some of our sicker patients. We've lost a few patients to COVID as well. Again, I don't think collectively we have enough numbers to say that there's a particular risk factor, but I think that the usual mortality rate we see in hospitalized patients in general is what we're seeing at MD Anderson right around the general statistical average.
Jean Sachs (12:25):
Yeah, I think you're right. There's so much we don't know yet. And it will probably be years before we can really know.
I know a lot of people travel to be treated at MD Anderson. and are you finding that that is still happening or has that slowed down?
Debu Tripathy (12:42):
It has slowed down somewhat. We still have people traveling and coming in. All our new patients are tested if they're coming in for surgery or if they're coming in as a new patient, just because the community rate is so high. But the number of people that are flying in has gone down. I think the threshold for getting a second opinion or traveling really far to get your care has affected that.
We have a lot of patients who get their regular care here, but come from places like Florida and California and fly here every 3 to 4 weeks for their follow-up visits and many of them have now stopped coming and have found a local physician, but still stay in touch with us. We still set up video visits with them so that they can at least be plugged in. They'll send us their lab tests and the results of scans and things like that, so that we can make decisions along with their local doctors. We've always historically worked very well with our partners in the community or in other cities, with other oncologists, so that we can still be involved and still provide some advice and be able to communicate directly with the patients, but have their treatment be done locally.
Jean Sachs (13:53):
That is so important for our community to know that you could still have someone at an MD Anderson overseeing your care, but you can stay local. So they're less concerned about that.
I feel like you've covered most of the issues. I guess my final question is just, I know telemedicine has become much more utilized and I'm wondering, from your perspective, what's it like for you? And do you think this is something that's here to stay and insurance will continue to pay for it?
Debu Tripathy (14:23):
Well, I really think that if there has been a silver lining to this whole event, it is that we are learning how to use telemedicine more effectively and more innovatively. For example, there are ways now you can monitor heart rate and temperature even EKG and things like that, so we have definitely been taking advantage of that.
I'd say anywhere from 10 to 25 percent of my visits on a given day are remote visits, and we've learned how to do it and how to ask questions. Patients, similarly, have learned how to write their questions and store them up. They've all learned how to use Zoom. We have Zoom built into our electronic medical record, so it's really nice. You just open the medical record and there's a picture of your patient talking to you and you're entering data into the electronic medical record, placing your orders, and everything. It has worked well, and I think it will clearly carry beyond this. It's been a long overdue trend.
We've been talking about telemedicine for a long time. I can envision a future where you can go into an emergency room and have an expert neuro-radiologist redo your head CT [scan] that you needed because you were in a car accident or you have a funny rash and you'll get a video camera out. And you, you have an expert dermatology team take a look and make recommendations. As the technology gets better I think it'll be a democratization of healthcare and I think it'll lower costs. It'll increase convenience, and I think it may even improve quality. And we can measure all of those things. I think there's going to be a lot of revolution coming in this area that was spawned by this.
Jean Sachs (16:03):
Yeah, I think we have to look for the silver linings always, if we can. Technology has been such a life saver for so many businesses, healthcare industry, and really we've learned that this is something we can use to our advantage.
I want to thank you for joining us this afternoon. I want to thank you for being such a compassionate doctor to the breast cancer community and always be being willing to do things for Living Beyond Breast Cancer.
We of course, want you to stay safe and stay well, you and your family. Thank you everyone for joining us. As always, if you want to connect more directly with other patients Living Beyond Breast Cancer has closed Facebook pages. Just log onto our website and we will connect you to those. They're very active. You can get real time support.
I want everybody to stay safe and stay well and stay connected to Living Beyond Breast Cancer.