Questions about coronavirus and breast cancer
We know that our community has questions about how COVID-19, the disease caused by the new coronavirus, and efforts to prevent its spread can affect them. Many are asking their doctors about changes in treatment or delays in surgery.
We’re here to help you find answers. Living Beyond Breast Cancer CEO Jean Sachs, MSS, MLSP, spoke to medical oncologist Don Dizon, MD, FACP, FASCO, and asked some of the most pressing questions we collected from people in our community. They discuss the ways cancer care is changing to protect you from the virus while ensuring you get the care you need. Watch the video, listen to the audio, or read the transcript below.
Don S. Dizon, MD, FACP, FASCO (@drdonsdizon)
Dr. Dizon is a professor of medicine at Brown University and director of women’s cancers at Lifespan Cancer Institute in Providence, Rhode Island. He is a medical oncologist specializing in women’s cancers and sees patients in a clinic for those experiencing sexual dysfunction after cancer. 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, the CEO of Living Beyond Breast Cancer and I am here this morning with Dr. Don Dizon, a medical oncologist specializing in women's cancers, a professor of medicine at Brown University, and director of women's cancers at Lifespan Cancer Institute in Providence, Rhode Island.
Don, thank you so much for being with us today.
What we did last night was we put a call out to our community and asked for pressing questions that they wanted to ask Dr. Dizon in the wake of this COVID-19 crisis. I have a bunch of questions. I'm just going to read them off and hopefully we can give our community some answers. I just want you to know that we posted that and we got so many questions right away. We know there's a lot of anxiety out there.
Let's get started. There's a lot of questions about who is immune-compromised, could you give the quick overview of who with a breast cancer diagnosis do you consider immune-compromised?
Don Dizon (01:14):
I think the shortest answer to that question is anyone who's receiving standard chemotherapy because chemotherapy does reduce your white cell counts and that's the very definition of being immunocompromised. Now what's important to know with this infection that's going through communities is that it's a viral infection and one of the hallmarks of the infection is a lymphopenia. It's actually reductions not in the cell lines that are affected by chemotherapy, which oftentimes will reduce the white cells and produce a neutropenia. The importance of all of that is that neutropenia, neutropenic fever, a neutropenic sepsis, typically is bacterial. But what we tend to think of as the risk, even with COVID-19, is that if your immune system has been impacted by treatment, whether that's the neutropenia or, globally, a pancytopenia, which is when all the cell lines are depleted, that meaning your platelet counts may be down, you might be anemic, and you might have low white [blood cell] count. It does make you less able to fight off any kind of infection than if you had normal cell lines. Essentially, if you're on therapy for cancer, whether that's chemotherapy, whether that's anti-HER2 treatments, whether that's immunotherapy, we are worried about just a relative neutropenia that will put you at lower abilities to fight a COVID-19 infection.
Jean Sachs (03:06):
What about for those in our community who have had early-stage breast cancer? They [have] completed their first-line treatment, but they may be on an aromatase inhibitor or Tamoxifen or Lupron. Did these drugs have any role in compromising the immune system?
Don Dizon (03:29):
No, it doesn't. And one of the things we're just not that clear about yet is whether or not just having had a cancer makes you more susceptible to a more severe infection with COVID-19.
The data that sparked a lot of this came from China and it was published in the Lancet earlier this year — this month, I think — and it did show people with a history of cancer and people on treatment for cancer had a higher risk of a severe infection and also a death due to COVID-19. But when you look at the cohort that they had in China, these were also patients with a lot more comorbidities and they also had a history of smoking and they also tended to be older. Based on that singular dataset, having cancer as a medical history issue did have an impact on, on deaths from COVID-19, but so did having hypertension, having cardiovascular disease, having diabetes, and having respiratory problems.
So again, it's hard right now to pinpoint if just having cancer and you're otherwise healthy, are you at an increased risk?
I think all of us are taking the more cautious interpretation of that data and saying the rules that apply to the public still apply to you who have had a history of cancer. You still need to practice the handwashing, the social distancing, the cleaning of the surfaces. These are still very important because we have no guarantees at all that if you get sick, it won't be severe.
Jean Sachs (05:28):
What about for those who have finished chemotherapy and are not taking any other treatments? How long are you immune-compromised from that last treatment?
Don Dizon (05:40):
Usually you are able to recover a fairly normal immune system within 4 weeks of your last chemotherapy. Depending on what that [chemotherapy] is, I typically tell people, 3 months later, you're fine. There are no restrictions on you. You can go to the dentist, you don't have to wear a mask outside, things like that. Definitely 3 months, [but] as early as 4 to 6 weeks after therapy.
What's nice about modern chemotherapy for breast cancer is that it's not as toxic as it was 20, 30 years ago. Plus we're being much more precise in who requires chemotherapy and who's going to do fine even without it.
Jean Sachs (06:25):
What about those who are either actively in radiation or just finishing radiation?
Don Dizon (06:31):
Yeah, that's a big issue right now in terms of radiation: timing of the start of radiation and whether or not it should be delayed. I think most cancer centers are still going to complete radiation plans and people undergoing treatment. Whether or not that predisposes more [people to] severe COVID-19 infections is not clear. I did get a question on social media about if someone has fibrosis of the lung due to radiation, does this set them up for more severe infections? And again, that's a big unknown. But if you look at the classic presentations of COVID-19 in the lungs based on CAT scans ,for example — which by the way are only present in about a quarter of cases — you're seeing peripheral, inflammatory changes in working lung fields. No one has that dataset on patients who had prior radiation and the natural history of a COVID-19 infection.
In fact, if you look at the folks who are getting very sick right now, the demographics in the U S don't seem to be mirroring that in China and in Italy, we're seeing younger patients get very sick and requiring ICU care. Where prior medical therapies for cancer is gonna play out is not clear because I don't think the demographics in the U S are mirroring what we know already.
Jean Sachs (08:07):
Right. So we're still learning a lot.
Dr. Dizon, you may have said this and I might not have heard you, but did you address the patients who are taking the newer CDK 4/6 inhibitors?
Don Dizon (08:19):
No, I didn't actually specifically mention the CDK 4/6 inhibitors. Again, these are a pretty precise and targeted treatments to a pathway. They do cause myelosuppression. In general, thinking about how these oral therapies might impact risk, I would fall towards CDK 4/6 inhibitors and lumping them together with chemotherapy because again, they are causing side effects that do impact bone marrow.
Jean Sachs (08:53):
Thank you. This is, I don't know if you're going to be able to answer this question, but we did get it. If someone who is actively in chemotherapy does contract the virus, do you know what they can expect to happen?
Don Dizon (09:09):
No, unfortunately, we cannot predict at this point what would happen. I can say it's a concern within cancer centers that, given the high unknown population of asymptomatic carriers, it runs through all of us that, are we running into a situation where we're actually exposing people because they have no symptoms of COVID-19, but are carriers of this?
At this point we have no idea what would happen if patients got COVID-19 and were also on chemotherapy. I think there's a bunch of variables that might play into that. Where they are in their cycle? Are they need altering in terms of, are their white counts on the way down? Are they recovering at the time of their infection? And also the comorbidities and certainly age seems to play a factor in how COVID-19 affects people and the severity. I think it's just very hard to predict.
I certainly wouldn't say it's appropriate to believe that if you get COVID-19 and you're on chemotherapy, that you're going to die from this. We are worried that the course might be very difficult. We are worried that there might be an increased risk that you won't do as well as someone your age without a history of cancer. But again, there's just so much we don't know.
Jean Sachs (10:40):
This question came from someone who's living with metastatic breast cancer, but given what I'm learning from you this morning, I think it actually would be good for anyone who's in active chemotherapy, whether they're early stage or metastatic. Do you think those people will be advised to stay isolated until we develop a vaccine? So this is more of a forward looking question.
Don Dizon (11:03):
No. I think the hallmarks of the public health response, which we have not yet seen in the United States, is this whole notion of flattening the curve is trying to get a handle on the infectivity and ensure that we can go on with our lives even though this infection is in the communities. So universal testing, we'll find those folks who are exposed, who have an infection.
That can lead to the second part, which would be to isolate those folks into self-quarantine but also trace the people who they were in contact with. So we can then target them for testing and potentially for isolation. Right now we're in a situation where for large swathes of the country, in fact, I would probably say the majority of this country, we are operating with blindfolds on.
We have no idea who's been infected. We're looking for areas where the infections appear to be gathering momentum, just like in New York City and New Orleans, but that is really hindering the response.
So you do not have to stay in quarantine until there's a vaccine because realistically we're talking about a year from now. What we're hoping to do by flattening the curve is get to a situation where we can then roll out better, more proactive testing, leading to isolation, and then tracking of potential spread. And we're just not there yet. But I think once we get there, we will be able to live a more normal life. That's what we're hearing know.
Jean Sachs (12:55):
There's a lot of talk on social media and we know this is happening that some patients, their treatment is being delayed or they're triaging patients and trying to decide, can you continue?
How are you managing that and what do you have to share?
Don Dizon (13:15):
At our institution, we are operating with normal rules of engagement, let's put it that way. We're not closing the infusion unit. Everyone who has started on treatment, we're aiming to treat them on time.
In terms of delaying chemotherapy, we're not doing that. There might come a time when resources become stretched or, as is happening in other parts of the world, cancer centers close so that we can manage an aggressive response to COVID-19. Fortunately, we're not there. We're obviously doing what many centers are doing, which is limiting visitors into the infusion unit, limiting family into the infusion unit, looking at who needs to be seen in-person versus video consults, and trying to identify those patients who need to come to the hospital to be seen, cleared, and treated with intravenous therapies.
Right now it's really provider-specific discretion, provider and a patient making a decision. Those decisions might be, should we do use IV meds or can I prescribe an oral regimen for you which will buy us time if you're stable on therapy? Can we reduce the number of treatments you need versus continuing the full course? That's an active discussion point right now. But I think at the end of the day it's really important for people undergoing treatment, particularly in infusion units, to know that this is still a shared decision that's being made at the level of the patient and her provider.
Jean Sachs (15:17):
We have heard about surgeries being stopped also maybe people who would have been getting surgery first switch.
Don Dizon (15:28):
There is a movement to stop elective surgeries. The question on the table is the interpretation of elective. At the Lifespan Cancer Center and the Brown University institutions cancer surgeries are not elective, so those will be scheduled. Those will continue to go on.
What is being pushed back is folks who, have a triple-negative breast cancer or a HER-2 positive breast cancer that is not exceptionally small. There's some wiggle room here. It might be anything smaller than a 5-millimeter cancer will go to surgery, everything else will go to neoadjuvant chemotherapy. Or it might be at 1 centimeter. But remember, all of these measurements also take into account what does the breast look like for this patient? Because that tumor-to-breast ratio is really the determining point between a mastectomy and breast conserving surgery.
Even with the most broad guidelines, there has to be room for individualization. The real impetus across the country is, what is the institution's perspective on elective surgeries? Based on that, how do we want to rule out surgical decisions at our institution? Cancer doesn't fall into that elective category.
We are using neoadjuvant chemotherapy. We're being very, very conscientious about who gets the surgery and who should get neoadjuvant chemotherapy or neoadjuvant endocrine therapy. Again, it's coming down to the individual basis and shared decision-making.
Jean Sachs (17:17):
If a patient is told by their doctor, we're going to delay your treatment a little bit, or we're going to delay your surgery, they should feel confident that these doctors are really thinking through every case. Right? You're looking at every everyone and figuring out how to triage?
Don Dizon (17:40):
That's definitely happening. I can sense the panic even on social media and I can't speak to how folks say in metropolitan New York City are handling their cases or in Seattle, for example. I think so much of this is going to shift depending on the number of cases in communities. There is not going to be a national policy. This is all going to be centered by [cancer] center and by city. This is what we're looking at and this is how we're responding, but in every case, I think the patient should still be empowered to ask the question, how is this going to impact me and my cancer? Is it going to impact my chances of cure? What is safe? And again, there is no singular answer to any of those questions.
Jean Sachs (18:38):
I want to thank you so much and I want to take a minute to say that I know you and all the healthcare providers are on the frontline of this and we are so grateful for you and thinking of you all the time and wanting you to stay safe.
I, and Living Beyond Breast Cancer, we really understand that this is a very, very tough moment. Please know we're serving you with what, if I could pray, I would do that, but I'm surrounding you with light and love and I hear that over and over again.
Don Dizon (19:15):
Thank you very much. And again, it's like our thoughts are always with the people we’re treating with cancer first, it’s with our families, it’s with our colleagues, and our friends and we're really putting the priority on my health is probably the last thing I think about because this is what we were trained to do. but everybody needs to try their best to stay healthy.
Jean Sachs (19:40):
Yeah. We need all of you to stay [healthy]. Thank you again, and thank you to everyone who's listening. Remember that Living Beyond Breast Cancer is here for you in lots of different ways. So stay connected with us. Thank you very much.