Radiation therapy during the coronavirus outbreak and what comes next
As healthcare providers continue to take precautions against the spread of COVID-19, the disease caused by the new coronavirus, we are here to help you understand the decisions being made around breast cancer treatment at this time. Radiation therapy requires going to a hospital every day for weeks, a major concern at a time when medical centers want to limit in-person visits.
Living Beyond Breast Cancer CEO Jean Sachs, MSS, MLSP, spoke with radiation oncologist Nicole Simone, MD, about what is being done to get people the treatment they need while protecting against COVID-19. They discuss when it is safe to delay radiation and what hospitals are doing to protect people who are getting radiation now. They also look ahead to clinical trials on how diet interacts with radiation therapy and shorter schedules of treatment. Watch, listen, or read the transcript below.
Find out more about how breast cancer treatment is changing during this outbreak on our COVID-19 resources page.
Nicole Simone, MD
Dr. Simone is a radiation oncologist, the Margaret Q. Landenberger Professor of Radiation Oncology, co-leader of the Breast Cancer Research Program at the Sidney Kimmel Cancer Center at Jefferson, and radiation director for the Jefferson Breast Care Center in Philadelphia. 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):
Hello, everyone. It's Jean Sachs, the CEO of Living Beyond Breast Cancer. I hope everybody is doing well and is safe and is finding ways to keep occupied and stay positive during this very challenging time. For the past 7 weeks, Living Beyond Breast Cancer has been working hard to bring you content that is important for you to know if you are in active treatment for breast cancer during the COVID-19 outbreak and I'm really pleased today that we have Dr. Nicole Simone who is a radiation oncologist at Thomas Jefferson University Hospital right here in Philadelphia where Living Beyond Breast Cancer is based and we know it is a hot spot and we know your hospital has been really active. so first of all, welcome and thank you for all you're doing.
Nicole Simone (00:50):
Thank you very much. Thanks for having me.
Jean Sachs (00:52):
Great. We have a bunch of questions, so I'm going to just get right to it.
We know that there have been some changes in guidance for radiation oncology from some of the large associations about how to safely deliver breast cancer radiation treatment during this time. So can you just tell us about that?
Nicole Simone (01:13):
So ASTRO (American Society for Radiation Oncology) is our national body for radiation oncology, and so far they've actually been leaning, in terms of breast cancer, on the surgical association and ASCO (American Society of Clinical Oncology) as well. Several institutions have created guidelines, but there hasn't been one big consensus in terms of radiation, so we've created our own at Jefferson.
Jean Sachs (01:39):
Tell us how you're managing early-stage patients.
Nicole Simone (01:43):
In early stage there is a window in which radiation works really well, and we know that. There have been studies looking at “Can we delay radiation if it's needed in certain subsets of patients?” and the answer is yes, we can delay the start of radiation. If a woman has had surgery, we can probably wait 8 to 12 weeks after her surgery to start the radiation. So we are doing that and we're working very closely with our medical oncology colleagues so that if a person is estrogen positive there's the likelihood that we'll start them on an anti-estrogen therapy like tamoxifen or anastrozole to start. Then they'll delay the radiation a little bit safely knowing that they're doing something to decrease their chance for recurrence during that time period.
On the other chance, that it happens to be a triple-negative cancer or HER2-positive, we are looking at the size of the cancers to determine whether or not we should bring patients in, remembering that this is a curative window, right? We know that we can cure these patients and we don't want to do anything that would offset that chance, so we're taking each patient case by case. I'm looking at their estrogen status, progesterone, and HER2 and trying to make a decision, whether or not something can safely be delayed based on literature that we have or whether or not we should bring them in right away for treatment.
Jean Sachs (03:12):
That's helpful. What if you were someone who was already in the middle of your radiation course when the pandemic hit?
Nicole Simone (03:20):
We continued people. We've done a number of things and throughout this country people have done a number of things in departments to keep our patients safe. We've been very vigilant about having patients wear masks; every patient that walks in the door gets a mask. There’s a temperature screen.
We're wearing masks as well, which is a little uncomfortable because I can't smile at my patients anymore. Everything's being wiped down between patients, their exam rooms, the doors, the exam tables, the chairs. We've taken all the precautions and we've done a fairly good job. We've actually had no COVID-19–positive patients in our department so far. We've been really lucky, but we did continue taking those extra precautions and reassuring our conscience that we're doing everything we can to keep them safe while they're undergoing treatment.
Jean Sachs (04:14):
Great, it's very helpful that you haven't had any COVID-19–positive patients. I'm sure everybody's really happy to hear that.
What about for your patients that are living with metastatic breast cancer and have been recommended to have radiation therapy?
Nicole Simone (04:30):
We're treating patients, and as you know, [also] patients with inflammatory cancer, there are some things that just can't wait. We’re taking into account how quickly can we get the radiation done, if there a shorter fractionation that we can treat with something with fewer days we will try that at all costs. Especially in the metastatic setting. Is it pain that you're being referred for? Can we just treat with one treatment? Those types of things are being taken into account, like the number of trips into the radiation department to try to minimize our patient's exposure.
Jean Sachs (05:07):
That's helpful. So I know our community does want to know if you're having radiation therapy, are you immune compromised?
Nicole Simone (05:18):
The radiation is a very local therapy and when we treat with radiation, whether or not we're treating your lymph nodes and an extensive area encompassing the breast and lymph nodes, we're not targeting anything that will suppress your immune system very much. There are some ribs there that don't carry very much bone marrow, but other than that, our patients are usually in very good shape.
Usually [radiation] is the time that we start talking about adding in things like exercise and diet too, because we know that people are recovering from their chemo and everything else. So that's usually the stage where people are good shape.
Jean Sachs (05:58):
For someone who's early stage and had chemo first, how long are they immune compromised? I mean, I know they wait until they have radiation, so what's that window?
Nicole Simone (06:11):
That depends. That's a tough question. Probably better for a medical oncologist, but a lot of patients actually do fairly well. It's the patients that become neutropenic that we're a little bit more concerned about. And that window may take a little while longer, but generally by the time they're referred and starting radiation they're in a safer place.
Jean Sachs (06:31):
Okay. So for your patients, are you just telling them to follow the CDC [Centers for Disease Control and Prevention] guidelines in terms of protecting themselves or are you asking them to do anything additional?
Nicole Simone (06:41):
I just follow the CDC guidelines and I think we're recommending that for all patients, whether or not they've had chemotherapy. We want everyone to be safe. This virus can affect people in many different ways and we have no idea which patients are going to be affected more significantly, so we're telling patients to be very careful, minimize their outings as much as they can while they're doing their radiation or any cancer treatment.
Jean Sachs (07:09):
And in general, how do you, how are your patients reacting to all of this and how are they doing during this time?
Nicole Simone (07:16):
I think it's disconcerting for everyone, whether or not you have cancer. Our cancer patients, obviously they're already dealing with something and now they have to have another worry in their lives, which isn't very fair. Emotionally I think it's affecting everyone and to try to keep the positivity going in the department and everything is really important. To find things that can make you happy once a day, even something little, is really important to carrying on right now.
Jean Sachs (07:48):
I want to just talk for a few minutes about clinical trials. I know that some changes have been made. So the first question is what is going on with clinical trials specifically for radiation therapy? And then I know there are two trials you've been involved in, one about a shorter radiation course as well as another one more about caloric intake.
Nicole Simone (08:12):
Unfortunately all clinical trials are on hold right now unless it's something so novel that it could lead to a better cure, so most of our breast cancer clinical trials are closed right now. And the reason for that is minimizing [contact]. We still want you to get your treatment if it's necessary, but we want to try to minimize your contact with anyone around. Which is why another precaution that we're taking is not allowing, unfortunately, people to bring a friend or significant other into the hospital. That extra person that you would see for the clinical trial or something else or an extra blood draw, whatever it is, we're trying to minimize all that to make sure our patients are safe at the moment. Everything is on hold until we get a better handle on this. And it will probably be a few months, I'm guessing, until we have things up and going.
We do have some clinical trials that will be open in a few months looking at caloric restriction. How can we change your diet during the course of radiation? We have some evidence, if you're able to decrease your calories over treatment or eat the right calories and we can talk about that, that perhaps the radiation may work better, and we can also talk about long-term habits and how that's related to breast cancer. It's a great trial. We do a lot of one-on-one counseling for our patients, what they're typically eating now and what they might do to change that.
One big thing that we know from the Nurses' Health Initiative that was published that was over 5,000 people who had breast cancer, who were actually nurses who were very well when they enrolled on this trial. What we know from the 5,000 women who actually did develop breast cancers, they were able to maintain their weight or drop their weight a little bit. They actually have better outcomes in terms of survival and then local recurrence.
We try to use that as our springboard for recommending some dietary changes, knowing that right now nobody's moving very much, right? Everybody's a little bit more sedentary. When we're giving hormone therapy like tamoxifen and anastrazole, which are known to decrease our metabolism, it's really important to watch the calories that you're taking in to make sure that you're at least maintaining your weight during this time.
Jean Sachs (10:39):
Even though that trial is not currently happening, is there a website or a place that our community could go on and read about it and maybe they could think about incorporating some of the healthy eating habits?
Nicole Simone (10:50)
We don't have one right now, but that's a great idea. We'll get one up and going.
Jean Sachs (10:55)
Well if you have any resources I think our community would be interested in when this is over, we'd love to talk more about it.
What about this, the idea of having shorter courses of radiation?
Nicole Simone (11:10):
When initial trials were done looking at breast conservation in the late seventies and early eighties, the standard of care was to deliver 30 to 33 breast cancer [radiation] treatments based on those randomized trials, and we know, through data that's mature — meaning there's 25 years of follow up — that our patients do very well with that standard 30 days of treatment.
There were then trials done in the U.K. and Canada suggesting that we can shorten that a little bit to 16 to 20 treatments or 21 treatments and at 10 years — so those data were published at 10 years and a little longer — have shown that 30 treatments is exactly equal to those 16 to 21 treatments.
The standard in this country has really moved towards incorporating that lower fractionation schedule. One thing that we do keep in mind is, if we're treating the lymph nodes, sometimes we still are sticking with that 30 treatments because it's a little bit safer for long-term toxicity of the brachial plexus and your arm movement and things like that. That's the one caveat. That's if we're just treating the breast, our standard has now become the 16 to 21 treatments.
Recently, there's been a few trials done in Europe as well. I'm looking at something called the FAST trial, F-A-S-T, fast, or the FAST-Forward trial. Both of those have been done and are showing really promising results actually decreasing that 16 to 21 treatments to only five treatments. We're all excited about that, but the jury's still out a little bit. As you guys pointed out, the FAST-Forward child was published just a few days ago.
The FAST trial, just to tell you how it works, is there's five treatments that are given just once a week. So the patients only travel in for their radiation once a week. The FAST-Forward trial is five treatments, but all in a row, so they're consecutive days.
Both actually look like they're going to do very well, but the jury still out on a few issues. A lot of the patients that were treated on those trials did have smaller tumors. The average size of those [tumors] were about 1 1/2 centimeters, and most of the patients, about two-thirds, were over 50 years old and had a very low-grade tumor. It was either a grade one or grade two. They have done well, the results were published at 5 years, and as you guys very well know, we don't, we love 5-year results. We really want those 10- or 20-year results for our early breast cancer patients. Until I see complete, mature data I am recommending it for patients who fit criteria, who have smaller tumors, who are low grade and who are at least over 60. We talk about that with our patients and we've actually been doing that at Jefferson for several years now and have had great results actually. So it is a way to get this done a little bit faster.
The other caveat too is in that FAST-Forward trial that was just published, a quarter of the patients actually got a boost. Even though it says that they had five treatments, a lot of them, a quarter of the patients, either had five or eight additional treatments. If you read the headlines that looks pretty good, but you realize you're almost getting to that 16 treatment area as well. They have eight additional treatments.
I think it's great and something that, during this COVID-19 period, we're paying attention to is does our patient really need to come in the 16 or 21 times, and shorten that and offer something else if they have a low-grade tumor, so we've changed a lot of patients to that.
Jean Sachs (14:58):
That is really exciting news and, at Living Beyond Breast Cancer, we'll certainly write more about this, but I appreciate your comprehensive overview.
Keeping in mind that we do have a national audience, is this something that moving to 16 treatments away from 30, is that pretty standard across the country or is that institution by institution?
Nicole Simone (15:20):
No, that's pretty standard now. We have done a large trial in this country, one of the NRG trials, to look at a subset of patients who are a little bit more at risk. So the patients that are [younger] than 50 years old who may have had chemotherapy. We're waiting on the results from that, but most patients who are low-risk, early breast cancer, that is the recommended standard from ASTRO.
Jean Sachs (15:45):
Okay, that's really helpful.
I want to thank you so much for taking time out of, what I'm sure is, a busy and stressful period of your life to share this information. And again, we will write more about this, so to our community: check back and we'll get more information about these trials and certainly let people know when they're up and running again.
In the meantime, Dr. Simone, I just want to thank you and your colleagues and all the healthcare providers that are working so hard to keep us all safe and healthy. We are greatly, greatly appreciative. And to everybody else, please stay tuned to Living Beyond Breast Cancer at our website, LBBC.ORG. Remember, we do have closed Facebook pages, so if you're looking for support, log on and we will add you. These communities have been really active and you really get answers to your questions in real time.
Everyone stay safe and stay strong and take care. Thank you.