Updates on COVID-19 and breast cancer care
Since March, we have covered ways the COVID-19 pandemic has affected people who have or had breast cancer. Now nearly 3 months after much of the U.S. shut down, parts of the country are opening up and new data is starting to come out on the effects of COVID-19 on our community.
We spoke to Pallav K. Mehta, MD, about what has changed in our understanding of and dealings with COVID-19. He discusses how breast cancer care has changed – both temporarily and in ways that may change practice going forward. He also explores what doctors and people affected by breast cancer should watch for as the country moves forward, such as making sure people who had screening delays are prompted to come in again and watching how changes to care are affecting those in treatment and their outcomes.
Watch, listen, or read the transcript below.
Pallav Mehta, MD
Dr. Mehta is a hematologist/medical oncologist and director of integrative oncology and director of practice development at the MD Anderson Cancer Center at Cooper in Camden, New Jersey, and a member of LBBC’s Board of Directors. 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. First of all, I hope you're all safe and doing well and managing during these really difficult times today, we are going to have a short conversation with Dr. Pella Maita, who is a medical oncologist at MD Anderson Cancer Center in New Jersey. He is also a member of the Living Beyond Breast Cancer board of directors and our medical advisory committee. We keep him very involved and engaged, and he has been practicing since this pandemic started.
Welcome Dr. Mehta.
Pallav Mehta (00:36)
Thank you. Thanks for having me.
Jean Sachs (00:38)
Of course. I know this has been a really challenging week for everyone on top of the pandemic and then the murder of George Floyd and the protests, and so many things going on. We just want to take a moment to make sure everybody knows that Living Beyond Breast Cancer stands with Black Lives Matter, and we are committed to doing everything we can to improve health, equity, and justice for everybody.
And to that end, today we want to talk about the impact of COVID-19 on cancer care. I had the honor of talking to Dr. Mehta back in March when, at least for the Northeast part of the country, we were just starting the shutdown. We didn't really know what that was going to be like and were asking you, What can we expect?
Now we're more than 3 months into that. This is a great time to touch base as most of the country really is starting to open up in one way or another. I’m wondering what have you observed over these last 3 months in terms of cancer care and treating your patients?
Pallav Mehta (01:46):
Yeah, it really has been a change in our day-to-day practice. I think the last time we talked — and I've seen patients now that I last saw 2, 3 months ago — and it's interesting how the world really has changed in many ways and the day-to-day cancer care has changed. There's many different minutiae and many broad strokes that have changed, but the biggest difference has been in our day-to-day visits with patients. Telehealth has become a routine part of our care. I'd say about half the patients we see — and in cancer care, there are patients that we just have to see, they're here getting chemotherapy, they're getting radiation, we have to examine them but then there's others who are our follow-up visits, patients who come in every 3 months, every 6 months, sometimes even annually. Those folks we’re not physically seeing. I think we forget how valuable the visit is for those patients to actually come and see us. There's a sense of security that patients get that they really need right now and they're not able to necessarily get immediate. Though we are changing some of our policies now, starting to open up a little bit
Jean Sachs (03:14):
For the patients that you feel are struggling to connect or get that personal connection during a telemed visit, what are some things that you could recommend that patients could do to better prepare for future visits?
Pallav Mehta (03:30):
I think one of the simple things is to understand the tech behind the telehealth and prepare, because I can't tell you how many times I have these telehealth visits and there's two or three times we're trying to connect and then the video doesn't work or the audio doesn't work and sometimes I can't get to them because it's 20 minutes later and I have to reschedule the visit. Talking to your doctor's office and understanding what platforms they're using, testing it out the day before and making sure that it works, then you have a more seamless, more integrated visit with your physician because 20 minutes in person is quite different than 20 minutes on a video screen.
Jean Sachs (04:18):
That's really helpful. I know for some patients who don't have the technology, that the phone is always an option, and I know we're all a little bit more used to talking on the phone and sometimes that can be more intimate than staring at a screen.
Pallav Mehta (04:32):
Yeah, it's interesting you mentioned that because patients have actually said that, I think because of the glitches in the video and everyone's access to wifi and cellular networks. We're lucky in Philadelphia, there's parts of Philadelphia that have great access and then there's other parts of Pennsylvania that probably have more limited access and around the country. The phone conversations, have been great. And I think you can focus more on the words.
Jean Sachs (05:05):
Got it. I know there's been many changes and another change has been diagnostic mammograms have continued but screening has not. I’m wondering, what do you think the impact of this shutdown is going to be on cancer rates?
Pallav Mehta (05:22):
Screening mammograms at most centers are starting to open up now. We're looking at about a 3-month lag. If you look at 3 months from the standpoint of screening, for the most part, for most women, that shouldn't make a difference. I think our concern though, is that many centers and many women may forget to actually schedule that test, which means once you forget, and you're off the reminder list for whatever center you go to, then it could be a year before you remember, because obviously the world is getting more and more stressful and you're thinking about other things and then it's 2021 and you realize you can get your mammogram.
I think when you look at the actual physical time, most of us aren't too worried, but really the whole process. My center is, like many, putting together processes to ensure that the patients that would have gotten these in the preceding 3 months would make sure to be reminded.
Jean Sachs (06:26):
Yeah, that's such a good point. I think we all, or many of us say May is when I do all my wellness visits and suddenly, if you don't, it's hard to remember. It's important for people to make those notes and figure out when their clinics are opening.
There's also been changes in treating some breast cancers. We've heard whether you're doing chemo before surgery or people putting off surgery, and may be having tamoxifen for a period. Talk a little bit about that.
Pallav Mehta (06:59):
I think when the epidemic first started, several of the large breast cancer organizations came out with COVID management guidelines or breast cancer management guidelines during COVID and many of them really focused on what is the risk? What is your risk of getting COVID? Is it higher with surgery? Is it higher with chemotherapy? And we did for many patients change the sequence of treatment. Patients who would have gotten surgery first, maybe they were already at a somewhat lower risk, we felt more comfortable giving the hormone medicine that they would've gotten after surgery.
Anyway some patients who we knew were going to get chemotherapy after surgery, we gave it before surgery. Most centers, and the NCI (National Cancer Institute) is looking at this, but we're all putting together a registry of these patients and trying to figure out, Will this impact outcomes? I hope not. Most of these organizations were obviously very thoughtful about putting this together and even at our center, every single patient in whom we made a change, we all convened. The breast surgeon and the radiation oncologist, the medical oncologist, and our team convened to say, Does this make sense?
Jean Sachs (08:21):
What was that like for you after having a practice where you're like, this is best practice, this is what the clinical data say?
Pallav Mehta (08:27):
When we saw these guidelines it was interesting because, depending on the organization their assessment of risk was more geared towards the organizations stated goals. For example, surgical organizations, I think looked at surgery as a bigger risk. And then some of the medical organizations said, chemotherapy might be a little bigger risk. It's tough. I don't know if anyone has a clear answer on what is the risk.
Chemotherapy? Sure, it suppresses your immune system and puts you at a little higher risk of getting infections, but does it puts you at a higher risk of getting COVID? Maybe, maybe not.
Does entering a hospital make puts you at a greater risk? How long do you stay in a hospital where people now, as many patients have seen, we're doing mastectomies and reconstruction and having people leave that same day. It was unheard of previously, and patients are doing well.
Jean Sachs (09:34):
I've certainly talked to a lot of newly diagnosed women who would have had surgery first, may not need chemotherapy and were put on tamoxifen while they're waiting for surgery to be scheduled.
Pallav Mehta (09:48):
I think the hormonal therapy decisions tend to be a little easier. There's some women that we actually want to give hormone therapy first to try and shrink the cancer, to allow them to get surgery. And that ends up being 6 months, 9 months. In this case, we knew it was going to be a relatively short time.
I think when you look at surgical ORs, one of the concerns was that there was going to be this huge backlog now that elective procedures have opened up. We've now started looking back at all these cases now and really almost triaging, which ones need to go sooner versus which can wait.
Jean Sachs (10:28):
It's reassuring to hear that there's a registry being created, that we're going to really learn from this and figure out what works, because obviously this could change practice moving forward.
This is a bigger question, but maybe you could speak briefly about the impact COVID-19 has had on clinical trials?
Pallav Mehta (10:49):
It likely has had a pretty significant impact across the board. Many centers, most centers, stopped accrual for a little bit with studies. MD Anderson in Houston stopped, local centers stopped for a little bit, and I individually have had patients who needed or were really looking into studies that they could not enter. We had to change their care and put them on something as a bridge to trials.
I think we'll be looking at clinical trials a little differently because it's not like COVID is going away. It's going to be here for the foreseeable future. Understanding how we conduct the trials, how we assess patients. I go back to telehealth. I think it will be used more in those scenarios where we need quick visits without exam, particularly for patients who might be too far away to travel. Obviously there are some risks associated with that. I think right now a lot of the newer studies that are coming out are temporarily reassessing and recognizing that COVID is going impact accruals.
Jean Sachs (12:14):
We realized that for the metastatic community, but really for anyone with cancer, this is anxiety provoking and we know progress comes with clinical trial data. We'll be following that.
Let's talk a little bit more about COVID-19. I know when we talked a few months ago we weren't sure how cancer patients would do if they were actually diagnosed with the coronavirus. Have you had patients diagnosed? What have you learned?
Pallav Mehta (12:42):
I've had several patients who were diagnosed. Most of them I would've seen for an office visit and they were doing fine, then 4 or 5 days later they had a symptom and then they get tested. And some of these patients were routine, others were on chemotherapy. I've had several patients on chemotherapy who got diagnosed and, knock on wood, at least anecdotally for my population, they've done well. Each regimen is different. Each chemotherapy regimen is different. Each patient was different.
We know that age is a risk factor in getting more serious illness for COVID. I had a couple of older patients who had a little tougher time with it but were able to recover and were able to resume their treatment. But we're looking at it.
There's the patient end of it for that individual patient, but there's also the cancer center end of it, where a patient who steps into a cancer center, who has COVID now and who didn't know it at the time, has interacted not just with me, but with the staff, with the nurses, and with the medical assistants and the front desk and everyone else that's showing up here every day, making sure these patients get seen. That means that other patients who interact with them now are potential risks.
When you look at the policies and procedures that we've put in place, particularly since we last spoke a couple of months ago when we weren't sure exactly what to do, I think we've really we've honed it down as best we can right now.
Jean Sachs (14:29):
Have you had any staff get, come down with a virus?
Pallav Mehta (14:33):
Nope. We've had a few folks from our infusion area to radiation who have gotten it but thankfully have all recovered.
Jean Sachs (14:46):
I know there were two studies presented at ASCO about COVID-19, can you share some of the outcomes of that?
Pallav Mehta (14:54):
One of them was a lung cancer or thoracic cancer trial, looking at outcomes in in those malignancies for patients who were COVID-positive, and it did show a higher incidence of mortality in that population, but a lung cancer population is quite different than a breast cancer population in terms of the types of issues that many of those patients come into their diagnosis with.
In a larger database that was looked at in COVID-19, about a thousand patients with various malignancies, and I believe about 20 to 25 percent were actually breast cancers. The overall increase in mortality seemed to be related to age but not to a specific type of cancer which is interesting.
I think the problem is the numbers. When you're looking at a thousand patients and various cancer types, every cancer has different treatments and some are chemotherapy, some are immunotherapy. Immunotherapy did not seem to increase risk, again smaller numbers, but it didn't appear to increase risk. Chemotherapy in the other trial did seem to increase risk a little bit.
These are not randomized trials. For example, the larger database looked at drugs that have caused a lot of controversy over the past couple of months, hydroxychloroquine, azithromycin, and that one did show an increased risk of mortality with the use of those drugs. But again, these are not randomized. You're looking at a population that maybe was sicker and they got those drugs. It’s a little tougher to extract the information just yet, but we're hoping these larger databases can tell us more moving forward.
Jean Sachs (16:56):
It's interesting because we know more than we knew 3 months ago, but we know so little still. I think we're also impatient and want to just have all the answers. I think we have to be comfortable knowing we're going to have to wait and really see how it plays out.
That leads into my final question: We're moving into opening up more and I think for some people they're really ready but many people have anxiety. I’m wondering what are your thoughts on this and any specific advice for cancer patients who are still actively in treatment?
Pallav Mehta (17:38):
Yeah, I can tell you all I hear in my house is, “We're going yellow! We're going yellow!” I'm not sure that they realize exactly what going yellow means, but as we know, some states have decided to open up a few weeks ago. We've been looking at whether those states are seeing increased case loads. I think the way we're looking at it in cancer care is not just increased cases, but increased hospitalizations.
I suspect that currently what's happening, where certain states have seen more just people getting out and maybe not social distancing or not wearing masks and gathering in large groups and all of that, the types of patients that are the types of people doing that are generally younger, healthier people. We may not see an increase in hospitalizations in that group, but I want to be careful not to be lulled into a false sense of security, because then if we suddenly start to use that data to say that everything's okay and then get everyone out there, people who are older, people who might have lung issues, people who might have cancer, we might start to see an increase again.
I think over the past week with the nationwide protests, which are obviously very large gatherings of people — some of whom are wearing masks, some are not — social distancing obviously is out the window in most of these. We're curious to see what happens because there's always about, we think when you look at COVID, a 3 week lag from a gathering to a hospitalization increase and most states have seen that. Over the next 2 weeks, see what the numbers look like and from there, hopefully be able to make some decisions. We were hoping maybe the warmer weather would help, not sure that necessarily helped just yet.
I would recommend you're safer at home if you can't be right. Yeah. Particularly for our patients who are on treatment. If you're on active anti-cancer therapy, meaning chemotherapy, even immunotherapy, even if the data right now is still questionable. If you have metastatic breast cancer then yes, you need to follow the guidelines that we were a month and a half ago at the peak. If you're on active chemotherapy for localized cancer, same recommendations. I think the questions I'm getting a lot are from people who are in the follow-up period. Patients who might be 2, 3, 5 years later. Those patients, for the most part, outside of any other illnesses, they might have their immune function, even if they've gotten chemotherapy. We think by 6 to 9 months, their immune function starts to return more to normal. Then their risk is really like that of anyone else of their age and medical history. But nonetheless, I think wearing masks is still going to be an important and unfortunate part of our life for a while.
Jean Sachs (21:01):
Yeah. We're all getting a little bit more used to that, figuring out how to follow the social cues when you just see someone from their eyes up. Are they smiling?
I'll just add if you have any other thing to say, as I've definitely talked to a lot of women who are actively in treatment, but they don't live in a bubble. They live with kids and partners and extended family. It's still really important for everybody in your circle, your pod, to be as careful as you are.
Pallav Mehta (21:34):
Right, right, right. I think one of the concerns we have is that when we open the door a little bit, people are going busting through. I think particularly in a household, if your children, older children, that aren't necessarily always under your control, partners that have to work or partners that may not feel the same way about all this, which we're seeing those sorts of conversations happen in households. Everyone really does need to follow the rules, particularly if you're in a household with a patient who has active cancer or is on active cancer therapy.
Jean Sachs (22:12):
Yeah, Americans have to learn how to be patient and care about the greater good.
Thank you much for your time this morning, this was really informative and always great to get your insight and your compassion. I know how much you put your patients first and how much time and extra energy you give to them. I also know healthcare providers have continued to be really the soldiers in this unfortunate war, and we are always very grateful for all you're doing.
I want to thank everyone for tuning in. Remember Living Beyond Breast Cancer is here all the time. If you're interested in getting immediate support, we have several closed Facebook pages, go onto our website LBBC.ORG, we'd be happy to have you join. They're very interactive, lots of real time support, and we have many other programs coming up. Stay safe and stay strong. And thank you for staying connected to Living Beyond Breast Cancer.