Managing breast cancer treatment during COVID-19

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Dr Ashish Joshi, Director & Consultant Cancer Specialist, Mumbai Oncocare Center, expands on the myths and facts that are stopping breast cancer patients from going for treatment during the ongoing pandemic, in addition to the fear associated with contracting COVID-19

Breast cancer is the most common form of cancer and the second leading cause of cancer death in women. Given the current COVID-19 situation in India, it has become difficult for breast cancer patients to go for routine breast examinations. This has led to significant delays in the treatment of the patients. The COVID-19 pandemic has posed significant pressures on healthcare systems, raising concern that related care delays will result in an increase in the number of sub-optimal treatments, disease progressions, worsening of symptoms and cancer-related deaths in India.

It has been observed by various health experts that with the pandemic as a major cause for concern, women seem to be neglecting their breast health by delaying mammograms and avoiding visits to doctors. Fear of inadvertent encounter with COVID-19 patients at larger centres and travel restrictions imposed by government bodies are leading patients to seek treatment at the centres in their vicinity, who can offer them best of care from the experts and yet lessen the risk of COVID-19.

Patients from smaller cities, who travel to urban centres for treatment, were also affected because of the lack of travel options and imposition of lockdown. Over the past few months, women grappling with the fear of contracting COVID-19 have been found to be neglecting or inevitably living with the symptoms and delaying consultations. According to a recent survey by SurvivorNet, 1 in 3 women reported that they have delayed taking their annual mammogram and about 45 per cent of women also said that the outbreak has made them nervous about visiting their physicians.

Effects of COVID 19 on breast cancer treatment

Oncologists across the nation have observed that delay in consultation with the doctor has resulted in delay in treatment by 2-6 months. Clinicians are also worried that breast cancer cases and surgeries being reported during the pandemic are less than usual, which may lead to potential rebound in the number of cases, once the fear of coronavirus subsides. Clinicians have also reported that among women who underwent a biopsy in September 2020, several of them admitted to noticing symptoms as early as in March or April 2020 but did not consult a doctor due to the ongoing pandemic. Since they waited six months before consulting a doctor, they are now being diagnosed with advanced stages of the cancer. Cancers that could have been treated with a smaller Lumpectomy (removal of lump from the breast) in March may now need a Mastectomy (complete removal of Breast). Patients with existing diagnosed disease are also finding it difficult to continue their chemotherapy regimens.

In addition to the fear associated with contracting COVID-19, there are a few myths that are stopping patients from going for treatment.

Myth 1 – All patients require chemotherapy! There is an assumption among patients that all breast cancer patients have to undergo chemotherapy.

Fact:

Breast cancer has moved away from a one-size-fits all approach. Through the use of prognostic tests, Oncologists can now decide if a patient requires chemotherapy. A prognostic test categorises the patient as ‘high or low’ risk. Depending on this, the optimum course of treatment is decided by the oncologist.

Breast cancer patients undergoing chemotherapy are more prone to catching the COVID-19 infection due to the toxic side effects of the aggressive treatment. Some chemotherapy medicines and targeted therapies can also cause lung problems, which could put people at higher risk for serious COVID-19 complications.

Solution:

One possible solution to this challenge is that clinicians can take the help of a prognostic test to plan the treatment of breast cancer patients. An Early-Stage Breast cancer patient can be suggested to consider a prognostic test which helps decide the clinician if the patient required or shall benefit from chemotherapy and thereby reduce hospital visits for any kind of chemotherapy administration. One of such tests available is an immunohistochemistry based, machine learning based test, that can be used for early-stage HR+/HER2- a prognostic test for breast cancer patients to provide them a personalised treatment and determine their risk of cancer recurrence. If the patient falls under the low-risk category, the clinician can eliminate chemotherapy from the treatment regime and thus reduce the patient’s risk of complications and visits to the hospital. Not to forget that chemotherapy is a backbone of cancer treatment and not all patients can avoid it.

Myth 2- Teleconsultation does not help!

Fact: 

Under no circumstances should patients stop consulting their clinician. Though the process may not be as effective as a face-to-face consultation, it surely helps in continuity of treatment and to keep oncologists updated about the patient’s condition.

Solution:

It is essential that patients continue to get their routine diagnosis done to prevent detection of cancer at a later stage. It is unfortunate that due to the coronavirus outbreak, many hospitals have stopped doing regular preventive breast cancer screening and checks, not just because of the social distancing rules but also because all the resources have now been diverted to the coronavirus management. Oncologists also admitted that breast cancer screening, diagnostic exams and surgical procedures were being restricted or postponed at hospitals until recently.

Clinicians have come up with possible solutions to ensure safe and timely diagnosis and treatment for breast cancer patients. Patients on palliative therapy have been advised to shift to oral formulations whenever possible and modifying chemotherapy protocols to reduce the number of hospital visits. Many hospitals have also implemented a telemedicine program to deliver these services to the patients. Many doctors have advised the patients to opt for video consultation wherever possible for the benefit of both, the doctors and the patients.

Setting up outpatient visit priorities can also help to manage patients during a pandemic. Post-operative unstable cases, patients with pregnancy, excision of malignant recurrence, bleeding or painful inoperable mass can be given higher priority followed by patients detected with invasive breast cancer or showing side effects or new symptoms during course of treatment, clinically low risk (HR+, low grade). Patients needing psychological support, routine post-operative visits, patients with benign lesions (fibroadenomas, papillomas), breast reconstructions with tissue or implants can be given low priority or can be counselled with Teleconsultation sessions.

Usage of Neoadjuvant systemic therapies (those given before the definitive treatment) can also be considered as a good option for patients whose surgeries are not on top priorities. Wherever it’s appropriate, Neoadjuvant Chemotherapy (NAC) or endocrine therapy prior to surgery for such patients can not only help in reducing exposure to COVID-19 but also helps in down-staging (reducing the size and stage) of tumour.

Breast cancer treatment can be safe during these times if both healthcare providers and patients follow all safety norms and protection. With so many uncertainties around, it’s important that the clinician as well as the family members play an active role in managing the treatment effectively. The right kind of diet, a healthy environment at home, regular counselling sessions and a sense of empathy can help patients overcome feelings of anxiety, stress, and trauma.

breast cancerchemotherapyCOVID-19Neoadjuvant Chemotherapypersonalised treatmentprognostic test
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