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How does treatment for breast cancer change during COVID-19 times?

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Dr Kinner C Shah, Director, Department of Surgical Oncology, SAL Hospital, Ahmedabad mentions that the best way to beat breast cancer is through early diagnosis, patients shouldn’t delay diagnosis even though it might be scary to visit a hospital during the current pandemic as hospitals are following stringent protocols to prevent COVID-19 infections

As per WHO data, there are 18 million new cases of cancer every year across the world with lung and breast cancer being the most common types of cancers. Cancer is the second leading cause of death worldwide, accounting for a staggering 9.6 million deaths per year. In other words, cancer is responsible for one in every six deaths globally. In India, there are about 12 lakh new cases of cancer every year, with breast cancer being the most common, followed by lip and oral cavity cancers. Breast cancer has become the commonest cancer in urban women in India and second most common in rural women. The numbers are expected to rise dramatically by 2030, due to increased urbanisation and changing lifestyles. We in India need to dedicate more resources to breast cancer in the coming years to ensure that the current mortality rate of 50 per cent goes down.

Breast cancer is not one disease, but can be considered a group of diseases. Broadly breast cancers may be divided into Stage I, II A and II B, III A and III B and IV. For treatment of the disease, doctors often categorise breast cancers as early, locally advanced and metastatic breast cancer. There has been enough evidence that early breast cancers are associated with improved prognosis, better quality of life. The earlier the disease is diagnosed, the less expensive it is to manage as well.

The stress on early diagnosis has always been there but in these times of COVID-19, special efforts are needed to increase our efforts for early diagnosis by creating mass awareness about breast self examination and also the available treatment options especially breast conservation procedures and oncoplastic mammoplasty and other reconstructive procedures so that patients don’t hesitate to come forward. The earlier the cancer is detected, the more options open to the patient and the less money the patient has to spend. They can avoid so many aggressive treatments like mastectomy and chemotherapy.

Aversion for a mastectomy by patients is well known. Removal of the whole breast by mastectomy can adversely affect a woman’s feelings of femininity and self-confidence. It can lead to depression and other psycho-social issues. If patients are detected in early stages, they can opt for breast conservation. What has changed in India over the last decade is 1. Increased availability of skilled surgical oncologists who can perform breast conservation surgeries 2. Improvement of surgical results with breast conservation 2. Increased availability of radiation therapy machines that are needed if the patient opts for breast conservation.

Today, early stage breast cancer patients can even avoid chemotherapy altogether. For selected Stage I and II A patients, oncologists can prescribe a prognostic test. If their result is low-risk as per this test, they can safely avoid chemotherapy and all its associated side-effects. Especially during this COVID-19 pandemic, avoiding immunosuppressive chemotherapy can be a big boon to both the patient’s physical and mental health. It is well known that chemotherapy causes immune suppression for up to one year. Data coming from hospitals in China, Italy and the US show that the patients who are receiving chemotherapy are at double the risk of dying from a COVID-19 infection. They are also at an increased risk of requiring ICU admission and ventilator support. Leading cancer organisations in the world like European Society for Medical Oncology (ESMO) have issued treatment guidelines that heavily advocate for use of prognostic tests that help patients avoid chemotherapy. These tests tend to be very expensive. Thankfully, patients have a more affordable option today in terms of a test called CanAssist Breast offered by an Indian company OncoStem Diagnostics. This is also the only test validated on Indian patients and is therefore best suited for use in India compared to foreign tests.

Early detection is critical even today, as it offers patients the best chance to beat the disease. Patients should not hesitate in approaching their doctors to seek medical advice if they suspect breast cancer. They should not let their fear of contracting COVID-19 come in the way of visiting a hospital. Even if a patient has to undergo surgery to remove the tumour, various precautions are taken in the hospital in line with international recommendations, to ensure that the patient’s exposure to COVID-19 is reduced and there are no complications during treatment.

Some of the measures suggested by international guidelines on how to treat breast cancer patients during the COVID-19 pandemic are:

  • Stringent screening of all patients and hospital staff for COVID-19 symptoms, exposure and travel history
  • Suitable modifications to ensure negative pressure in operation theatres
  • Evidence based use of chemotherapy weighing the benefit to the patient against the risk posed by COVID-19. For hormone positive patients, a prognostic test can be used to assess whether chemotherapy can be safely avoided
  • If chemotherapy is required, reduced dosing schedules or conversion to oral chemotherapy as far as possible
  • If radiation is required, hypofractionated schedules are used as far as possible for shortened durations. For example, early breast patients can get one week versus the traditional three weeks
  • All follow up is done through teleconsultation to limit hospital visits and reduce exposure to COVID19.

COVID-19 is going to haunt us for the foreseeable future. But patients can be rest assured that their oncologists are there to guide them through these difficult and scary times. New data emerges every day on how to triage and treat cancer patients effectively. It is important to remember that cancer treatment is not an elective procedure. Even though the COVID-19 numbers appear to be rising significantly in India, the mortality rate is not that high. Patient’s should not let their fear come in the way of good health. The quicker people seek medical advice the faster the return to wellness. In these daunting economic circumstances brought about by COVID-19, a delay in cancer diagnosis can be very costly indeed.

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