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Professor of Medicine
Director, Breast Oncology and Clinical Trials Education
Division of Hematology/Oncology
Department of Medicine
UCSF Helen Diller Family Comprehensive Cancer Center
San Francisco, California
Hope S. Rugo, MD, has disclosed that she has received funds for research support from Amgen, Daiichi, Eisai, Genentech, Immunomedics, Lilly, MacroGenics, Merck, Novartis, OBI, Odonate, Pfizer, and Seattle Genetics and support for travel from Amgen, AstraZeneca, Daiichi, MacroGenics, Merck, Mylan, Pfizer, and Puma.
Breast cancer is the most common malignancy in women worldwide, and like other cancers, it will not slow down for a pandemic. Although many have drawn comparisons to the 1918 influenza pandemic, we must remember that we live in a very different world. In 2020, we have tools that were not previously available, including the technology to conduct telemedicine visits, and highly effective treatments for breast cancer. How can we best use these tools and balance the risks of the pandemic with the imperative for providing the best possible care for our patients? Here’s what we have implemented at my cancer center in San Francisco.
Treatment and Decision-Making
In the immediate wake of the pandemic, we abruptly halted screening tests such as mammograms in patients with no clinical findings. However, we strongly encouraged women who had clinical findings or abnormal imaging to continue their visits. Because treatment is critical for improving outcomes, we have counseled our patients to continue with their workup and treatment; it is better to deal with the “devil you know” than to delay treatment over concerns of the “devil you don’t.” For patients with a mass in their breast, it is better to have that worked up than to be afraid to come in for evaluation.
Of importance, our clinics have taken a proactive approach to protecting our patients and staff from transmission of SARS-CoV-2. In addition to careful cleaning, we have moderated scheduled visits to avoid crowding in shared spaces and to promote social distancing, and both patients and providers are required to wear masks. Compared with other public activities, such as grocery shopping, visiting a cancer center today is much safer.
That said, if we can help limit in-office visits, then we can further reduce the risks of COVID-19 exposure for all. In my clinic, we have pivoted to telemedicine visits when a physical examination is not needed. One benefit of virtual visits is that no one is constrained by mask wearing. Although valuable for reducing the spread of droplets, masks interfere with our ability to communicate and convey emotion. This can be especially tough for patients who are in a difficult situation. In a telemedicine visit, patients and providers can see each other’s faces and patients can be surrounded by their family/caregivers (who may not be permitted to accompany at in-office visits). I think this is an important use of our technology to better care for our patients emotionally as well as physically.
Clinic Visits and Screening
For patients who require chemotherapy or other treatment to control their disease and improve their chances of survival, we have maintained treatment schedules. However, we did delay nonurgent surgeries initially. More recently, as our ability to screen and test for COVID-19 has improved, we have been able to safely schedule surgeries again.
Patients who are scheduled to come into the clinic receive routine prescreening for COVID-19 symptoms and exposures. If patients self-identify a potential symptom, a nurse will contact them. Upon further concern, the nurse will discuss the symptoms with a physician or nurse practitioner. When necessary, patients are referred for SARS-CoV-2 testing in our respiratory screening clinics.
At my clinic, we conduct COVID-19 screening on patients who are coming in for surgery or any procedure that might produce aerosols (including bronchoscopy, colonoscopy, etc) within 1 week prior to the procedure. In addition, healthcare providers at UCSF are receiving random screening for COVID-19. Moving forward, as we navigate the current persistence of COVID-19, I think this kind of screening will be a critical element of reducing exposure. Combined with other risk mitigation strategies, I think our approach is working well. For example, despite rising cases in California, we have not seen exposures related to healthcare settings.
It is important to help educate our patients about minimizing their risks of contracting COVID-19 and to work with them on their individual risk tolerance. I have some patients who are extremely frightened of COVID‑19. I try to work with them and understand when it is critical to be seen and how we can minimize their exposure. Other patients need to be reminded to wear masks and practice social distancing in their daily routines.
As healthcare providers, we should also reassure our patients that we are here to care for them. We will not let their care suffer because of COVID‑19; we have implemented strategies to treat them appropriately within the confines of keeping them safe from the pandemic.
I have found that offering support is especially critical for my patients with metastatic disease who have a limited life expectancy, particularly if they live alone and are forced to isolate from others to remain safe from COVID-19. In this scenario, we must provide as much support as possible. I recently helped one of my older patients to set up some simple video conferencing, because having face to face contact is so important during this time to help ward off isolation and depression.
As providers, we have been very concerned that patients would delay needed care during the pandemic, leading to an eventual influx of new patients and others who had not been seen for several months. As Americans struggle to balance the risks of COVID-19 with other health concerns, I suspect we are now at the beginning of this predicted influx. In my busy practice, I recently had 5 new diagnoses in 1 week, including 3 patients with locally advanced breast cancer—2 of whom are 42 years of age. Again, we should encourage patients to deal with the “devil they know” sooner rather than later.
How have you navigated new precautions to continue providing the best possible care for your patients with breast cancer? Answer the polling question and join the discussion by posting a comment below.