The new respiratory illness commonly referred to as “coronavirus” and officially called COVID-19 has changed life as we know it for the foreseeable future.
It can be alarming to hear news reports about the coronavirus spreading, cities shutting down, and experts telling us to stay home and limit contact with others. Adjusting to this new normal where schools and businesses are closed can be difficult, and many are worried about how their jobs and finances may be affected. For people with serious health conditions, such as breast cancer, and their loved ones, the uncertainty of this situation, the need for physical distancing, and possible delays in cancer treatments can be especially distressing.
The Centers for Disease Control and Prevention (CDC) says that the risk of becoming seriously ill from COVID-19 is low for most people. However, it’s very important to know that people being treated for breast cancer may have a higher risk of severe illness if they get COVID-19.
Some breast cancer treatments — including chemotherapy, targeted therapies, and immunotherapy — can weaken the immune system and possibly cause lung problems. People who have weakened immune systems or lung problems have a much higher risk of complications if they become infected with this virus. For most people, the immune system recovers within a couple of months after completing these treatments, so those who have been treated for breast cancer in the past don't necessarily have a higher risk of severe illness.
People with breast cancer that has metastasized (spread) to the lungs also can have lung problems that may get worse if they develop COVID-19.
Because people can be exposed to the virus in healthcare facilities, many hospitals and healthcare providers have delayed or recommended delaying elective surgeries, screenings, and other procedures that are not considered urgent. These tough decisions are being made to protect people from unnecessary exposure to the virus and to make sure healthcare providers have the resources they need to treat people who become seriously ill from COVID-19. This situation continues to change — you can read more about it in our Special Report: COVID-19's Impact on Breast Cancer Care.
The virus has now spread to most countries in the world and across all 50 states here in the United States, but the number of cases varies in different regions, so your immediate risk of coming into contact with the virus depends on where you live. The risk of infection will continue to change over the coming months as cases increase and decrease in different areas.
To protect yourself and help reduce the spread of the virus, it’s important to listen to health experts who recommend staying at home, limiting contact with others, and following other precautions.
If you or a loved one are receiving treatment for breast cancer during the COVID-19 pandemic, here’s what you need to know:
- What is coronavirus?
- How does COVID-19 spread between people?
- What are the symptoms of COVID-19?
- Who is at risk of getting COVID-19?
- How can I protect myself and others?
- Should I wear a face mask?
- What should I do if I develop symptoms?
- Is it safe for breast cancer screening or treatment to be delayed?
- How can I manage anxiety and loneliness while isolating?
- Listen to the latest COVID-19 podcast episodes
- Watch our special COVID-19 video series
- Join our COVID-19 and Breast Cancer Care Town Hall on July 30, 2020 at 2pm ET
What is coronavirus?
Coronaviruses are a large group of viruses that can cause respiratory illness in humans and animals. The new (novel) coronavirus you’ve heard about in the news is called SARS-CoV-2, and the illness it causes is called coronavirus disease 2019, which is why it’s abbreviated as COVID-19.
The first case was diagnosed in China in December 2019, and it has since spread to almost all countries throughout the world. Some coronaviruses spread from animals to people, and that appears to be the case with SARS-CoV-2, which is thought to have originated in bats and first infected people at a live animal market.
How does COVID-19 spread between people?
This virus mostly spreads through close contact with other people (within 6 feet) through droplets of respiratory fluids produced when a person coughs or sneezes. These respiratory droplets can travel through the air and either be inhaled or otherwise get into the noses, mouths, or eyes of people nearby.
The virus is very contagious — about 3 times as contagious as the flu, CDC director Robert Redfield, M.D., said in an interview. People become contagious up to 2 days before developing symptoms, but it’s important to know that up to 25% of people who become infected don't develop noticeable symptoms, and you can still catch the virus from them. Data from China suggests that up to 80% of the people there who were infected with the virus that causes COVID-19 had no symptoms. Still, we don't know yet if this is happening in the U.S.
It’s also important to know that the virus has been found in fecal matter — in other words, it can live in your poop.
Respiratory droplets and fecal matter can end up on surfaces more often than you might think, and the virus can survive on these surfaces for hours or even days. When you touch these surfaces and then touch your face, you can be exposed to the virus. However, this doesn’t seem to be the main way the virus spreads — most often, it’s through close contact with others.
There is no evidence that COVID-19 spreads through food or food packaging. Still, research shows that the virus can survive for up to 24 hours on cardboard and up to 3 days on plastic and stainless steel. So, it’s smart to wash your hands for at least 20 seconds after handling mail, takeout containers, and packaging from groceries. If you’re worried, you can always disinfect food packages using a cleaning product that kills viruses (but do not use disinfectants on food).
What are the symptoms of COVID-19?
According to the CDC, a wide range of symptoms have been reported for COVID-19, ranging from mild to severe. Symptoms may appear from 2 to 14 days after you’re exposed to the virus.
People with these common symptoms may have COVID-19:
- shortness of breath or difficulty breathing
- aches and pains
- sore throat
- loss of taste or sense of smell
- nausea or vomiting
- runny nose or congestion
This list doesn’t include all the symptoms that have been linked to COVID-19. Call your doctor if you have other severe symptoms or if you are concerned about symptoms you’re experiencing.
“Often, [COVID-19] can start out with symptoms similar to a common cold,” Halle Moore, M.D., director of breast oncology at the Cleveland Clinic, told Breastcancer.org. “Patients may experience fatigue, a sore throat, and a cough, but they will usually get a fever, as well. The illness can also progress to shortness of breath and respiratory difficulties.”
Most people who get COVID-19 have mild respiratory symptoms and can recover at home in about 2 weeks. However, symptoms can become severe in certain people.
Severe symptoms that require immediate medical attention include:
- difficulty breathing or shortness of breath
- persistent chest pain or pressure
- confusion or inability to awaken
- blueish color in the lips or face
If you or a loved one experiences any of these emergency warning signs, call 911 immediately. People who are older than 60 and people who have existing serious health conditions such as heart disease, lung disease, and diabetes appear to have a higher risk of developing severe illness and complications from COVID-19. This includes people who are receiving cancer treatments that can weaken the immune system or cause lung problems and people who have cancer that has spread (metastasized) to the lungs.
Possible complications of COVID-19 include:
- organ failure
Who is at risk of getting COVID-19?
The CDC says that most people have a low risk of becoming seriously ill from COVID-19. However, it's important to understand the difference between the risk of becoming seriously ill if you do get the virus vs. the risk of being exposed to the virus in the first place.
The virus has now spread to most countries in the world and in communities across all 50 U.S. states, and your individual risk of being exposed to the virus — whether or not it makes you seriously ill — depends on where you live and what precautions you're taking. The risk of being exposed to the virus will continue to change as COVID-19 cases increase and eventually decrease in different areas of the country.
People who currently have a higher risk of becoming infected include:
- those who live in communities where the virus is spreading
- healthcare workers who may be exposed to sick people
- people who require frequent hospital visits for medical care
- those who have had close contact with people who have been infected
- people who have recently traveled to places where the virus is known to have spread
- people who are unable to limit their contact with others
While people who are being actively treated for breast cancer may be at higher risk for severe illness if they do become infected, it’s important to know that they do not necessarily have a higher risk of becoming infected compared to others who live in the same area, as long as they are limiting their contact with other people and aren't making frequent trips to the hospital.
“For most breast cancer survivors, the risk of becoming infected is going to be similar to that of the general population,” says Dr. Moore. “For people who are on active treatments that compromise the immune system, there will also be a similar risk for acquiring the infection, but they may have a higher risk of a more severe case should they become infected. So, similar to the precautions that they take regarding other illness, patients who are on treatments that affect the immune system should also be vigilant.”
How can I protect myself and others?
The best way to avoid becoming sick from this coronavirus is to avoid being exposed to it. There are no treatments or vaccines yet, but scientists are working on them.
It’s important take precautions to lower your risk of getting sick, especially if you have a serious health problem such as breast cancer. “Social distancing” or “physical distancing” practices are being recommended or enforced in most areas of the U.S. and in many countries throughout the world to reduce the spread of COVID-19.
Social distancing means limiting close contact with other people — even if they appear to be healthy — to reduce your own risk of infection and prevent the virus from spreading. Staying at home and not seeing your loved ones can be difficult, but it’s important to do right now for your own safety and for the greater good.
Social distancing practices include the following, when possible:
- stay at home
- avoid public spaces
- avoid public transportation and unnecessary travel
- avoid social gatherings
- work from home
- stay at least 6 feet away from people when out in public
- avoid physical contact such as handshakes, hugs, and kisses in social situations
- avoid contact with people who are or may be sick
- reschedule non-urgent medical appointments or complete them virtually by phone or internet video
In addition to limiting contact with other people, here are some steps you can take to help protect yourself and others against this virus or any harmful germs:
- Wash your hands frequently using soap and water for at least 20 seconds, especially after being out in public, coughing, sneezing, or blowing your nose.
- Use alcohol-based hand sanitizer with at least 60% alcohol when soap and water aren’t available.
- Don't touch your face when your hands aren’t clean, and make it a habit to not touch your face when you're outside your home.
- Wear a face mask when in public places (but make sure you do this safely; learn more below).
- Clean and disinfect surfaces you touch daily, including things you might not think of such as doorknobs, light switches, faucet handles, and phones. Make sure you use a cleaning agent that the Environmental Protection Agency says is effective for killing this virus.
- Practice healthy habits: eat well, exercise, avoid or limit alcohol, don't smoke or vape, and get enough sleep.
- Switch to glasses if you wear contact lenses to avoid touching your eyes more than necessary, or at least follow proper contact lens hygiene.
If you are receiving treatment for breast cancer that can weaken your immune system or cause lung problems, or if you are living with breast cancer that has metastasized to the lungs, the following extra precautions may help you protect yourself:
- be extra vigilant about hand hygiene and not touching your face
- avoid close contact with friends and family and take precautions if you depend on them for medical care
- make a plan with your doctor to monitor for symptoms
- make a plan with your caregiver or other loved ones in case you or they get sick
- make a plan with your employer to work from home if you’re not already doing so
- stock up on medications
- ask a friend or family member to shop for groceries or pick up medications for you
“The main thing you should do if you know your immune system is suppressed is try to avoid putting yourself in a position where there may be exposures, especially in areas where there may be a high prevalence of the disease,” says Dr. Moore.
However, the risk of exposure is higher in healthcare facilities, and if you’re receiving treatment for breast cancer, you may need to travel to a doctor’s office or the hospital for your medical care. Together, you and your doctor can determine if you should continue treatment as scheduled or make adjustments to your treatment plan to reduce your risk of being exposed to the coronavirus in a healthcare facility.
If you do need to visit a healthcare facility, make sure you are diligent about washing your hands and not touching your face to minimize your risk of infection. Wearing a face mask may help, and your healthcare provider may be able to provide one for your appointment (it’s smart to ask in advance). It’s also OK to ask healthcare providers and caregivers to wash their hands before touching you. It’s a good idea to talk to your oncologist about any other protective measures that may be recommended for your unique situation.
“Hospitals throughout the country and state health departments are putting procedures in place to try to reduce exposure, so most hospitals have some sort of screening in place to try to quickly identify people who are at risk and provide those individuals with masks and isolation and appropriate testing,” says Dr. Moore.
Because this is a rapidly changing situation, it’s wise to pay attention to the CDC’s updates to continue assessing the risks in your area.
“Since this is such a changing landscape, it’s important for people to visit CDC.gov or their state health department website for updated information,” says Dr. Moore. “Some hospitals and state health departments are also setting up hotlines to help keep people informed or answer questions.”
Should I wear a face mask?
You may have heard conflicting information about whether you should wear face masks to protect yourself and others from COVID-19. At the beginning of the pandemic, the World Health Organization (WHO) and the CDC said that only sick people needed to wear a mask to avoid spreading the virus to other people. But on Friday, April 3, the CDC started recommending that everyone wear a cloth face mask when out in public places. Many states, including New York and New Jersey, made wearing a cloth face mask in public a requirement.
The recommendations on cloth masks for everyone changed for several reasons. First, the CDC initially didn’t recommend everyone wear a mask because the organization didn’t want people hoarding masks, especially N95 respirator masks and surgical masks. Healthcare workers depend on N95 masks to keep them safe when they’re caring for COVID-19 patients.
Second, new research has shown that many people who are infected with COVID-19 don't know it because they have no symptoms. Wearing a face mask in public can help prevent people with no symptoms from spreading the virus.
Research also has shown that the coronavirus that causes COVID-19 travels in droplets that range in size from larger blobs (think of a drop that you can see when someone sneezes) to very tiny aerosol microdroplets. Cloth masks can help keep the larger droplets from getting into your mouth from your surroundings and also help keep any large droplets from leaving your mouth and getting into the air.
While no large controlled studies have been done on cloth masks, smaller studies show that wearing a cloth mask is better than wearing nothing.
The CDC recommends that you use a mask with two layers of 100% cotton fabric that is tightly woven. Fabric with a thread count of 180 or higher is a good option. To check on how tightly woven the fabric you plan to use for your mask is, hold the material up to the light. If you see a lot of light coming through or even see the fibers of the fabric, it’s a good idea to choose a different material.
If you only have bandanas, use two. If you only have a scarf, wrap it around your face twice. If you’re using a t-shirt, use two layers.
It’s also very important to make sure that you put on, wear, and take off your mask properly:
- The mask should be tightly fitted to your face. Any open space on the sides allow droplets to get through. Many news reports have shown people wearing masks that don’t cover their noses or are flopping on their faces. These masks are not doing much to protect the wearer or the people around them.
- When you’re taking off the mask, never allow the outside of the mask to touch your face and never touch the outside of the mask with your hands. Take the mask off by the ear loops or ties and very carefully move it away from your face. When you’re out in public, don’t pull the mask down below your mouth to talk and then put it back on again. Keep your mask tightly fitted to your face the entire time you’re out. It’s a good idea to wash your mask with warm water and soap as soon as you’re done wearing it and then let it dry thoroughly before you use it again. A mask is not as effective when it’s wet.
The CDC cloth face covering guidelines have instructions on how to make both sewn and no-sew cloth face masks. Some people are even adding squares of HEPA vacuum cleaner bags in between the two layers of cotton fabric.
Still, it’s hugely important to know that wearing a face mask is not a substitute for social distancing practices. Just because you and your friends are wearing masks doesn’t mean that you can be close to each other. You still need to avoid contact with others, stay 6 feet away from people when out in public, and stay home if you are sick.
It's especially wise to wear a face mask when visiting a healthcare facility for medical care. Ask your healthcare provider in advance if they will be able to provide one at your appointment or if you should wear your own.
What should I do if I develop symptoms?
If you experience fever, cough, or shortness of breath, you should call your doctor. If you or a loved one experiences severe symptoms that can signal an emergency, such as difficulty breathing, persistent chest pain or pressure, confusion or inability to awaken, or blueish color in the lips or face, immediate medical attention is needed and you should call 911. Make sure to tell the 911 operator that you suspect COVID-19 so the responders can take the necessary precautions to protect themselves.
People who experience mild symptoms can usually stay home while the illness runs its course and recover in about 2 weeks. But if you are receiving treatment for breast cancer, you should definitely let your doctor know.
“Anybody who’s on any treatment that can suppress the immune system should always call their doctor if they notice a fever or if they have severe cold or flu-like symptoms,” says Dr. Moore. “For someone who’s receiving chemotherapy for breast cancer, a fever is a medical emergency anyway, so that’s something that they need to contact their medical team for.” If you do need to seek medical care for symptoms of COVID-19, Dr. Moore says it’s very important to let your healthcare provider know about your symptoms ahead of time.
“It’s important to call ahead and not just show up to a doctor’s office with symptoms,” she says. “That way the medical team can get a better sense of the severity of the symptoms, determine whether this is something that can be managed at home, something that can be seen in the clinic, or something that needs to be treated in the emergency department. In addition, calling ahead will help the healthcare team take precautions to help prevent exposure to others.”
If you do become sick, you can take the following steps to protect others:
- stay home, unless you need medical care
- separate yourself from others in your home
- cover your mouth and nose when you cough or sneeze, properly dispose of tissues, and wash your hands
- monitor your symptoms and temperature
- wear a face mask when around others; you should also wear a face mask if you are caring for someone who is sick
You should follow these steps until:
- 10 days have passed since you first noticed symptoms
- your fever goes away for 1 full day without fever-reducing medicine
- your symptoms have improved
Not everyone needs to be tested for COVID-19. If you develop symptoms, ask your doctor if a test is available and recommended for you.
Is it safe for breast cancer screening or treatment to be delayed?
Many hospitals and other healthcare facilities have delayed or canceled elective procedures, meaning screenings, surgeries, and other treatments that are not considered urgent, emergencies, or otherwise indicated for life-threatening conditions. This can be distressing if it’s happening to you or a loved one — if you’re scheduled to have a cancer screening, surgery, or other treatment, you probably feel that it’s urgent. But these tough decisions are being made to help protect people from the increased risk of being infected with the virus that causes COVID-19 in healthcare facilities and to make sure healthcare providers have the resources they need to treat vulnerable people who do become infected with COVID-19.
Treatment cancellations and delays are often being made on a case-by-case basis, and the policies are different and rapidly changing among healthcare facilities. If this is happening to you, know that you are not alone — many people diagnosed with cancer are having their treatments rescheduled right now.
Most radiology and imaging centers are now offering routine mammograms again. So, if your annual mammogram was delayed, you should reschedule as soon as possible. Routine screenings are different than tests performed on people with cancer symptoms — if you have symptoms, you should tell your doctor and follow their recommendations for next steps.
The American College of Surgeons has recommended that all elective surgeries should be postponed, but this situation continues to change depending on where you live. Surgeries have not been delayed if surgeons determine that the risk of delaying the procedure outweighs the risk of exposure to the virus that causes COVID-19. As long as your hospital doesn’t have high numbers of COVID-19 patients to treat, the American College of Surgeons has recommended that certain breast cancer surgeries should still be performed for certain people, including:
- those who are completing treatment before surgery (doctors call this neoadjuvant treatment)
- people diagnosed with hormone-receptor-positive, HER2-negative cancer with certain characteristics
- anyone diagnosed with triple-negative or HER2-positive disease
- people diagnosed with a breast cancer recurrence
- people who had a breast lump checked with a mammogram and a biopsy and the results of the two tests don’t match; for example, the mammogram may show the lump isn’t cancer, while the biopsy shows the lump is cancer
“We recognize that this is a frightening time,” said Dr. Elisabeth Potter, a board-certified plastic surgeon who specializes in autologous breast reconstruction. “I don’t want anyone who is going through breast cancer wondering, ‘Am I being left behind? Does anyone remember me?’ I see you, and I’m thinking about you, and I am planning for your surgery. We just aren’t operating right now.”
Talk to your doctor about the best way to proceed to make sure you can get the best care possible in this challenging situation. You may be able to see healthcare providers virtually for certain appointments through telemedicine (by phone or internet video).
How can I manage anxiety and loneliness while isolating?
Limiting your contact with others is critically important for protecting yourself and lowering your risk of getting COVID-19. But long-term social distancing is not easy and can lead to feelings of anxiety, depression, and loneliness. If you’re experiencing these feelings while isolating at home, you are not alone — so many of us are going through it with you.
Fortunately, there are plenty of things we can do to manage these feelings and stay connected with our loved ones. Here are some tips from licensed clinical social worker Kelly Grosklags on how to manage the loneliness or anxiety you might be feeling during this time of social distancing because of COVID-19:
- Use social media and electronic tools such as FaceTime, Zoom, Google Hangouts, messaging apps, and texts to stay in touch with loved ones.
- Start a virtual book club with your friends.
- If you don’t have internet access or have limited access, phone calls are also a great way to keep in touch.
- Consider writing letters to people with dementia who are in care facilities and may not be able to work a phone.
- Take up a new hobby: knitting, jigsaw puzzles, crossword puzzles. Learning something new can take your mind off the COVID-19 situation for a little while.
- Many museums, aquariums, and zoos are giving people online access to their resources. Soothe yourself with some beautiful artwork or some waddling penguins.
- Above all, remember to breathe and live in the now. Living in the past can make you depressed. Living in the future can make you fearful. Live in the now and practice gratitude for the good things in your life.
Listen to the latest COVID-19 podcast episodes
Hear from experts about delayed surgery, insurance, staying active, treatment plans, and more:
Quarantine Fatigue: How to Stay Vigilant About Your Safety During the COVID-19 Pandemic, with Jackie Gollan, M.D.
COVID-19 and Metastatic Breast Cancer, with Shirley Mertz, chair, Metastatic Breast Cancer Alliance
Update: Breast Surgery and Reconstruction During COVID-19, with Julie Sprunt, M.D., FACS, and Elisabeth Potter, M.D.
COVID-19 Insurance and Financial Issues for People With Breast Cancer, with Joanna Morales, Esq, CEO, Triage Cancer
Staying Active During Quarantine: Tips for People With Breast Cancer, with Sami Mansfield, cancer exercise specialist
Breast Surgery and Reconstruction During COVID-19, with Julie Sprunt, M.D., FACS, and Elisabeth Potter, M.D.
COVID-19 and Breast Cancer Treatment, with Brian Wojciechowski, M.D.
Managing Loneliness and Anxiety During This Time of Social Distancing, with Kelly Grosklags, LICSW, BCD, FAAGC
COVID-19: What We Know Now, with Angela Rasmussen, Ph.D.
Breastcancer.org Founder and Chief Medical Officer Marisa Weiss, M.D., answers important questions from Breastcancer.org Community members about safety, treatment, and patient needs while self-isolating:
Dr. Weiss and Beth DuPree, M.D., FACS, ABOIM, explain what patients need to know about delayed surgery, mammograms, telemedicine, and how to make a plan with your doctor:
Watch all of the COVID-19 videos on our YouTube channel for more expert insights and information.
We’re all in this together
While the developing news about COVID-19 can be distressing, Dr. Weiss would like to remind you that we’re all in this together and that there are common sense precautions we can all take to protect ourselves and our families.
“The COVID-19 pandemic reminds us that it’s a small world out there,” she says. “We are all interconnected in good and sometimes dangerous ways. For now, it’s wise to lay low and stay home whenever possible, especially if you’re at high risk of having complications from getting this virus.”
Please practice social distancing for the time being as recommended by the CDC, WHO, and your local and state governments:
- stay home
- avoid close contact with others
- wash your hands thoroughly and often
- wear a mask
If we all do our part, we can protect ourselves, our families, and our communities from this pandemic.
We want to know how the COVID-19 pandemic is affecting your life and your treatment. Join the conversation in the Breastcancer.org Community Discussion Boards, and tell us how you’re managing this situation throughout your treatment or survivorship.
Adam Leitenberger, editorial director
Jamie DePolo, senior editor
This content was developed with contributions from the following experts:
Halle Moore, M.D., director of breast oncology, Cleveland Clinic
Marisa Weiss, M.D., chief medical officer
Brian S. Wojciechowski, M.D., medical adviser
World Health Organization COVID-19 pages: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
U.S. Centers for Disease Control and Prevention COVID-19 pages: https://www.cdc.gov/coronavirus/2019-ncov/index.html
American Society of Clinical Oncology COVID-19 Patient Care Information: https://www.asco.org/asco-coronavirus-information/care-individuals-cancer-during-covid-19
MIT COVID-19 Relative Risk Factors Comparison Map: https://www.covidalliance.com/interactive-data-tools
Johns Hopkins Coronavirus Resources Center: https://coronavirus.jhu.edu/map.html
Harvard Health Publishing Coronavirus Resource Center: https://www.health.harvard.edu/diseases-and-conditions/coronavirus-resource-center
Science Magazine Coronavirus Research, Commentary and News: https://www.sciencemag.org/coronavirus-research-commentary-and-news
New England Journal of Medicine COVID-19 page: https://www.nejm.org/coronavirus
National Comprehensive Cancer Center Network COVID-19 Resources: https://www.nccn.org/covid-19/
American Society for Radiation Oncology Recommendations and Information: https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information
Annals of Internal Medicine. “A War on Two Fronts: Cancer Care in the Time of COVID-19”: https://annals.org/aim/fullarticle/2764022/war-two-fronts-cancer-care-time-covid-19
American Society of Breast Surgeons Recommendations on Treatment During COVID-19 Pandemic: https://www.breastsurgeons.org/docs/news/The_COVID-19_Pandemic_Breast_Cancer_Consortium_Recommendations_EXECUTIVE_SUMMARY.pdf?01
American Society of Plastic Surgeons Statement on Breast Reconstruction During COVID-19 Pandemic: https://www.plasticsurgery.org/documents/medical-professionals/COVID19-Breast-Reconstruction-Statement.pdf
This special content made possible in part through generous support from AstraZeneca; Daiichi Sankyo; Eisai; Genentech; Lilly Oncology; Pfizer; Seattle Genetics; an independent educational grant from Merck & Co., Inc.; and individuals like you.