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COVID-19 Testing Confusion
Megan Kruse, M.D.
September 15, 2020

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Dr. Megan Kruse is a breast medical oncologist at the Cleveland Clinic.

On Aug. 24, 2020, the Centers for Disease Control and Prevention (CDC) modified its COVID-19 testing guidelines to say that people who don’t have symptoms don’t need to be tested, even if they’ve been exposed to the virus. Many experts questioned the change, and on Aug. 26, the director of the CDC issued a statement saying that, “testing may be considered for all close contacts of confirmed or probable COVID-19 patients.” It’s the “may be considered” language that seems to be confusing people.

Dr. Kruse joins us to help clear up any confusion about COVID-19 testing recommendations.

Listen to the podcast to hear Dr. Kruse explain:

  • how she’s talking to her patients about COVID-19 testing
  • how someone who is immunocompromised should approach COVID-19 testing
  • why testing recommendations for people being treated for breast cancer have to be nuanced

Running time: 9:36

Editor’s Note: This episode was recorded before September 18, 2020, when the CDC again changed its recommendations on COVID-19 testing to say that people without symptoms should talk to their doctor about being tested if they may have been exposed to the virus.

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Show Full Transcript

Jamie DePolo: Hello, thanks for listening. Our guest is Dr. Megan Kruse, a breast medical oncologist at the Cleveland Clinic. She joins us to talk about COVID-19 testing recommendations, which we hope will clear up any confusion you may have about whether you should be tested or not. Dr. Kruse, welcome to the podcast.

Megan Kruse, M.D.: Thank you for having me. 

Jamie DePolo: On August 24, the Centers for Disease Control and Prevention [CDC] modified its COVID-19 testing guidelines to say that people who don’t have symptoms don’t need to be tested, even if they’ve been exposed to the virus. Many experts questioned the change, and 2 days later, on August 26, the director of the CDC issued a statement saying, “Testing may be considered for all close contacts of confirmed or probable COVID-19 patients.” Now, it seems that it’s the “may be considered” language that’s confusing people. So Dr. Kruse, how are you talking to your patients about this? 

Megan Kruse, M.D.: I will tell you that this has been a source of confusion for us as providers as well. I think the guidelines up until this August 24 really gave us a clear picture of who we should consider testing and who was at risk. And once we got this guideline, we had to challenge some of the things we were telling our patients before then. 

So, what I have been asking our patients to do is, if they are concerned that they’ve been exposed to another person with COVID-19, to give us a call and so we can dig into the details of that exposure. 

Jamie DePolo: Okay, so whether the person has symptoms or not. It’s just if they’re concerned, you’re asking them to call you and sort of talk the whole thing through. 

Megan Kruse, M.D.: That’s right, and that’s because not all exposures are created equal. So, we like to dig into who the person was who was exposed, were they symptomatic or not, were they tested or not. A lot of those details will help us to understand how at-risk our patients really are and what we should do moving forward and when they should call us back with an update. 

Jamie DePolo: Okay. Now, if someone is immunocompromised, say they’re currently receiving chemotherapy, and realizes they’ve come into contact with someone who is infected with COVID-19, do you think the immunocompromised person should automatically be tested even if the person has no symptoms? 

Megan Kruse, M.D.: So, it’s a really good question, and I think it’s the question that we get most commonly these days. In general, even if one of our patients is immunocompromised, we tend not to do automatic testing after an exposure to someone with known or presumed COVID-19. Now again, it depends what the exposure was. So, if it’s a household exposure, someone that our patients are around a lot or all the time without protective gear or a mask, that would be a contact in which I would say, “Even if you’re immunocompromised and asymptomatic, we should consider it,” and if the patient feels strongly about it, we often do go ahead. But for the typical person who may still be immunocompromised and asymptomatic, it’s not routine to say, “Okay, you must go in and get tested right away.” 

Jamie DePolo: Now, I know some experts were worried that the change in the CDC recommendations were going to affect whether insurance companies continue to cover COVID-19 testing. Have you seen anything like that in your practice, any changes? 

Megan Kruse, M.D.: I have not. Actually, I think that with patients who have breast cancer and are being treated, we still consider these patients high risk. And so insurance companies have really gone along with paying for testing if the provider thinks that a person should be tested. So, thankfully, even though the guidelines have become a little bit confusing, we haven’t seen any issues in terms of testing those people that we really want to get tested. 

Jamie DePolo: Okay. That’s very good to hear. So, overall, for anyone who’s been diagnosed with breast cancer — and I guess the recommendations could be different if they’re in active treatment versus completed treatment — what are your recommendations as far as approaching COVID-19 testing? Is it a little bit more special than, say, an average person who has not been diagnosed with breast cancer? 

Megan Kruse, M.D.: I think it is. I think it’s a more nuanced discussion about an individual person’s level of risk. And thankfully, as the treating oncologists, we often know these patients well enough to be able to factor in the medical problems that they came to us with before breast cancer diagnosis, because those are often so important when you’re thinking about COVID-19 risk. And then we also factor in where they are in their breast cancer journey. So, as you suggested, the recommendation might be very different for testing for a patient who is undergoing active chemotherapy versus one who has completed that 6 or 12 months down the road, or maybe never received chemotherapy. 

So, my practical approach and the way that we generally have done it in our breast cancer group at Cleveland Clinic, is that if a patient is actively undergoing chemotherapy, we have a much lower threshold for testing, because that is when a patient will be at their maximum immunosuppressed state. If they’ve completed treatment within the past year, then those are patients that we still may consider for testing with potential exposure or with a lower burden of symptoms than someone who has completed their therapy long ago. 

And I think it’s an important distinction for patients who are just thinking about breast cancer therapy, that not all of the therapies are created equal. So, when we’re talking about risk, we’re really talking about patients who have received chemotherapy. For a large number of patients who are on targeted therapy or endocrine, or anti-estrogen, therapy, those patients really should not be immunocompromised in the same way. So thankfully, we get to think about their risk in a little bit different way. 

Jamie DePolo: Okay. That’s great. And I will say, we have received several questions from people diagnosed with metastatic disease who are on Ibrance or another similar type of medicine very concerned about the status of their immune system taking that type of inhibitor. And would you advise anything different? Would those people be similar to people on chemotherapy, or would it… 

Megan Kruse, M.D.: You know, it’s a really interesting question, and it shows just how well our patients understand their treatment and what it is actually doing to their bodies. Because with drugs in the class of CDK4/6 inhibitors — so that would be drugs like Ibrance, Kisqali, or Verzenio — those drugs all do have the potential to lower the white blood cell count, and it’s something that we watch very, very closely in our patients. Although the white blood cell counts go down with those drugs, it’s really a different reason, I would say, that the white blood cells are low compared to when patients are on standard IV chemotherapy. And the best thing about these drugs is that if a patient does get infected or does have an exposure, the white blood cells will pop up relatively quickly once the drug is put on hold. 

And so I think it’s a very, very complicated situation for these patients, because we know their immune system is not perfectly normal, they shouldn’t be at risk the same way someone on chemotherapy is at risk, but we probably should include them in the group of patients that we test with a lower threshold. So if they call us with a potential exposure, since we can’t know quite what their immune system is doing at that moment in time, I would be more worried about them and potentially recommend testing. But it’s certainly one of the more nuanced parts of the decision making for us as providers. 

Jamie DePolo: Thank you so much, Dr. Kruse. This has been very helpful, and I’m hoping that our community will listen to this and take this all to heart. Because like I said, we have been getting quite a few questions about this. Thank you so much for clearing some of that up. 

Megan Kruse, M.D.: You’re welcome. Thank you for having me, and thanks for doing this story. I really hope that we can normalize some of what the COVID risk and testing procedures should be for breast cancer patients.

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