COVID-19 and Breast Cancer Treatment
On the Breastcancer.org discussion boards and on our Facebook page, people are talking about doctor and treatment appointments being delayed or cancelled because of COVID-19. And many people whose appointments haven’t been cancelled are scared to go out.
Listen to the podcast to hear Dr. Brian Wojciechowski talk about:
the general recommendations oncologists are following when deciding which treatments should be delayed
which breast cancer treatments can compromise the immune system and how long it takes the immune system to recover
the most important things someone being treated for breast cancer should know about COVID-19
Dr. Wojo is a medical oncologist outside of Philadelphia, PA, with Crozer Health. His research has been presented at the San Antonio Breast Cancer Symposium, and he is a speaker on medical ethics and the biology of cancer. Dr. Wojo sees cancer as a scientifically complex disease with psychological, social, and spiritual dimensions.
— Last updated on January 7, 2022, 8:04 PM
Jamie DePolo: Hello, thanks for listening. Our guest is Dr. Brian Wojciechowski, who practices medical oncology in Delaware County, Pennsylvania at Riddle, Taylor, and Crozer hospitals and also serves as Breastcancer.org's medical adviser. A native of South Philadelphia, he trained at Temple University School of Medicine and Lankenau Medical Center. Dr. Wojciechowski is a sought-after speaker on the topics of medical ethics and the biology of cancer. On the Breastcancer.org Discussion Boards and on our Facebook page, people are talking about doctor and treatment appointments being delayed or cancelled because of COVID-19, and many people whose appointments have not been cancelled are scared to go out.
Dr. Wojo joins us today to talk about what he's recommending to his patients and how everyone can be as safe as possible. Dr. Wojo, welcome to the podcast, and thank you so much for talking to us about this important topic.
Brian Wojciechowski: Thanks for having me, Jamie.
Jamie DePolo: So, I know each patient is unique, but are there some general rules that oncologists are following when deciding on when appointments and treatment should be delayed or cancelled?
Brian Wojciechowski: Well, Jamie, I think there is one general rule, and that is any appointment should be delayed or cancelled if, in the doctor's judgment, it does not risk harm to the patient. So, for example, if I'm seeing someone who is a long-term follow-up breast cancer survivor, maybe her treatment was a few years ago, she may or may not be on hormonal therapy, this is someone who I'm usually seeing every 6 months or so, I'm quite comfortable with delaying her treatment 3 months hoping that all of this will have blown over by then.
Jamie DePolo: You mean her appointment?
Brian Wojciechowski: Yeah. Yeah. Delaying her appointment.
Jamie DePolo: Yeah. Sorry. Yes. Got it.
Brian Wojciechowski: Because it's really just routine follow-up and blood work, an exam, and not a whole lot is going to change in 3 months. Now, it's a different story if she feels a new lump, or she's got a specific concern, then that becomes an urgent issue. But for any routine visit where we don't think delaying is going to cause harm or risk to the patient, now is the time to delay that visit.
Jamie DePolo: Okay. So, it sounds, then, what you're saying, too, is if someone, say, has surgery to remove a breast cancer, that should probably go forward. We are hearing from some people that surgeries are being delayed or rescheduled. Are you seeing that in your practice?
Brian Wojciechowski: Yes. We have seen some of that with both breast and lung cancer patients. There is some guidance from the Society of Surgical Oncology. So, for example, for things like DCIS, those surgeries can be delayed 3 to 5 months, and in the meantime, you can actually, if it's hormone positive, you can treat them with hormone therapy. And the same could be said for invasive cancer that is ER-positive, [it] can be treated with hormone therapy. Of course, we don't want to delay those surgeries more than 3 months if we can help it.
But it would be a different story if we were dealing with, say, a triple-negative breast cancer or HER2-positive breast cancer, where that becomes an urgent surgery. And we're going to push to have those surgeries done, or if we can't do that surgery, start neoadjuvant chemotherapy if it's indicated.
Jamie DePolo: Okay. Now, that's a good segue into my next question. We've also received a lot of questions about which breast cancer treatments can compromise the immune system and therefore, put someone at risk for a more severe case, more severe complications I should say, from COVID-19 if the person does happen to become infected. So, if you could kind of go through just every single treatment in the general sense. So, like surgery, on the surface it may not seem like surgery would compromise the immune system, but that's actually kind of hard on the body, and my suspicion is that the immune system could be a little taxed if someone has had surgery recently.
Brian Wojciechowski: Yeah. I think surgery is not on the same level as, say, chemotherapy, but there is some compromise to the immune system, at least in the short term, after someone has major surgery. You know, I think the main reason why elective surgeries are being pushed back, though, is not about concern for the immune system, but just concern about preserving hospital resources and making sure that the hospitals are not filled and decreasing the exposure of patients and medical staff to people who might have the virus.
Now, obviously, cytotoxic chemotherapy — drugs like Taxol, Taxotere, Cytoxan, carboplatin, those kind of drugs — are very immunocompromising, and patients can definitely get into trouble, especially 2, 3 weeks after their chemo where the counts are going to drop to their low point. In these days, I'm trying to use more Neulasta, whereas before, you wouldn't necessarily give growth factors to everyone on chemotherapy. But my threshold has gone up. So, I'm trying to use those more than I have in the past. The insurance companies can be a little tough about those.
Jamie DePolo: Right, and just in case somebody doesn't know, Neulasta is a medicine that kind of builds up white blood cells and builds up the immune system in the body.
Brian Wojciechowski: Yup.
I don't think of hormone therapy as being particularly immunosuppressive. I don't think there's a significant problem with immunosuppression and COVID for patients who are just on hormone therapy.
Targeted therapy, that's a big group of different drugs, so that could include anything from Herceptin or Perjeta, which target the HER2. Those are not very immune suppressive at all, if at all, but other targeted drugs such as Ibrance or Kisqali or Piqray, those can be significantly immunosuppressive. It's not uncommon to have low white blood cells while on those drugs. So, yeah. You have to be a little more vigilant with those.
And then an immunotherapy really is not significantly immunosuppressive. If anything, it revvs up the immune system. But a patient who's just on immunotherapy is probably about the same level of concern for me as someone on hormone therapy or targeted therapy like Herceptin.
Now, I should say that more important than being on treatment for cancer is just the fact of having cancer when it comes to the coronavirus, because the death rate for a younger, healthy person with no medical problems right now is about 1% for coronavirus. But when they take the group of all patients with cancer, the death rate is more like 7%. I don't know if it's a combination of the body being weak, being on treatment, having cancer… it's hard to tease out what is what. But it seems like just having cancer increases the risk of death from the coronavirus.
Jamie DePolo: Okay. So anybody who's been diagnosed, it sounds like from what you're saying, should be very, very cautious.
Brian Wojciechowski: Right. Right, and it's hard for me to tease out, “Well, what if I had breast cancer that was cured 10 years ago, am I at the same risk of someone with chemotherapy right now?” Well, in my heart of hearts, I would say no. You're probably not at the same risk, but it's hard to know for sure from the limited studies that have been released on this so far.
Jamie DePolo: Right. It's so new we don't really have that much information on it that's really been vetted. We have a lot of what I would call anecdotal information, like somebody saw this in maybe 10 people, but we don't really have any studies, do we?
Brian Wojciechowski: Nothing that specific where we could tease out one cancer or the other, but we do have some pretty reliable data on, what's the death rate for someone with cancer? What's the overall death rate? What's the death rate for people with diabetes? With heart disease? With respiratory disease? We know that all of those conditions increase the risk of complications.
Jamie DePolo: Right. Oh, and one treatment we didn't talk about was radiation therapy. And we have been getting some questions. People who are really concerned, you know, radiation to the breast can sometimes hit the lung area. Or people who are having radiation to metastases in the lungs, could be that increase their vulnerability to COVID-19?
Brian Wojciechowski: I would kind of answer that the same way I answered the chemo question. Again, anyone with cancer, anyone going through cancer treatment, is going to be at a uniquely elevated risk, and we really can't tease out what's the contribution of radiation versus chemo or anything like that. But I think, again, just like with the question of surgery, it would be wise to maybe delay radiation. If we don't think it's going to harm the patient... example: if you have a HER2-positive patient, starting with neoadjuvant chemotherapy and delaying the surgery and radiation might be wise. Hormone positive, start with hormone therapy so that we can push everything back.
You know, it really boils down to: Our patients who come to the website really need to have a conversation about their condition, about their situation., with their doctor and weigh the risks and benefits of continuing or delaying surgery.
Jamie DePolo: Okay. Now, what about the time for a person's immune system to recover after treatment? I know you said that, say, if somebody had been treated a year, 2 years ago, and they were coming to you for follow-up visits, you would probably feel comfortable about delaying their appointments. Say somebody just finished chemo, I don't know, 2 or 3 months ago, is their immune system starting to recover?
Brian Wojciechowski: Yeah. Generally speaking, in my experience, about 2 months after finishing chemo, all the blood counts are back to normal by then.
Jamie DePolo: Okay. And would that be the same for a lot of the treatments, like radiation or some of the targeted therapies that do affect the immune system?
Brian Wojciechowski: I would expect radiation and targeted therapy to recover even sooner.
Jamie DePolo: Okay. Okay.
Brian Wojciechowski: Weeks to a month maybe.
Jamie DePolo: Okay. And I do you know, want to clarify, because you talked about how people who have been diagnosed with cancer are more susceptible to, perhaps, having more severe cases of COVID-19 or even dying from COVID-19, but are they any more susceptible of becoming infected? Do we know that?
Brian Wojciechowski: We don't think they're any more susceptible to becoming infected. It's just what happens after the infection.
Jamie DePolo: Okay. Okay. Thanks for clearing that up.
So now let's move on. Say somebody, they've talked to their doctor and they've decided, “Yes, I need to move forward with treatment.” How are you advising your patients who are going in for treatment, like what sort of steps should they take to protect themselves?
Brian Wojciechowski: Okay. So, the first thing is to listen to the guidance from the CDC and the civil authorities. That means the local, state governments. And it is really important to socially isolate and avoid any unnecessary human contact, especially if you're a cancer patient. You know, I don't think a lot of our patients who visit the website are going down to Daytona Beach for spring break on a big party. I think people are smarter than that, but the best information and the best guidance really is from the CDC. And I would definitely follow exactly what they recommend in your day-to-day life.
If you are on lockdown, try to obey that lockdown. There's no specific data about the use of masks and different kinds of masks and how they might protect you, but it's certainly reasonable if you do have access to masks and gloves to use those when you go out to, say, the pharmacy or the supermarket. Or if you have helpers in your life who can do those chores for you, I think that's a great idea. But it really is very important to follow the guidance of the civil authorities.
Now, in terms of going to the doctor's office, I did an informal poll of my colleagues, other oncologists, and most of us are staying open, but we have very aggressive policies with regard to no visitors coming in with you unless it's absolutely necessary. If you have fever, if you have cough, you really shouldn't be treated, you really shouldn't come into the office if you're feeling sick. And, of course, very aggressive hand washing, they say try to avoid door handles, and try to avoid touching your face, and all those sort of common-sense precautions.
Jamie DePolo: Okay. Okay. That's good. And I guess if you are being treated for cancer or were recently diagnosed, to me — and tell me if this makes sense to you — it makes much more sense to err on the side of caution, so to self-isolate yourself, have your necessities delivered, have somebody shop for you but drop the items off on your porch and then you can wipe each one off before you bring it into the house, and then wash your hands and do all those kinds of things. Because it may be a little more time consuming and a little more work, but it's not going to hurt you in the long run. It may benefit you.
Brian Wojciechowski: Right. And I'll be honest, I'll be frank, that's what we're doing at home.
Jamie DePolo: Are you? Okay.
Brian Wojciechowski: Yeah. I mean, we have Amazon dropping the boxes off on the porch, and we open them on the porch, and then we bring the stuff inside.
Jamie DePolo: Okay. Okay. Yeah. I mean, I feel like anybody who works in healthcare right now is on the front lines because you've got people coming in and you don't know who they've been in contact with and some of them may be very sick already. So, it's very hard — and especially with the whole idea that people who really don't have symptoms of the virus can still be transmitting the virus.
Brian Wojciechowski: Yeah.
Jamie DePolo: And with the shortage of testing or shortage of tests, I should say, it's difficult because you can't just test yourself and find out.
Brian Wojciechowski: Yeah. You kind of have to assume that everyone you contact has it and act accordingly.
Jamie DePolo: Right. Right. Now, I've read that some doctors, oncologists specifically, are seeing patients online. Is this something that you're doing and do you think it's helpful for people who've been diagnosed with breast cancer?
Brian Wojciechowski: Yeah. We've been doing telemedicine for the past week. You know, we're working out the kinks, but most people have been very glad to do it and are glad they can still be seen and can stay at home while doing it. Medicare is reimbursing doctors for this technology, which is also helping to keep us open, keep the lights on, keep the bills paid. I think as long as someone has a smartphone or a computer, it's very easy.
On the platform that we're using, basically what happens is I send a text to the patient's smartphone, they click on the text, they're asked if the application can use their camera, and then voila! It goes right on, and it's been pretty smooth so far. So, yeah. I'm very happy with that.
Jamie DePolo: Okay. Okay. That's good to know, because I think some people were concerned they weren't going to get the same quality of care if they weren't seeing a doctor face to face, but it sounds like it's working out well, at least in your practice.
Brian Wojciechowski: It's obviously not an ideal situation, and for most patients I say, “Let's do a 3-month follow up to this visit so I can actually examine you and do a hands-on visit,” but for now I think it's certainly better than just not seeing people at all.
Jamie DePolo: Okay. Okay. Now, have you heard anything about any of your patients having trouble getting palliative prescriptions filled, because some people have mentioned that. And I don't know if that's because the pharmacies were overwhelmed, if it's just because supply chains have been disrupted.
Brian Wojciechowski: Yeah. I haven't heard any problems with that. Of course, I live in a metropolitan area where there's an abundance of pharmacies, and there's always something in supply. I don't know what's happening in the rural areas. You can imagine that the longer this thing goes on, the more you might see problems like that, but thankfully, where I'm at, I haven't had that problem.
Jamie DePolo: Okay. Okay. Thank you. So, to wrap up for people, if someone's being treated for breast cancer, what would you say are the most important things that person should know or should consider?
Brian Wojciechowski: So, follow the directions of the CDC and the local authorities. That is isolation, social distancing, hand washing, and protective gear and equipment as available. Don't go to the office if you're sick. And definitely talk to your doctor about your own unique situation and the risks and benefits of continuing or postponing treatment.
Jamie DePolo: Okay. Thank you. Thank you so much, Dr. Wojo. This, hopefully, will help a lot of people. And as you are on the front lines, please take care of yourself.
Brian Wojciechowski: Thank you very much, Jamie. Let's all keep calm and carry on.
Jamie DePolo: Sounds good. Thank you.