Shannon Puhalla, MD, is an assistant professor of medicine at the University of Pittsburgh School of Medicine, and a medical oncologist and hematologist with UPMC Hillman Cancer Center. She specializes in breast oncology, Phase I clinical trials, and novel therapeutics in breast cancer.

Dr. Puhalla shared that COVID-19 has had many influences on current practices in treating cancer patients. Every single piece of how patients are treated has been impacted from getting a yearly mammogram, to a biopsy, to receiving treatment, and coming in and out of the cancer centers. Institutions and doctors have had to critically exam their current practices.

Each individual case has been considered and many centers have come up with guidelines of how to treat patients during this time. Individuals who are healthy, follow-up patients that are seen every 6 to 12 months for surveillance or those who are taking medication, may be asked to push their appointment if they are feeling good and don’t have any new symptoms. Many institutions are also offering telemedicine through either video or audio format to review test results or discuss any new symptoms to determine if a visit is needed. An important part that is missing for breast cancer survivors in particular is the breast exam. These patients should still be seen by if their appointment can be pushed back safely, it should be considered. Institutions do not want to put these individuals at risk for COVID-19 by having them come into the center but also do not want these individuals bring in anything that may impact those currently receiving treatment.

Those who are most vulnerable to COVID-19 are those currently undergoing active treatment. Doctors have to consider if a delay in treatment will affect outcomes and in many cases, the answer is yes. Doctors also have to consider the treatment affect on the immune system that makes these patients vulnerable to the infection. There are certain situations where treatment can be safely delayed but it has to be considered on a case-by-case basis. It is known that is chemotherapy is delayed beyond 16 weeks, the benefit of chemotherapy is lost. Guidance has been given that if treatment can be safely delayed 6-8 weeks, it should be considered and if not, the patient should be treated. For those currently receiving chemotherapy, institutions are reducing foot traffic and patients are no longer allowed to have visitors come in with them for their chemotherapy treatments. They are trying to work around this as there is a lot of information shared during those treatments so patients may call their families on the phone or do FaceTime so they can also hear the information. It has also been recommended that those currently receiving chemotherapy should be kept on schedule as best as possible.

Dr. Puhalla has provided advice for her own patients on how to stay healthy and safe. She has shared that social distancing is important and necessary for the safety of the patient. She has recommended that patients not leave their house for any reason other than to go to the cancer center. She has suggested that they can take a walk, provided that there are not many people out and about within the neighborhood, sit in the backyard, or take in some sunshine. She also recommended that individuals wash their hands often, don’t let sick people visit, and stay at home with their immediate household.

Based on the limited data from China, those with underlying issues such as cancer or those going through treatment have a higher mortality rate. In addition, there are many patients who also have other comorbid conditions such as respiratory issues. For those patients, the outcome, if infected, may not be good at all.

In terms of radiation therapy, this treatment may also be pushed back safely for some. Prior to COVID-19, there was already a push to critically exam who actually needs radiation therapy and if shorter courses of treatment can be offered. For some groups, radiation can safely be pushed back 16 weeks from the last surgery or chemotherapy. However, there are some populations where pushing back radiation may not be safe, such as, inflammatory breast cancer, triple negative breast cancer, really young patients, or those that had a lot of positive lymph nodes.

The current guidance is for elective surgeries to be delayed. While breast cancer surgery may not be as urgent as a triple bypass, it is not as routine as a colonoscopy. There are some patients who are more urgent in terms of the need for surgery. Doctors have to consider if there are safe alternatives to doing surgery at this time. For those who are estrogen positive that do not need chemo, doctors can safely offer medication for 6-12 months prior to surgery or chemotherapy can sometimes be offered prior to surgery.

Given that elective surgeries have been delayed, it is impacting decision making at this time for those patients electing to have construction because plastic surgery is considered elective. Patients will not be able to undergo reconstruction at this time if breast surgery is completed. There is also consideration of the number of people an individual patient is exposed to when undergoing surgery. For even a regular outpatient lumpectomy, the patient will be exposed to at least 25 people within that day. In addition, the personal protective equipment- masks, gowns, gloves- have to be a part of the conversation, as there is not an endless supply.

Dr. Puhalla recognizes that many patients may be experiencing some feelings around the delay of treatment. Many institutions are offering telemedicine to include services provided by social workers, counselors, and psychologists. It is important for doctors to have careful conversations with their patients that it is not that the patient is not cared for but it is for everyone’s safety that treatment is delayed. If there is a safe alternative at this time, that has to be considered. Many places have the capacity to offer something. She also recommends staying active, doing yoga, or meditating. There are many free apps that individuals can download.

It is recommended that those individuals who are experiencing symptoms or have found a lump to still be seen. Institutions have to figure out a way to stratify the patient. These individuals cannot be seen via a telemedicine visit. Doctors have to be able to see and feel the breasts. It is better to have symptoms checked rather than stay at home due to concerns with virus exposure. If someone is experiencing symptoms, they should continue to seek the care that is important.

Dr. Puhalla also talked about patients who may be out of active treatment at this time. They think that those who are years out from any kind of cancer treatment should be fine. They don’t believe that hormone therapy has impacts on the immune system. However, there is not hard data on this so it is difficult to say. She indicated that if an individual is 6-12 months out of chemotherapy, they should not be any more concerns than someone that has not had cancer. However, she recommended that if someone is more susceptible to picking up an illness from another person, she should social distance herself. She also pointed out that even if you are not at higher risk, that does not mean you should be cavalier about this.

Dr. Puhalla shared that we are all in this together and we definitely want to keep everyone as safe as possible. Her heart goes out the patients, especially those who are newly diagnosed or trying to navigate chemotherapy and concerns of the virus. This is an opportunity where people can think if they know someone going through chemotherapy and how to support that person. People can drop off groceries and be sure to wash their hands well.

Social distancing is real and important.

This is again where we have an opportunity to affect everyone’s outcome. I think having someone who has gone through breast cancer probably knows it better than anyone else that it is important to be safe and look out for other people.