Managing Breast Health During a Pandemic

Managing Your Breast Health During a Pandemic

By Dennis R. Holmes, M.D., FACS

The world is now abuzz with news about Coronavirus (COVID-19), the viral disease that has taken the world by storm.  California is on lockdown; corporations big and small are keeping employees at home; sport institutions like basketball, baseball, hockey, and soccer teams are cancelling events and entire seasons; colleges and grade schools are closing and providing classes only online; national medical conferences are being cancelled or postponed; the tourism and airline industries are experiencing major turbulence; Broadway has drawn its curtains; cleaning products, toilet paper, and paper towels are experiencing their very own gold rush; “social distancing” is all the rage; and “war” metaphors are everywhere.

Whether or not the current global response is an appropriate reaction or an over-reaction is unclear at this point in time. What is clear is that the COVID-19 pandemic will likely continue to cause considerable societal disruption over the coming months as we come to understand the size of the problem and necessary solutions.  California’s mandatory stay at home order is a perfect example of societal upheaval.  However, the stay at home order exempts healthcare providers and those who must leave home to seek essential healthcare.

While no one is immune to the COVID-19 virus or the collateral damage that it has caused, breast cancer patients may be particularly concerned about the impact of this crisis on their efforts to maintain their breast and overall health. Anxiety will likely be heightened by recent decisions by many medical facilities to reduce their office hours, cancel or reschedule non-urgent appointments, and postpone elective non-essential operations as they reassign limited medical staff and equipment (e.g., ventilators and personal protective devices) to more critical departments like the Intensive Care Unit.  Although breast cancer operations are considered essential elective operations that should receive priority scheduling, limited personnel and equipment may still delay scheduling of non-emergency procedures.

Another reason for canceling and postponing elective appointments and procedures is to protect healthcare personnel from apparently healthy patients who may be carriers of COVID-19 but have yet to exhibit symptoms.  Just imagine the impact on a medical office or hospital if an apparently healthy patient were diagnosed with COVID-19 a few days after her visit?  It could lead to a 2-week or longer quarantine of all exposed medical staff, which would disrupt the healthcare of all other patients, even if none of the exposed healthcare professionals actually develops a COVID-19 infection.

A more pressing concern is that many breast cancer patients have weakened immune systems due to older age, ongoing or recent receipt of chemotherapy or targeted therapy [e.g., Ibrance (palbociclib), Kisqali (ribociclib), Lynparza (oliparib)], or other health conditions (e.g., cardiovascular disease, chronic lung disease, diabetes, chronic liver or kidney disease, or asthma) that place them at increased risk of complications from a COVID-19 infection.  These vulnerable patients may also be put at risk by younger, healthier, symptom-free COVID-19-infected patients whom they encounter during routine office visits. 

With such ongoing uncertainty, I thought it would be timely to offer the following guide about how to navigate your breast health during this pandemic.

1. You can still seek healthcare.  The California mandatory “stay at home” order does not prevent you from seeking essential healthcare.  Therefore, if you have a new suspicious breast symptom or mammogram finding, or have been recently diagnosed with breast cancer, you can still leave home to seek healthcare.  If you are currently receiving chemotherapy or radiation, you may continue to see your healthcare providers for these essential treatments. If you are currently scheduled for breast cancer surgery, you should expect to have surgery performed in a timely manner.
   
   
2.  Reschedule your breast health appointment if sick or exposed.  If you are having symptoms of respiratory infection (cough or shortness of breath), severe cold or flu symptoms, fever, or suspect that you might have been exposed to someone with COVID-19 infection, please tell your primary care doctor about your symptoms or exposure and postpone your breast health appointment until at least 2 weeks after you have fully recovered or 2 weeks after your last contact with a sick person.  If you are currently receiving chemotherapy or targeted therapy, please notify your medical oncologist before postponing a medical oncology appointment so that he or she may come up with a game plan to adjust your medications and manage your care.
   
   
3.  A modest appointment delay is O.K.  Don't get too alarmed if your follow-up appointment gets postponed by your doctor’s office or if you must delay your appointment for a few months. However, if you are receiving chemotherapy or targeted therapy, have a concern about the healing of your wound, or have a new breast concern, please inform your doctor’s office so that you can be given a priority appointment. 
    
4. Practice proper hygiene.  Regardless of the state of your health, the most important thing you can do to avoid contracting or transmitting COVID-19 is to wash your hands regularly with soap and water and/or frequently use alcohol-based hand sanitizers that contain at least 60% alcohol. You should also avoid unnecessary touching of your face, mouth, and eyes unless your hands are clean, since these are the places where the COVID-19 virus enters the body.  Of course, this is easier said than done.  In the few minutes it took for me to write the first few paragraphs of this advisory, I absentmindedly touched my face at least a dozen times.  So clean hands are a must!  You should also do your best to avoid any family, friends, or strangers suspected of having or displaying symptoms of COVID-19 infection.  Please see the Centers for Disease Control and Prevention guide (www.cdc.gov/coronavirus/2019) for more tips about COVID-19 symptoms and avoiding infection.
   
   
5. Maintain safe social distance in the doctor's office.  When you come to the doctor’s office for an appointment, you may wish to wait in the hallway or wait outside the building to avoid sitting in a crowded waiting room.  Just leave your cell phone number with the reception desk so that you may be called minutes before the doctor is ready to see you.  Expect to fill out forms?  Bring your own pen and clipboard to avoid sharing these with other patients.  In our office, we clean all exam room contact surfaces (e.g., door knobs, faucet handles) after each patient visit to minimize the risk of patient-to-patient transmission.    
    
   
6. Wear a mask if your immune system is compromised. Wear a high quality mask especially if your immune system is compromised. Chemotherapy and many targeted therapies weaken your immune system, making it more difficult to resist or fight infection. Although the current recommendation of the Centers for Disease Control and Prevention is for American’s to wear a mask (even home-made masks) to prevent spreading the virus from themselves to others, my personal recommendation to patients currently undergoing or recently completing chemotherapy or targeted therapy is to wear a medical-grade mask, if possible, when you are in public spaces where you cannot maintain 6 feet separation from other persons to protect yourself from viruses that might be spread by those NOT wearing a mask. In addition, a mask keeps you from touching your nose and mouth. If you are uncertain if you are on a medication that weakens your immune system, please ask your medical oncologist. However, commonly used anti-estrogen medications like Nolvadex (tamoxifen), Arimidex (anastrozole), Femara (letrozole), and Aromasin (exemestane) DO NOT weaken your immune system. Furthermore, merely having a recent history of breast cancer does not mean that your immune system is compromised.
   
   
7. Can’t get an appointment in mammography? Many breast concerns may be resolved in the surgeon's office.  Delaying routine mammograms and breast cancer screening by a few months might cause you a bit of anxiety.  However, such delays are unlikely to harm your long-term physical health even if there is a hidden cancer developing.  On the other hand, if you have a new breast lump or symptom and can’t seem to get a quick appointment in the mammography department or breast center, our office has the ability to perform breast and lymph node ultrasound to quickly exclude the presence of cancer or perform ultrasound-guided needle biopsy of any suspicious ultrasound-visible finding.
   
   
8. Consider a telehealth visit instead of an in-person visit.  If you are voluntarily or involuntarily quarantined or simply too afraid to go out in public, you might have the option of a telehealth visit with your doctor.  Real-time telemedicine permits a live interaction between a health professional and patient using secure, HIPAA-compliant audio and video communication.  Think Facetime, just more secure!  For example, a surgeon might use a telehealth visit to provide a new consultation, second opinion, post-operation wound check, or to discuss the surgical pathology results.  
   
   My practice now offers “face-to-face” VideoChat office appointments which you may access through your personal desktop computer, laptop, tablet device, or cell phone.  To participate in a VideoChat office visit, Dr. Holmes's office will send to you a connection weblink via email or text message.  Simply select the weblink to “Join the VideoChat", respond to the prompts to turn on your camera and microphone, and seconds later you will be able to see and speak with Dr. Holmes from the privacy of your home. 
   
   To schedule a VideoChat office visit, please contact our office at 1-800-203-5515 or www.drholmesmd.com. It is my understanding that all PPOs, Medicare, IPAs and Medi-Cal will pay for properly conducted telehealth visits during the pandemic.  You may wish to verify this with your health plan.  However, if telehealth visits are not covered by your health plan, you have the option of paying out-of-pocket for these services.
   
   
9. You can share medical records online.  Patients newly diagnosed with a breast problem may be particularly anxious to see a surgeon.  Here, too, telemedicine provides a solution.  Virtual appointments have been greatly facilitated by mymedicalimages.com, a HIPAA-compliant medical record-sharing  website that Dr. Holmes uses to receive medical records from patients.
   
   Mymedicalimages.com allows patients to use their personal computers to upload reports and full CDs of mammogram, ultrasound, and MRIs to a secure website where Dr. Holmes can view your medical records in minutes!  Not only is this a rapid method of sharing your medical records, mymedicalimages.com costs as little as $19 with a discount code provided by Dr. Holmes’s office.  That’s cheaper and safer than the cost of sending medical records by express mail without the risk of lost mail or mail delays. 
   
   
10. There are ways to keep most tumors "in check" while awaiting surgery.  What if you’ve been diagnosed with breast cancer and are unable to promptly undergo surgery due to one of the reasons listed above? Don't worry, there are several things you can do in the meantime to keep the cancer from growing and spreading.  For example, if you have been diagnosed with non-invasive (stage 0) breast cancer or ductal carcinoma in situ (DCIS), you can safely wait up to 3 months before proceeding with surgery.  If you’ve been diagnosed with non-invasive or invasive breast cancer that is strongly sensitive to estrogen, you can be started on anti-estrogen pills [e.g., tamoxifen (Nolvadex) or anastrozole (Arimidex)] to suppress cancer growth for 6 months or more while awaiting surgery.  On the other hand, if you’ve been diagnosed with triple negative invasive breast cancer or a cancer that is only weakly sensitive to estrogen, you should seek a priority appointment for surgery or chemotherapy since anti-estrogen pills do not work well (or at all) against these tumors.  Selected patients may also undergo cryoablation or tumor freezing (www.cryoablation.com) as a substitute for surgery or as a means of controlling a breast tumor while awaiting future breast and/or lymph node surgery.

There you have it: your Breast Health Pandemic Survival Guide, which you may share with family and friends.  Although it is reasonable to remain nervous about where the current international health crisis is heading, be assured that there is reason for optimism.  In the past decade, the world has been rocked by the H1N1 (SARS) virus pandemic as well as the Zika virus pandemic as little as three years ago.  Now, H1N1 and Zika are but distant memories, and in time COVID-19 will likely share the same fate. Till then, I encourage you to remain attentive to your personal hygiene to keep yourself safe and stay hopeful that your breast healthcare can be reasonably maintained in spite of this ongoing pandemic.