Breast Cancer during Covid times

Breast Cancer is the most frequent causes of cancer amongst women and being diagnosed with it comes with a great deal of anxiety and stress. Even though the survival rates in early stage breast cancer are quiet high, the treatment protocol is a long and tedious process and mostly spans over 4-6 months. Treatment of breast cancer is multidisciplinary and includes surgery, chemotherapy ,radiotherapy in most cases and may require immunotherapy in Herceptin receptor positive breast cancer or in terminal breast cancer patients. In addition to the difficulties the patients and their loved ones are already facing comes the added vulnerability of these patients to the novel Corona Virus.

The Covid 19 pandemic as we know it has far reaching consequences on social, economic, political and religious well being, as well as an increase in incidence of domestic violence and psychological issues and individuals with cancer are among the worst hit groups of the population.

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The battle rages on

The current situation is fast evolving and it has become a need of the hour to make sure that breast cancer patients as well as other cancer patients in general our given adequate care while maintaining safety and adequate social distancing at the same time.

For the rest of the article I have mentioned a list of common problems breast cancer patients face in my opinion, during the pandemic and how they can possibly be tackled.

Weakened immunity

A good immunity is a crucial shield against the novel coronavirus infection, and this is exactly what most cancer patients lack due to the rigorous treatment they have to undergo. Chemotherapy and radiotherapy play a key role in the treatment of breast cancer but at the same time are known to lower immunity.

Chemotherapy affects rapidly dividing cells which include not just cancer cells but also bone marrow cells and white blood cells that are responsible for maintaining cellular immunity.

The mucositis caused by such drugs can lead to a breach in our innate immune system which can lead to easy viral entry. Inspite of all the heavy impact of chemotherapeutic agents on the immune system they cannot be avoided in the treatment of breast cancer.

Patients should be given guidance regarding handwashing, proper hygiene and avoidance of large crowds. Immuno-boosting agents should be prescribed to these patients mainly zinc tablets, vitamin c and vitamin D supplements as these are known to boost the immunity. Alcohol, smoking and drug abuse are known to impair immunity and are to avoided at all costs.

And most importantly daily exercise, a healthy diet and adequate sleep for 6-8 are mandatory. These habits are often ignored but are crucial in maintaining the integrity of natural killer cells which is said to play a key role in fighting the virus.

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Travelling for treatment

Cancer treatment is a long term treatment requiring frequent doctor visits. Whether a patient is in the newly diagnosed state, early stage or terminal stage, every individual has a unique story and most of them are in a compromised situation.

Newly diagnosed patients if not treated on time can progress and terminal patients have an increased risk of developing severe symptoms. So it lies in the hands of the treating doctor to weigh the pros and cons of travelling during the pandemic during such a situation.

If a patient really does need to travel than the following precautions can be taken:

i) Protect yourself and others during the trip and make sure proper hygiene is maintained. Carrying a 60-70% alcohol sanitizer is a must during travel, and as far as possible avoid touching your face.

ii) Wear a mask or cloth face covering in public, practice social distancing of atleast 6 feet or more from others, and avoid eating at public places.

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Telemedicine services

Telemedicine is a system in which the patient interacts virtually with the treating physician.

One of the key measures most centres across the globe are focussing on is telemedicine. Improvements in telemedicine services is a must so that cancer treatment can be carried out seamlessly and unnecessary visits to the hospital are avoided.

Either telephoning the patient or video calls can be practiced. Video calling is a more effective measure as it reduces psychological stress and helps patients receive the right amount of knowledge that they may want.

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Patients who require chemotherapy

Patients who are require chemotherapy can be divided into two main groups-

i) Those treated with a curative intent- patients in early stages of breast cancer who show response to chemotherapy, it is advisable that chemotherapy be continued and the course of therapy shortened wherever feasible as decided by the treating doctor.

ii) Those treated with a palliative intent- palliation involves dealing with the symptoms and lowering the disease burden when the cancer cannot be cured. Palliative chemotherapy requires a careful assessment of the indications, response to treatment and the general condition of the patient.

If patient is in complete remission chemotherapy maybe omitted. If the patient happens to be hormone receptor positive (ER/PR +ve) breast cancer endocrine therapy maybe started.

The patient can be switched to oral chemotherapy if required which can be prescribed over telemedicine. For example Tablet cyclophosphamide can be started at home instead of giving it intravenously.

In hospitals which have a large number of covid positive patients the duration and frequency of visits can be shortened on an individual basis.

Patients receiving radiotherapy

Just like in chemotherapy patients who have a chance of cure and a rapidly progressive disease must receive radiotherapy if indicated. Wherever possible alternative forms of therapy should be started such as endocrine therapy in hormone receptor positive breast cancer.

In palliative patients the course of radiotherapy may be shortened in order to reduce hospital visits. For example patients with painful bony metastases can be treated in a single day with high dose radiotherapy to the site of lesion.

Patients due for surgery

In patients who are due for elective surgery, just like in other forms of treatment the benefits and risks have to be weighed. The benefit the patient will receive should be compared against the availability of hospital resources, the case complexity and the risk of exposure to covid-19.

In emergency cases where testing maybe delayed, surgeries with PPE must strongly be considered in order to avoid risk of infection

In elective surgeries testing of patients as well as health care workers is strongly recommended.

One of the steps necessary in breast cancer patients are to prioritise them on a case to case basis:

The can be grouped into high priority, medium priority and low priority.

High priority group consists of all those patients with post op infections, hematomas, complicated cases, pregnant patients, newly diagnosed patients for invasive breast cancer and those with new symptoms and side effects.

Medium priority includes– New diagnosis of non invasive breast cancer, post op visits with no complications, early stage breast cancer with hormone receptor positivity.

Low priority patients includes those for follow up and psychological support.

Radiation priorities

High risk Patients with brain mets causing symptoms or acute spinal cord compression need urgent radiotherapy, patients who are already on treatment and those with triple negative or HER 2 disease also come under high risk category.

Low priority patients- elderly patients can be started on hormonal therapy and radiotherapy can be delayed.

After prioritising, patient’s treatment may be started or delayed accordingly.

It must also be kept in mind that may patients who are being faced by unemployment and falling economy need to be considered and treated with lower priced treatment options.

None of us neither, the health staff nor the patients were prepared for such a pandemic which came all of a sudden while we were unarmed; Patients and clinicians neither have significant experience regarding the rationing of care in such a situation. But the best we can do now is to make wise decisions and work as a team to fight the current situation together.

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