Breast Cancer Care and COVID-19: From the Frontlines with Dr. Judy Garber
By BCRF | March 24, 2020
By BCRF | March 24, 2020
Breast cancer—and any cancer—can be incredibly stressful under the best of circumstances for patients, survivors, and their families. In this time of the novel coronavirus (COVID-19), concerns can feel like they’re rising exponentially. So, what do we all need to know? With tons of new information bombarding us at once, what should cancer patients and families consider? Are there practical tactics or is there tangible guidance to stay safe?
In this special episode of Investigating Breast Cancer, we talk to Dr. Judy Garber for the answers. Dr. Garber is BCRF’s scientific director and chief of the Division of Cancer Genetics and Prevention at the Dana-Farber Cancer Institute in Boston.
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Chris Riback: Let's talk first about breast cancer patients and their families. There's so much news and so many rumors as well, and obviously we're talking about folks who are under a fair amount of stress, to put it mildly, even in the best of circumstances. What are you hearing from the breast cancer community, and what are you hearing from your own patients?
Dr. Judy Garber: Well, from the community, I think people are making the same efforts as all of us to get reliable information. When people are part of large organizations, often they are sending what can seem like an overwhelming amount of information every day with updates and statistics and recommendations and requirements for the way we're to manage in this crisis.
I think for our patients, for my patients, some of them use me as the source of information and Dana-Farber, where I am, and I'm sure everywhere else people have tried to make that information accessible to patients. The CDC remains an important website. The World Health Organization [WHO]. Everyone has tried to put access to reliable information. And I really emphasize that there's so much fear that it's hard to know where to go for the real thing. So WHO has been a good place and the CDC especially.
I think people's doctors can help them to place themselves in this context, in this craziness. But because everyone feels that they know the reasons they might be especially vulnerable. And fortunately some people are just the same as the rest of the population. People who are long-term survivors of breast cancer, we hope are not compromised by their treatment long ago. People who are currently in treatment, well they do need to take special precautions when that treatment includes things like chemotherapy or immunotherapy, maybe less so when it's hormonal therapy. So doctors and nurse practitioners and PAs who are part of their care can help them.
Chris Riback: I want to ask you about the various therapies and some practical concerns, questions, and guidance that you might have. But broadly on viruses in general and maybe this one in particular, to the extent that you have insight or thoughts on this? What do you know about the virus? And more specifically maybe, what guidance would you normally give patients about how to protect from a virus? We are surrounded by viruses potentially all the time. Is this situation different in the way you think about it for patients?
Dr. Judy Garber: Well, it certainly is different. But let's say under usual circumstances most of the chemotherapy for breast cancer, for example, is not as toxic to the immune system as let's say things like treatment for leukemia, which is so intense and meant to wipe out the immune system. Most chemotherapy for our patients affects their ability to fight bacteria and for that reason, we give things, injections to try to keep their white blood cells up. They're less affecting their immune function against viruses. So we always tell people you'll be miserable if you get a cold, but that's all.
And yet you see that some viruses like herpes virus, for example, people who are ill and under stress are more likely to get an attack of shingles, which is just reactivation of their chicken pox virus.
Chris Riback: Yes.
Dr. Judy Garber: So viruses are not all the same. This Coronavirus is different because very few of us are immune to it. Even though it's part of a family of viruses we might've seen long ago, there's so little crossover that our immune systems don't seem to remember. And that seems to be part of why we're having so much trouble fighting it off. And if, on top of that, you have to have treatment that may make you overall a little less strong than you normally would be, a little more debilitated, then there is more fear that your response to that kind of stress would be more difficult.
Chris Riback: Let's follow up on what you were saying about various treatments, people who might have cancer right now, and survivors. Are cancer survivors at a greater risk than the general population? Are there special concerns for people currently being treated for cancer? You touched on this a little bit. And as well, are there certain types of cancers that are at greater risk than others?
Dr. Judy Garber: So it's a little hard to know how to group all this but let's say that for people who have cancers requiring, at the moment, immunotherapies, that those people have special challenges. Some of the side effects of those treatments can affect the lungs to begin with and we know that the lungs are the most vulnerable place for the Coronavirus and their immune systems overall are being altered. We're suppressing part and hoping that the cancer fighting part will be more potent. But I don't think we know exactly how that's going to do in relation to the virus. And people are very concerned that patients getting immunotherapies and who gets immunotherapy.
Well, they're standard of care now for things like advanced melanoma or lung cancer, bladder cancer, kidney cancer. Not so much in breast cancer, although there is some use in treating triple-negative disease. So, patients who require immunotherapy already are being specially managed and this will be part of that special management now.
I think patients getting chemotherapy also are always a little more vulnerable to other outside influences and are trying to balance treating the cancer and managing to have normal systems survive the treatment. And that is in varying degrees of intensity. And I think that's a place where it's particularly important to have your doctor advise you. But look, we're asking people who have no health conditions to try to protect themselves by staying inside and cleaning everything inside. And I think we, at the very least, would recommend that to our patients undergoing chemotherapy.
And then there are patients who have other kinds of treatment. Breast cancer patients getting hormonal therapy or prostate cancer patients getting hormonal therapy. And although those people often don't feel completely normal in their treatments, their immune systems are much less compromised. So, I think they are less vulnerable.
Now, if they have some underlying lung conditions or other medical issues that can raise their risk. And those can be things just like cardiovascular disease, which are pretty common or diabetes. This is the time to try to make sure you're not stressing that part of the body or the parts of the body that deal with them as well. And so it's not to say that everyone who has these underlying conditions, including their cancers, will therefore be the ones who get the virus or do worst with it. But certainly, we want to try to protect everyone and our cancer patients as much as everyone. We want them all to be survivors. And if they're already in the fray, this may be much harder.
Chris Riback: And I would assume that for patients who are undergoing any kind of treatment, whether that's chemotherapy, other immunotherapies, etc., that anyone who's got a question on, "Well, I'm under this regimen. Should I cancel it?" I assume that first thing you would guide is I would assume not. And beyond that I would assume please talk to your doctor.
Dr. Judy Garber: Oh, absolutely, Chris. I think that everyone is concerned about even having to come to the hospital to be treated, that there are people here who might be more likely to be positive or just more people than all of us are trying to be in contact with. And we're well aware in the hospitals and the treatment centers that these risks are there and taking extra, extra precautions to try and protect the patients. I do think that it is as safe as it can be and for some people really important to come for treatment and for others maybe not so important. And maybe they and their physicians and providers and I leave nurse practitioners and PAs and this, everybody's trying to figure this out together.
Chris Riback: Yes, yep.
Dr. Judy Garber: But I think that they and the team can try to decide is this the right time to come? Do you have symptoms? Maybe you should stay home. What if we delay a little bit? What if we don't? And those are pretty individualized discussions and they're taking place all around us.
Chris Riback: And just to put a point on that, because I could imagine this would be the type of question that listeners would have, so on that guidance that might go to upcoming doctor's appointments. That might go to scheduled screenings for cancer survivors.
Dr. Judy Garber: Yes.
Chris Riback: That might go to whether or not to keep a scheduled annual mammogram. Am I understanding you correctly?
Dr. Judy Garber: Well, let's talk about that separately.
Chris Riback: Okay.
Dr. Judy Garber: So treatment is one thing and I think treatment most of the time, we're going to try to keep that on schedule and intact. Maybe spread out a little more, but I do think people want to maintain treatments they thought were important enough to have in the first place. Screening is different, and I think here many people are trying to go to virtual visits where instead of coming for that breast exam you thought was so critical, you might be able to ask questions, talk about any side effects from oral medications, but put off the exam and the screening imaging until things settle down a little more.
Many places are not offering screening mammograms or colonoscopies at this time. Saving their resources to try to deal more with the virus and its effects. And that is, most of the time really, I think in the balance of things, a safe thing to do. We are not worried, even among our highest risk patients, our BRACA carriers and our Lynch syndrome patients and our cancer survivors. Sometimes logistics put your appointments off a month or two and we're hoping here we're not talking more than about three months.
Chris Riback: Yes.
Dr. Judy Garber: But the risk of coming and being exposed against the benefit of a test that's 99% likely to be negative is really no calculus at all.
Chris Riback: Let's talk about precautions. You mentioned it briefly earlier, but as specifically as you can, what precautions should cancer patients take? At this point, we all know the general recommendations to wash our hands, refrain from touching our face. But should cancer patients be doing anything else? What about face masks, for example? Although, those are plenty hard to acquire. And our hospitals need them. So what precautions should cancer patients take?
Dr. Judy Garber: Well, I think in their normal lives at home, that really the things we've been recommended to do are what we should be doing, but really doing them. Suddenly you realize how many times a day you actually touch your face. Really have to try to be as clean as possible. Things brought into the house should be wiped down. The house should be wiped down. The doorknobs, places you don't think about. We really have to make every effort to be as clean as possible, and we all seem a little obsessive compulsive, but that's okay at this time. And then when there's time to go out and be among others, especially in a medical setting, I think extra precautions are needed and often patients will be offered some of that. You'll see the staff wiping down the room as you walk in the door and when you leave and it's not a reflection on what they think about you. It's just being as careful as we possibly can.
Chris Riback: And this also, I'm sure very, very tough to answer, but when should a cancer patient be concerned? I mean we all are looking around the second one of our kids coughs or we have a cough. You think, "Oh, are you okay? You feeling okay?" And you're like, "Well, it's allergy season, so I'm coughing because..." For what symptoms should they start to be seeking medical attention, thinking about it? Is a cough something that someone should be paying attention to? And here, I mean, cancer patients. A runny nose? How do you decipher between something that's just normal and something that’s more, "Hmm, I better pay attention to this"?
Dr. Judy Garber: What a good question and what a tough question as allergy season starts among us. Which is nice, at least things are blooming. But here we've got allergy season on top of all the effects and maybe a little less influenza, so that's a good thing. I think the most important symptoms to pay attention to, of course, are fever and any shortness of breath and those anyway, as a cancer patient, you always should call your providers for those. I think cough and runny nose, if it's at a tiny bit, you might be inclined to wait. I heard this morning a discussion for allergies. If you felt like you felt last year and you're not on active treatment with chemotherapy drugs or immunotherapy drugs, you might tolerate a little bit longer before you call. But if you have any concerns you should just call. Why worry by yourself when someone can help you decide? I do think for people who are receiving medications that it's a different thing. Some medications will mask a fever and you have to know if you're taking one of those. Anything that could cause a shortness of breath, obviously that's urgent. You really have to call.
Chris Riback: Taking one's temperature—
Dr. Judy Garber: You do know you have to call before you go and get tested because you can't just show up anywhere. I don't think. Certainly not in Massachusetts where I am. You can't drive to a drive through. You can't go to an emergency room without calling ahead so that they know you're coming and can deal with you when you come with this question.
Chris Riback: Yes.
Dr. Judy Garber: So you’ve got to call. Hopefully we'll have home tests soon, but not yet.
Chris Riback: Yes, yes. Soon. Soon, we all hope. To start to out the conversation, you just mentioned a moment ago something that was on my mind as well. You said if you've got that concern, call. Why should you worry alone? What is your guidance on stress? I mean from what any of us lay people know and hear about stress generally that it seems to always be something to be concerned about. Stress can cause all sorts of challenges for any of us at any time. This is obviously a particularly stressful time for the whole world and I would assume it's a particularly even more stressful time for the folks that we're talking about. What guidance do you have regarding stress? How to manage it, how to think about it.
Dr. Judy Garber: Well, I wish I had the secret, but I think everything we're all seeing now, now that we're all living with more stress than usual, suggests that we should pay attention to it and not pretend that we don't have it. There are a number of websites I've seen where you can have yoga classes online, where you can have someone to talk to. A lot of therapists are doing their work online. If you have a therapist, you might find out whether virtual visits are available through the institution where people are getting care. Many of the providers, social workers, psychologists, psychiatrists, et cetera, are making themselves available online. But people also have other ways that they manage stress in their lives.
They try to put some other activity into their day. Music, online many of the symphonies and musical groups are giving free concerts that you can tune into if music helps you relax. People are meditating, calling friends, people are having Zoom dinners and all kinds of—
Chris Riback: Yes, yes.
Dr. Judy Garber: ...virtual activities. I think finding a way to feed your inner self to help get through this time is critical for care for our patients and for their caretakers too. Families will find out how well we get along under this kind of stress and everyone wants to support people who are under particular stress and that certainly includes our cancer patients.
Chris Riback: Is there one thing, Dr. Garber, that you would want all patients to know? And no one wants false hope of any kind, but is there a message of hope that you would add that is not giving false promise by any stretch but just things that you think people should keep in mind?
Dr. Judy Garber: Well, I think I would say two things. One is your healthcare team, your healthcare providers, those people who've committed to getting you through this cancer experience are still very much committed and there for you. They don't think it's any less important helping you deal with cancer during this time than it is any time. They are still there and they're still available, maybe more so. So, I would say don't hesitate to involve them and don't feel alone. That community is still present, and all of your support networks hopefully are still present.
For the virus? Oh boy. I think, this is going to test our mettle, but everyone says that this is something we will ultimately get through. I'm sure we'll be different afterwards. But look at China, they are not having new cases. There is a limit. This is not the new reality that will last forever. We will get through this crisis and we'll pick up the pieces and go on. And I think our cancer patients, I hope, will be very much part of that survival.
Chris Riback: What's it like to be a doctor at this moment?
Dr. Judy Garber: Well I think that, Chris, it's a different thing. So I'm an oncologist and what I know to do for cancer patients is probably not what people need on the front lines. But my daughter is a cardiology fellow and my son is a pulmonary fellow who works in intensive care units. And I would say that they're very much on the front lines and absolutely as passionate and committed as you would want doctors to be and as worried. So we all hope the protective equipment will catch up with this crisis as well. I think it's still a privilege to take care of patients, especially in a time of crisis and to take care of each other. And I think we all are caretakers. That's what we do. We just try to adapt what we do to new demands.
Chris Riback: Dr. Garber, thank you. Thank you, of course, for what you do every day under normal circumstances. And thank you for taking the time to help explain and give folks some really practical things to think about at a time when everyone's looking for the information you described.
Dr. Judy Garber: Well, thank you, Chris. We will get through this together.
The CDC’s guide to protecting yourself
ASCO's guidance for cancer patients and providers
Virtual panel discussion on COVID-19 and cancer hosted by InKind Space with BCRF Investigator Dr. Neil Iyangar
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