The world is now abuzz with news about Coronavirus (COVID-19), the viral disease that has recently taken the world by storm.

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; Disney has closed its doors; and cleaning products, toilet paper, and paper towels are experiencing their very own gold rush!

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 develop solutions.

While no one is immune to the COVID-19 virus or the collateral damage that it has caused, breast cancer patient 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 operations like breast surgery as they reassign limited medical staff to more critical departments like the ICU and preserve hospital beds for sicker patients.  Such precautions are also meant to protect healthy healthcare personnel from apparently healthy patient who may be carriers of COVID-19 but have yet to exhibit symptoms.  Just imagine the impact on a medical office 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 the entire medical staff, which would disrupt the healthcare of every other patient seen by that office, even if no one else ever 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., heart disease, lung disease, or diabetes) that place them at increased risk of complications from COVID-19.  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 tips about how to navigate your breast health during this pandemic.

1. Practice Prober 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 use alcohol-based hand sanitizers often 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 COVID-19 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’ve 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 this link for more tips about COVID-19 symptoms and avoiding infection.

2. Reschedule Your 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 the 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 weeks.  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. 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.

5. Wear A Mask If Immune Suppressed. Chemotherapy and many targeted therapies lower your immune system, making it more difficult to resist or fight infection. Although the general recommendation is that healthy patients should NOT wear face masks, my personal recommendation to patients currently undergoing or recently completing chemotherapy or targeted therapy is to wear a face mask when you are in public spaces where you cannot maintain 6 feet separation from other persons. If you are uncertain if you are on a medication that lowers 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 lower your immune system.

6.  Many breast concerns may be resolved in the doctor's office. Delaying routine mammograms and breast cancer screening by 1 or 2 months might cause you a bit of anxiety but is unlikely to harm your long-term physical health even if there is a hidden cancer developing within. However, if you have a new breast lump or symptom and can’t seem to get a quick appointment in the radiology department or breast center, we have the ability to perform breast ultrasound in the office to quickly exclude the presence of cancer or perform ultrasound-guided needle biopsies of suspicious findings.

7.  You can insist on an expedited appointment. If you have been recently diagnosed with breast cancer and are hoping to expedite your consultation and subsequent treatments, please inform your doctor’s office so that you can be given a priority appointment.

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 audio and video communication. Think videochat or Facetime, just more secure!  For example, a surgeon might use a telehealth visit to do post-operation check-ins with patients, to make sure their wound is not infected, or to discuss the surgical pathology results.  My practice is in the process of setting up a telehealth service to enable virtual appointments.  Stay tuned for more information about our telehealth service which will be sent to you in a follow-up communication.

Some health plans will allow your doctor to bill insurance for telehealth services. However, if telehealth visits are not covered by your health plan, you might have the option of paying out-of-pocket for these services.

9.  You can also share medical records online. Patients newly diagnosed with breast cancer may be particularly anxious to see a surgeon. Here, too, telehealth may provide a temporary solution. Virtual appointments have been greatly facilitated by mymedicalimages.com, a HIPAA-compliant, online, medical recording sharing service that Dr. Holmes uses to receive medical records from of town patients.  Mymedicalimages.com allows patients to use their personal computers to upload reports and full CDs of mammogram, ultrasound, and MRI images to a secure website where Dr. Holmes can view your medical records in minutes! Not only is it this rapid, mymedicalimages.com costs as little as $19, cheaper than the cost of sending medical records by express mail.

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 a several things you can do in the meantime to keep the cancer in check.  For example, if you have been diagnosed with non-invasive (stage 0) breast cancer or ductal carcinoma in situ, you can comfortably wait 1-3 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 or Arimidex) to suppress cancer growth for few weeks or months while awaiting surgery.  On the other hand, if you have a triple negative invasive breast cancer or a cancer that is 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) for these tumors.  Selected patients may also undergo cryoablation or tumor freezing 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 Plan, which you may share with family and friends.  Although it is reasonable to remain nervous about the current international health crisis and where things are heading, be assured that there is room for optimism.  In the past decade, the world has been rocked by the H1N1 (SARS) virus pandemic followed three years ago by the Zika virus pandemic.  Now, H1N1 and Zika are but distant memories, and COVID-19 will likely share the same fate. Till then, I encourage you to be mindful of your personal hygiene while also remaining attentive to your breast health.

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