The world is now abuzz with news about coronavirus (COVID-19), the viral disease that has taken us all by storm. The global response has been extreme with most things cancelled or postponed and the disruption to everyday life is unprecedented. 

Whether or not the current global response is an appropriate action or an overreaction 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 health care providers and those who must leave home to seek essential health care.

While no one is immune to the COVID-19 virus or the collateral damage 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 health care 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 two-week or longer quarantine of all exposed medical staff, which would disrupt the health care of all other patients, even if none of the exposed health care 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 also may 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 health care. The California mandatory stay at home order does not prevent you from seeking essential health care. 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 health care. If you are currently receiving chemotherapy or radiation, you may continue to see your health care 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 two weeks after you have fully recovered or two 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 they may come up with a game plan to adjust your medications and manage your care.
3. A modest appointment delay is OK. 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 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 percent alcohol. You also should 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.
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 you can be called minutes before the doctor is ready to see you. Are you expecting to fill out forms? Bring your own pen and clipboard to avoid sharing these with other patients. Another option is to fill these forms out online, if possible, and bring them with you.
6. Wear a mask 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 general recommendation of the Centers for Disease Control and Prevention is that healthy people 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 six-foot separation from other people. At the very least, 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 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, your surgeon might have 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 VideoChat telehealth office visit to provide a new consultation, second opinion, post-operation wound check or to discuss the surgical pathology results.
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 HIPAA-compliant medical record-sharing websites some physicians use to receive medical records from patients. These platforms allow patients to use their personal computers to upload reports and full CDs of mammogram, ultrasound, and MRI images to a secure website where a doctor can view medical records in minutes.
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 three 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 six 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 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. Until then, I encourage you to remain attentive to your personal hygiene to keep yourself safe and stay hopeful that your breast health care can be reasonably maintained in spite of this ongoing pandemic.

Dr. Holmes is a breast cancer surgeon and researcher in Los Angeles and the lead investigator for the FROST Trial using cryoablation as a less invasive treatment for breast cancer. For more information visit www.drholmesmd.com or www.cryoablation.com or call (800) 203.5515.

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