Breast Oncologists Voice Coronavirus Concerns

Patrick I. Borgen, MD

The rapid developments regarding coronavirus 2019 (COVID-19) have raised the question of how this virus could impact patients with cancer who are receiving immunosuppressive therapies.

As such, multiple institutions, including The University of Texas MD Anderson Cancer Center and NYU Langone Health’s Perlmutter Cancer Center, have implemented travel bans for their faculty in an attempt to minimize the risk of disease spread.

"The most worrisome thing about COVID-19 is that we don't have a clear picture of what it is, incidence rates, who gets infected, and what disease course patients have," said Patrick I. Borgen, MD, program chair of the 2020 Miami Breast Cancer Conference (MBCC), and chair of the Department of Surgery at Maimonides Medical Center. "Unfortunately, I believe we are going to learn quickly. Over the next 2 to 4 weeks, our understanding of this virus will [increase]."

Adam M. Brufsky, MD, PhD

Beyond Borgen, several faculty who were on site at the 2020 MBCC Conference touched upon COVID-19, including:

• Adam M. Brufsky, MD, PhD, professor of medicine and associate chief in the Division of Hematology/Oncology, co-director of the Comprehensive Breast Cancer Center, and associate director of Clinical Investigation at the University of Pittsburgh Medical Center Hillman Cancer Center;
• Debu Tripathy, MD, professor and chairman of the Department of Breast Medical Oncology in the Division of Cancer Medicine at The University of Texas MD Anderson Cancer Center;
• Enrique Soto Pérez de Celis, MD, MSc, a geriatric oncologist and researcher in the Department of Geriatrics at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán in Mexico City, Mexico;
• Aditya Bardia, MD, MPH, director of Precision Medicine at the Center for Breast Cancer and founding director of the Molecular and Precision Medicine Metastatic Breast Cancer Clinic at Massachusetts General Hospital Cancer Center, and assistant professor of medicine at Harvard Medical School;
• Sara A. Hurvitz, MD, associate professor at the David Geffen School of Medicine, University of California, Los Angeles (UCLA), medical director of the Jonsson Comprehensive Cancer Center Clinical Research Unit, co-director of the Santa Monica-UCLA Outpatient Oncology Practices, and director of the Breast Cancer Clinical Trials Program at UCLA.

In an interview with OncLive, these faculty discussed the potential impact of COVID-19 on patients with cancer.

OncLive: What is currently known about COVID-19?

Debu Tripathy, MD

Tripathy: The impact of the rapid development of activities and events with the novel COVID-19 is unclear at this point. In our modern era, it is an interesting phenomenon to be involved in, in a virus that [is becoming] a pandemic.

We've seen mini pandemics with the Ebola virus. Ebola had a more virulent case fatality ratio but had very limited exposure. Now, COVID-19 does not have as high of a morality rate but is so widespread. Currently, the mortality rate is estimated to be between 1% and 3%, which is, in orders of magnitude, higher than the flu.

There is much about COVID-19 that we don't know yet. It appears that a group of asymptomatic patients can be carriers and be contagious, which is concerning in terms of containment. Many countries and institutions are adopting different policies for containment.

It is fundamentally going to change the way we live our lives, at least in the short-term. We don't know which way this is going to move. I liken it to a tropical storm off the coast of Africa. Many storms begin there and mature into hurricanes as they move into the Western hemisphere. They may wreak havoc, or they may move out to sea. The same happens with viral epidemics; there are so many factors that determine how they will operate.

Brufsky: [At the 2020 MBCC], a number of institutions chose to have travel restrictions on their faculty. I totally get that. We have been talking about COVID-19 a lot in the sidelines [at this meeting] because many physicians [were restricted from traveling to Miami, Florida] and it has been affecting the stock market.

The big consideration with COVID-19 is the unknown. Hopefully within the next 2 to 3 months, we will get a sense of how serious [this virus] really is, but that is unknown right now.

How could COVID-19 impact patients with cancer?

Soto: Older adults appear to be the most vulnerable population to COVID-19 from what we have seen so far in medical journals and [data] coming out of China. Also, patients with cancer are at a higher risk of having complications [from COVID-19] based on our initial reports.

Aditya Bardia, MD, MPH

Bardia: We don't yet know how COVID-19 will impact immunocompromised patients. From what was seen in China, we know that elderly patients are at a higher risk of developing a more serious infection. One could anticipate that immunocompromised patients may also be at risk of developing a more severe infection.Having said that, there is a lot of development going on in terms of developing assays to detect this disease earlier and developing vaccines. This work could change the natural history of this disease.

Borgen: COVID-19 clearly appears to be dangerous for immunosuppressed patients, and we do not a lot of immunosuppression in the treatment of patients with cancer. Maximizing amount of care and caution is the right thing for us to do right now, but we are in the early stages of understanding this.

It is possible this is a seasonal virus that will settle into another part of the flu vaccine. I don't believe this is Severe Acute Respiratory Syndrome or Influenza A virus subtype H1N1, but it may be stronger than the current influenza that took 18,000 lives in the United States this year.

What gives me pause and makes me most concerned is that there is so much we don't know.

Brufsky: Clearly, someone with cancer who is immunocompromised, older individuals, or who has existing pulmonary problems [are at a higher risk of complications from COVID-19]. Specifically, patients with metastatic breast cancer who may have pulmonary problems from lung metastases are at higher risk.

What steps should physicians take to help combat the virus?

Enrique Soto Perez de Celis, MD, MSc

Soto: What is scary about COVID-19 is that it is unpredictable. For now, it is better to overreact a bit. Avoiding places where there are a lot of people, and following the recommendations made by the World Health Organization and the Centers for Disease Control and Prevention [are good strategies to minimize risk]. In the future, we will see more cases of COVID-19 in older patients with cancer; our patient population will be very affected by this.

Hurvitz: I'm telling my own patients who are on active immunosuppressive anti-cancer therapy or have active metastatic breast cancer that they should avoid traveling or going into large areas—and shaking hands and kissing people.

Some of my patients are churchgoers. I tell them to go to church, but don't kiss or hug everyone. [We need to] use good precautions with careful use of hand sanitizers and [frequent] handwashing. Using a mask is also not a bad idea. COVID-19 is a respiratory virus so it is possible that if somebody were to sneeze, who is close by to [an immunocompromised patient], that the patient would be exposed.

Sara A. Hurvitz, MD

Patients who have already been on therapy for their cancer and are not currently on chemotherapy, or other treatments that lower their white blood cell count, are not necessarily at a higher risk of developing [a severe infection related to] COVID-19 than other patients. However, it is important to talk to one's oncologist and primary care physician to gauge risk and what activities one should avoid based on age, comorbidities, and current medications.Brufsky: Going forward, it is very important to think about case ascertainment bias. The way we are detecting COVID-19 is from the individuals who present in the emergency room with shortness of breath, fever, and have pulmonary infiltrates on an X-ray. That is the clinical definition right now.

We don't have enough testing kits for everybody, so there are probably many asymptomatic patients not being tested. The more of these asymptomatic patients we identify, the more likely the death rate will [decrease]. Currently the rate is estimated between 1% and 3%, but potentially that could get down toward what the flu is.

As such, it is reasonable to restrict health professionals from congregating in large groups because nobody wants their patients to get sick. On the other hand, there has been case ascertainment bias. That is [being discussed] at a national level.

We just don't know right now, but I have a feeling that the death rate is going to be a lot lower than it is currently.

Tripathy: In this modern era, we have more tools for containment and real-time awareness. Information and responsible communication from leadership is critical.

Our ability to test people needs to be ramped up quickly so we know who is a carrier and who is not so that people can self-quarantine. We have the technology for that, but it is a matter of ramping that up.

We all have to be aware and adapt the [best] we can. It may be a life-changing event that changes how we conduct our meetings, but it is hard to say how it is going to play out.