Much has changed since the original shelter-in-place order was issued in California in March 2020:
- Telemedicine is now an established part of care.
- Medical centers have implemented safe practices for in-person visits and procedures.
- Sufficient personal protective equipment (PPE) is available.
- Facilities have put preparations in place to prevent being overwhelmed if there's a surge of COVID.
The question is, can we safely return to care, and is it important to take care of other health concerns? The answer is yes. Importantly, the options for managing cancer treatment have improved during the pandemic – that's the silver lining.
Cancer treatment and clinical trials
At the beginning of the pandemic, several oncology societies recommended beginning systemic treatment before surgery: Many treatment centers, including UCSF's, have done this for years to learn what works. It's a much better approach in most cases, because by starting treatments before surgery, we can learn which ones work best.
While a cancer diagnosis can feel like an emergency, it very rarely is. There's time to learn about the cancer type and consider all treatment options. There's often time to address any pressing issues that affect your health and well-being (for example, fertility preservation for women of childbearing age) or that of your family. Share concerns with your providers so you can find the right path forward.
Investigating options for clinical trials is also important, because clinical studies are how we explore new approaches to treatment. Some test new treatments in addition to standard care, while others cater to personalized treatments based on risk and response. Finding ways to improve outcomes for cancer patients is essential, regardless of COVID.
Essential support for cancer patients
Twenty-five years ago, little attention was paid to how hard it is for patients to take in information about their cancer diagnosis at first. Now, most comprehensive care programs care for patients in a place where they are fully supported, with families and friends present. When COVID-19 came along, however, patients were initially required to go to their appointments alone. Fortunately, that's no longer the case.
Still, active cancer patients and survivors do face extra challenges in the pandemic. For example, patients receiving immunosuppressive chemotherapy have worse outcomes if they contract COVID. This may intensify their sense of vulnerability and fears of recurrence.
Increasing virtual support is an important part of our COVID-19 response. The pandemic is not a reason to return to times when people faced their treatments or decisions alone. At UCSF, we've been recording consultations, providing notetakers and documenting patient questions for decades. Now, video visits offer a convenient way for family and friends to join.
When that's not enough, a caregiver or trusted notetaker can accompany patients during in-person appointments, treatment and surgery. We're learning to incorporate social support – an essential part of care – in new ways.
Protecting patients from COVID-19
Many patients ask what their risk is of getting COVID when they go in for screening or treatment, and whether it's safe to have other health conditions taken care of. It is safe, as long as recommended health precautions are taken. And, with those precautions in place, the benefits of finding a treatable cancer early are about 100 times greater than the risk of getting COVID-19.
With safeguards are in place, a patient's risk of contracting COVID and dying is about 1 in a million. However, certain situations can increase your risk, such as taking public transportation, the prevalence of COVID-19 in your area, and the behavior of people in your community. If local COVID rates are high and you don't wear a mask, it might not make sense to come in.
Screening for other diseases
For the time being, having the SARS-CoV2 virus in our community at some level is the "new normal," and we continue to grapple with the question of how frequently to screen for COVID-19. That said, it's very important to return to screening for other diseases.
Why? Because they also pose a serious threat: More than 40,000 women die every year from breast cancer despite all that we're doing. We must continue to work hard and improve options for treatment, screening and prevention.
The national WISDOM study
The national WISDOM (Women Informed to Screen Depending on Measures of Risk) study, started by experts across the University of California, focuses on whether screening for breast cancer should be tailored based on personal risk.
Fortunately, participation in WISDOM (wisdomstudy.org) is virtual. No visit is required, making it extremely safe and beneficial. We hope every woman who has not had cancer will visit our website and join us in creating a new and improved approach to breast cancer screening and prevention.
New clinical trials for promising treatments
The future will be brighter. Our entire scientific enterprise is focused on efforts to create better tests, better treatments and a vaccine for COVID-19.
In addition, it's important to reduce the chance of dying in people who have a severe reaction to the virus. To improve their chances of survival and recovery time, efficient new clinical trials called "platform trials" are testing promising treatments for severe cases.
Trials that are making it faster to get targeted therapies approved for high-risk early stage breast cancer (I-SPY 2) have been used as the basis for creating an I-SPY COVID trial for critically ill patients. As an added bonus, we may also find treatments for acute respiratory distress syndrome (ARDS). The answers will come from a relentless commitment to research in the clinical care setting.
Conclusions and statistics
Ultimately, the benefits of breast cancer screening and treatment far outweigh the risks of COVID-19 infection when public health measures are followed (wear a mask!). It's essential to enable loved ones to participate, to give cancer patients the social support they need to make informed decisions and have the best possible outcomes.
The increased availability of effective remote visits for care, research studies and support groups is a silver lining to the pandemic. And finally, clinical trials should continue, as they play an essential role in improving cancer care.
Some estimates** to help assure you that it's not only safe, but important for your health to keep up with regular screenings. This data assumes you are following the standard safety protocols and wearing a mask.
Table 1: The chance of finding cancer through screening depends on your age.
|Chance of getting COVID vs. finding an early cancer with screening|
|Age||Cancers detected per 100,000 women
||Chance of getting COVID (per 100,000 women) if you go to get a mammogram*|
*This estimate is based on a 1% prevalence of SAR Co-V2 infection in the population in your area. You can adjust for the area you live in. For example, if f the rate of infection is 5%, you multiply by 5 and the right-hand column will be 5.
Table 2: The chance of dying of COVID also depends on your age, but if you go in for a treatment (e.g., about 10 times), your chance is about 1 in a million if you wear a mask and take other precautions. The chance your life will be saved by undergoing cancer treatment is 10 to 100,000 times higher.
| Chance of dying if you skip cancer treatment vs. dying of COVID
|Age||Lives saved with cancer treatment (for a population of 1 million women with cancer)||Chance of dying of COVID if you go in for treatment (in a population of 1 million women)*|
*This estimate is based on a 1% prevalence of SAR Co-V2 infection in the population in your area. You can adjust for the area you live in. For example, if the rate of infection is 5%, you multiply by 5 and the right-hand column will be 5 times higher, but still far below the benefit of getting treatment.
** Here's the math behind the estimate. The calculation for the risk of getting COVID-19 is based on these variables:
- How many people would have prolonged contact with you if you came in for screening and care.
- In a setting of masks and precautions, the chance of contact is cut 10 fold.
- Probability that anyone you come in contact with is infected. = 0.006 This includes the 1% prevalence for the SF Bay Area, and the chance that an asymptomatic person would have it is 60%.
- The formula is 1-( 0.99 to nth power where n is the number of people you’re in close contact with) x 0.006 x 0.1 (efficacy rate of masks).
- If, on a given visit, you come into contact with 5 people: [0.049] x [0.006] x [0.1] = 3 per 100,000 chance.
- For a cancer treatment, you might come into contact with 5 people and have up to 10 visits.The chance of dying of COVID if you're infected with the virus is 1% for someone in their 40s and 5% for someone 65 or older: [0.049] x [0.006] x [0.1] x [0.01] x 10 = 3 per million.