How Has COVID-19 Affected Metastatic Breast Cancer Treatment Decisions?

Victoria Stern, MA

Disclosures

February 26, 2021

Patients with metastatic breast cancer (MBC) face an elevated risk of severe illness or dying from COVID-19. Given the slow rollout of the Moderna and Pfizer COVID vaccines and new, more infectious viral variants circulating in the United States, oncologists will face a challenging balancing act for the foreseeable future: sustaining patients' MBC care while safeguarding them from COVID. The scale leans heavily toward continuing treatment, experts say.

"If we stop treatment for metastatic breast cancer, death will occur quickly," Fatima F. Cardoso, MD, director of the breast unit at Champalimaud Clinical Centre in Lisbon, Portugal, stated this past August in a Medscape perspective.

Joanne Mortimer, MD, director of Women's Cancer Programs at City of Hope, a comprehensive cancer center near Los Angeles, expressed a similar sentiment. "Having MBC is worse than getting COVID," she told Medscape. "We can't stop treating patients with MBC because of concerns of exposure."

But maintaining treatment does not mean business as usual. Oncologists have had to modify their pre-pandemic practices to some degree, and that degree largely depends on local COVID conditions.

"Weighing the risk of treatment with the risk of contracting the virus means that many places have carried on treating metastatic breast cancer in a more thoughtful, careful way," said Jill Dietz, MD, president of the American Society of Breast Surgeons. "That means focusing on high-value treatments for patients with the goal of maximizing their outcomes and quality of life while limiting in-person visits and potentially unnecessary elements of care."

To guide this more careful approach, Dietz and colleagues from the recently formed COVID-19 Pandemic Breast Cancer Consortium published recommendations in April 2020 to account for different disease types and severities. These recommendations align closely with those from Cardoso and colleagues in Europe, also published last April.

Although issued early in the pandemic when there was greater uncertainty about viral transmission, adverse outcomes, and treatment for COVID-19, these recommendations still hold almost a year later.

"The framework has proven to be timeless in that it can help institutions where they are in the pandemic," Dietz said.

The Recommendations at Play

For MBC, in particular, Dietz and colleagues focused on patients who need systemic care but whose treatment can be modified to keep them home more. The modifications include prescribing oral agents such as capecitabine, vinorelbine, and cyclophosphamide to minimize visits to the hospital or infusion suite.

To limit adverse events associated with these oral drugs, Dietz and colleagues also recommended reducing the dose when possible. For instance, research shows that lowering the dose of the CDK4/6 inhibitor palbociclib in patients with HR+/HER2-negative MBC does not diminish efficacy.

When oral agents are not an option, Dietz and colleagues suggested stretching out the intervals for chemotherapy infusions or injections. Data show that trastuzumab and pertuzumab injections for metastatic HER2-positive tumors "may reasonably be administered at longer intervals," such as 4 weeks instead of 3 weeks.

The extent to which oncologists have applied these recommendations hinges on two factors: the local severity of COVID-19 cases and institution-specific policies.

For some oncologists, the pandemic has largely left treatment decisions untouched. "COVID-19 has only minimally impacted my practice," said Rita Nanda, MD, director of the Breast Oncology Program and associate professor of medicine at University of Chicago Medicine.

Nanda recalled her concerns in the early days of the pandemic. As the nation watched COVID cases surge across New York City, Chicagoans prepared for the worst, fashioning the McCormick Place Convention Center into a field hospital for COVID patients.

"But fortunately, we were never overwhelmed at the University of Chicago and never needed to use the Convention Center," Nanda said. "We did not have to alter or limit the type of therapy patients with MBC could receive."

The main changes described by Nanda at the University of Chicago have centered around limiting the flow of traffic within the infusion suite or hospital by implementing prescreening checks to catch patients with COVID symptoms, keeping waiting rooms empty and infusion centers socially distanced, and having patients come in for appointments solo. The University's home phlebotomy service also came in handy. Implemented before the pandemic, this service allowed patients with MBC to get their labs done at home before coming in for treatment.

"Overall, with social distancing, mask wearing, and limiting who comes in to the clinic, we have been able to keep patients and staff safe without altering treatment-specific decisions," Nanda said.

Streamlining the foot traffic in the cancer center also worked well for Lisa A. Carey, MD, chief of the Division of Hematology/Oncology and deputy director of clinical sciences at University of North Carolina-Chapel Hill. "The truth is, oncological principles of care are still in place," said Carey, the Richardson and Marilyn Jacobs Preyer Distinguished Professor in Breast Cancer Research. "COVID hasn't altered those; it has only thrown a little wrench in how we deliver that care."

Kelly McCann, MD, PhD, a hematologist/oncologist in the Department of Medicine at the David Geffen School of Medicine, University of California, Los Angeles, has had to walk a tighter rope to protect her patients with MBC, as COVID cases began to soar in LA county last fall.

To keep patients with MBC home more, McCann said many chose oral cytotoxic chemotherapies over infusional therapies. Some patients with HER2-positive MBC, for instance, opted for the oral combination neratinib + capecitabine over a trastuzumab-deruxtecan infusion, and others with triple-negative tumors chose capecitabine over a taxane.

At City of Hope, Mortimer has had a different experience of LA county's COVID surge. Because the center only treats patients with cancer, "we have not had huge numbers of patients with COVID or had to significantly modify our practice outside of screening patients who come in and doing fewer scans compared to pre-COVID," she said. With these precautions, "we have had no internal transmission of COVID within our institution."

Still, patients with MBC have gotten COVID, and treating both illnesses does complicate decision-making. In some cases, Mortimer has postponed cancer treatment for patients who can delay for a few weeks while they recover from COVID. But patients who need to continue MBC treatment receive care in a separate unit, and Mortimer considers prescribing Eli Lilly's recently approved antibody therapy bamlanivimab to treat COVID symptoms. "For each situation, we can always page our infectious disease experts to address any concerns or questions," Mortimer said.

The MBC and COVID Toll

The biggest hurdle for patients with MBC has been less about treatment decisions and more about handling the psychological toll of the pandemic, according to Charles Shapiro, MD, medical oncologist, Icahn School of Medicine at Mount Sinai in New York City.

"These are my personal observations, but I've seen how much more stressful it is to have metastatic breast cancer during the pandemic," said Shapiro, who worries that fear of COVID may fuel or exacerbate patients' depression and anxiety. "Patients can't have family and friends by their side during infusions or appointments, and many feel isolated because of the risk of exposure."

Because most patients with MBC still need in-person care such as exams, blood draws, or chemotherapy infusions, McCann has found that many of her patients "are afraid to come to a medical center and have been delaying appointments, imaging, and procedures."

The psychological toll of treating breast cancer during the pandemic has touched oncologists as well. A recent survey found that burnout scores were significantly higher among physicians whose patients experienced delays in care, including chemotherapy or specialty consultations.

Getting patients vaccinated will improve protection and hopefully lessen fears surrounding COVID infection and transmission. Preliminary recommendations from the National Comprehensive Cancer Network's COVID-19 Vaccination Advisory Committee state that patients with cancer "should be prioritized for vaccination."

McCann agreed. "I've recommended COVID-19 vaccination to all of my patients with MBC," she said. But because a lot of these therapies suppress the immune system to some degree, "I'll recommend a period of time for vaccination in which the immune system is expected to have recovered, such as in the days prior to a dose of chemotherapy."

Overall, according to Carey, institutional responses to treating MBC during the pandemic have been very similar: The key has been that "no one is keeping secrets," she said. "Our global oncology community is sharing and adopting best practices. Our focus has been doing right by our patients."

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