CANCER – LIKE MANY other health issues – does not stop because a swiftly spreading coronavirus appeared late in 2019.
Fear of the Covid-19 virus and our overburdened healthcare systems have led to the delayed diagnosis and treatment of cancer with inevitable, unnecessary loss of life.
While the virus is still too new to draw conclusive evidence on its interactions with other illnesses, including breast cancer, much can be deducted from the readily available knowledge about the coronavirus infection pathways and the general influence cancer diagnostics and therapy have on infectious diseases.
Most infections occur when you are in close contact with an infected person and inhale tiny droplets of what they breathe out.
Recent guidelines emphasise that most of the diagnostics and care for breast cancer patients should be transferred to ‘non-hospital environments’, such as specialist breast health clinics to assist in reducing the negative impact on cancer diagnoses and treatments that is being globally observed.
In making the diagnosis of breast cancer, a biopsy is necessary. Biopsies can, in almost all cases, be guided by mammography or ultrasound in a practice setting, i.e. outside of a hospital environment.
Most international quality guidelines emphasise that in more than 90% of cases a diagnosis of breast cancer must be established before the patient is operated on.
Diagnostic services need to be available so that a prompt and accurate diagnosis can be provided.
Once the diagnosis is made, treatment consists of surgery, radiotherapy and systemic treatments: biologicals, hormonal and chemotherapy.
Concerning surgery, treatment is largely uninfluenced by the pandemic.
Outside of an active lung infection, during which a general anaesthetic would be hazardous no matter what the cause, surgery should proceed as planned as per normal indications.
There is a reluctance to be hospitalised for surgery due to a fear of infection, but this can be managed by opting for day procedures, where with adequate anaesthetic techniques, the patient could be sent home the same day.
Hospitals have been successfully following European protocols in separating and isolating suspected Covid-19 patients from other hospital patients, which minimises the risk of infection via surgery.
In some cases, it is possible to safely postpone surgery to a later date by providing hormonal treatment, which can halt or reverse tumour growth for six months to a year.
A concern that remains is the availability of healthcare resources.
Hospitals have had to prioritise the care of Covid-19 patients over patients suffering from virtually all other healthcare issues and, in many cases, have had to reallocate staff from theatres to assist with Covid-19 patients in wards.
This is also a side effect of staff shortages due to staff falling ill with Covid-19 or isolating due to exposure.
Radiotherapy is part of many treatment regimens and is thought to be minimally affected by the virus.
Radiation therapy for breast cancer does not majorly compromise immunity.
Although small parts of the lungs are irradiated, which is undesirable in a pandemic which attacks the lungs, careful planning of radiation fields can minimise lung irradiation.
Such higher planning skills are usually available in any breast-specialised radiation service.
Medical oncological therapy for breast cancer comes in the form of hormonal therapy, chemotherapy and biologicals. Hormonal therapy is thought not to alter immunity and therefore, only common coronavirus precautions need apply.
In contrast, some chemotherapeutic agents commonly used in treating breast cancer will decrease immunity to the virus and likely expose the patient to a heightened risk of infection and, if infected, may lead to more severe forms of Covid-19. As with hormonal therapy, there is neither theoretical reason nor data to suggest that targeted treatments for breast cancer, notably treatments targeting the HER2 receptor, will affect patients detrimentally in the case of a Covid-19 infection, and should therefore proceed unchanged, but considering the usual coronavirus safety precautions.
Due to the novelty of the virus and its disease manifestations, there is currently no data that allows for the concrete estimation of risks, and any such estimations are mostly based on extrapolations of longstanding clinical experience.
Breast cancer patients are advised to discuss the necessity of the treatment, treatment options and its benefits within the current coronavirus circumstances with their multidisciplinary treatment team.
And ultimately, not to delay with screenings or diagnoses out of fear of contracting Covid-19.
Remember that breast cancer is a highly curable disease if diagnosed early enough, so the long-term ramifications of delaying screening and diagnoses could result in one having to deal with a larger and more aggressive form of breast cancer down the line.
Cancer diagnosis and treatment can, and should, continue throughout this pandemic.
– Dr Justus Apffelstaedt is a specialist surgeon with an interest in breast, thyroid and parathyroid health, as well as soft-tissue surgical oncology, and is registered as a specialist with the Health Professions Council of South Africa.