By Dr. Katie Deming, Radiation Oncologist
Statistics and Data updated on April 2, 2020
If radiation is part of your breast cancer treatment and scheduled to start soon, you may be considering a delay in therapy due to COVID-19. In the past week, I have spent most of my time counseling patients about the pros and cons of delaying radiation vs. moving forward with treatment as planned. The issues are complex, and there is not a one-size-fits-all answer. But, like many radiation oncologists, I am using the available evidence to guide my patients. I wanted to share answers to the questions that keep coming up with my patients. I hope that this information will be helpful as you make decisions in your care.
1. Risk of Recurrence:
The first question most patients ask is, "Will a delay in treatment increase my risk of recurrence?" The answer to this question depends on the features of your breast cancer and the stage. The typical time between surgery and radiation is six weeks. For small (<2cm) tumors with no lymph node involvement, studies show that a delay in radiotherapy of up to twenty weeks after surgery results in no increased risk of recurrence. So, many radiation oncologists will support a delay in the treatment of up to twenty weeks in this setting. However, if your tumor is larger than 2cm, triple-negative, Her2Neu positive, or lymph node-positive, your doctor may recommend proceeding with RT sooner. The timeliness of radiation may be more critical in tumors with these features. It is essential to discuss the pros/cons of delay with your doctor. If you are having radiation directly after chemotherapy, the typical time between chemotherapy and radiation is four to six weeks. It may be possible to have a slightly longer interval between chemotherapy and radiation. Although this decision will depend on multiple factors and is one that will be determined by your team.
2. Alternative Treatments During Delay:
The next question most patients have is, "Are there alternative therapies available while I wait for radiation?" If your tumor is estrogen positive, the answer is "yes." Your medical oncologist may start you on anti-estrogen therapy during the delay. If your tumor is Her2Neu positive, you will likely be on anti-Her2Neu therapy for one year anyway. So you will be on this therapy while you wait for radiation. For triple-negative tumors, you will likely receive chemotherapy before radiotherapy. If you have a delay between chemotherapy and radiotherapy, the options for additional therapy are minimal. It will be necessary to discuss options with your care team.
3. Immune Status During Radiation:
Many patients ask, "Is my immune system compromised during radiation?" Radiation does not lower your blood counts and is not considered immunosuppressive. Although it is important to note that radiation does cause stress on the body, which can impact your immune system. During radiotherapy, your body expends more energy on DNA repair, and this may affect immune function. The best way to bolster your immune system during radiation is to eat well, sleep at least 8 hours per night (and more if you feel tired), and exercise. If you had chemotherapy before radiation, you would have immunosuppression from chemotherapy. Blood counts typically recover by four weeks after chemotherapy. It is essential to ask your medical oncologist how long he or she expects immune compromise after chemotherapy.
4. Risk of COVID-19 Infection:
Another question I hear is, "What will happen if I get COVID-19? What is the likelihood of critical illness or death?" The Report of the WHO-China Joint Mission on Corona Virus Disease published Feb 28, 2020, indicates that the mortality rate of COVID-19 in patients with cancer is 7.6%. This rate is higher than the mortality rates seen for COVID-19 in otherwise healthy individuals (listed below). Note, the 7.6% risk also is not specific to breast cancer nor the type of treatment a patient may be receiving. If you are immunocompromised from chemotherapy, your risk may be higher. Please note, these numbers are changing rapidly and are accurate as of April 2nd, 2020 from CDC statistics.
Risk of Death from COVID-19 by Age:
20 - 44 Years: <1% mortality
45 - 54 Years:, <1% mortality
55 - 64 Years: 1-3% mortality
65 - 84 Years: 3-11% mortality
85 Years & older: 10-27% mortality
5. COVID-19 Peak and Duration:
You may be asking, "How long will COVID last?" Nobody knows precisely how long the COVID-19 pandemic will last, but many experts predict months, not weeks. The surge of COVID-19 infection is just starting in the US. Initially, it was projected that the U.S. peak would occur in mid-April. Social distancing efforts are working but have been implemented variably by each state. For this reason, the timing of the peak depends on your location. Check out this site to track the peak in your state. Some of my patients have asked, "Shouldn't I have treatment now while the infection rate is low? Wouldn't it be worse to wait since we know this pandemic may last months?" The low infection rate is likely due to a lack of testing and a long incubation period of the virus (7-21 days). Yes, infection rates are indeed rising. But, as testing becomes more available, we will better understand the true incidence of infection and how to keep you safe. So, if a delay in radiation is considered safe by your doctor, waiting may make sense.
6. Social Irresponsibility:
One last question that surprised me was, "Is it socially irresponsible to come in for radiation treatment during COVID-19?" As my patient explained her concerns, I realized that there is so much pressure to make sure we practice social distancing. She was worried it would be wrong to break this practice to come in for treatment. As an oncologist, I firmly believe it is NOT irresponsible to come in for your cancer treatment. You should not feel bad for one minute about getting the medical care you need. If you and your doctor have decided you should receive treatment, please don't let this be a concern. Social distancing is for non-essential activities. Cancer treatment is essential to your health and wellbeing.
My goal is to provide information that is accurate and helpful to you during this challenging time. I will continue to blog as the COVID-19 situation progresses. Please feel free to contact us if you would like questions answered in future posts. I wish you the best. Please stay safe.
For the latest info, including more detailed responses to some common questions, please visit the following websites.
Centers for Disease Control (CDC)
World Health Organization (WHO)