Learning from a pandemic: are new breast cancer strategies here to stay?

In the second part of our brand new Q&A series, we spoke with Anne Peled, MD, Co-Director of the Sutter Health CPMC Breast Cancer Program, and Michael Alvarado, MD, Professor of Surgery and Director of Breast Surgery Fellowship at UCSF – both based in San Francisco, California.

At the time of recording, California has been one of the US states that has been worst-hit by COVID-19 with over 150,000 cases by mid-June.

We discussed how Dr Peled and Dr Alvarado's breast units are reacting, evolving and learning during this pandemic, the return of reconstructive surgery and the advice they have for patients concerned about visiting their centers for cancer screening and treatment.

A new look for breast surgery

Soon after the pandemic began, both Anne and Michael made major adaptations. At Michael’s surgery, that meant screening all visitors with a rigorous set of questions.

Facemasks became mandatory overnight. Appointments were spaced out, and staff worked longer hours. The number of people going in and out of the surgery was limited. For Michael, this was the hardest part - patients couldn’t hold a loved one’s hand, when they needed it most.

Anne’s surgery made similar changes and explained how she’s been humbled and amazed by the response from her patients. She’s received emails explaining how pleased they were about the precautions being taken and has found that in waiting rooms, they were completely respectful of the changes and each other. Most importantly, while at the surgery, people feel completely safe.

“I have to say it’s pretty remarkable how quickly these systems have been developed and implemented. In many ways our hospital is actually much safer than it would typically be.”Anne Peled, MD Sutter Health CPMC Breast Cancer Program

A rise in ‘scanxiety’

Of course, there have been some struggles. While most breast surgery has continued as normal, some reconstructions had been delayed, while some patients with lower-risk disease had also chosen to hold off treatment.

However, there is now a feeling that services are slowly returning to some form of normality.

Now we’re primarily over a lot of issues from COVID-19,” Dr Peled explains.

“For many of my patients having that second stage reconstruction, that really feels like they’ve completed their journey. It feels so fortunate that now we have the testing, we have the systems in place to allow these people to safely come in for these secondary and prophylactic surgeries.”Anne Peled, MD Sutter Health CPMC Breast Cancer Program

While doors have begun to reopen, the battle isn’t yet over. After months of staying at home, there has been a noticeable rise in ‘scanxiety’ – a phrase coined by Dr Peled to describe the fear and reluctance patients are experienced towards visiting for screening.

The key to overcoming scan-anxiety, she said, is clearly communicating the precautions that have been taken.

Finding silver linings

Despite everything Michael and Anne believe there have been “some silver linings to this whole craziness”.

For example, Dr Peled has found there is a lot you can get done in a telehealth consultation alone - in fact, seeing patients virtually can be far more efficient. For patients that live far away, everything can be planned and prepared in advance of when they come into the surgery.

“The concept of being able to plan everything for a patient, before they actually come to hospital, is going to be more efficient and more comfortable for the patients.”Michael Alvarado, MD University of California, San Francisco

The future of breast cancer care

COVID-19 has challenged surgeons on how to limit patient visits. For Michael, inter-operative radiation therapy (IORT) has proven a popular procedure, and it can save a patient coming in every day for three weeks. In this procedure, the patient undergoes a lumpectomy on the same day as a one-time dose of radiation, a more efficient and equally as effective approach.

As the conversation drew to a close, Michael explained that his practice is also working to reduce time spent by patients and surgeons in theatre, and told us how the Magtrace® lymphatic tracer has been a great tool for tackling this.

By injecting the tracer as a mapping agent for the sentinel node, surgeons can save time looking for the node during surgery, a process popularized in Andreas Karakatsanis’ SentiNOT study. This is particularly important as on average 80% of patients can be spared a sentinel lymph node biopsy (SLNB) that they do not need.

“It’s a really great way to limit the amount of time a patient is in the operative theatre.”Michael Alvarado, MD University of California, San Francisco