After reading our previous blog post about Covid-19’s impact on breast cancer, many of you sent in your own questions for Professor Ian Smith to answer. You can read Professor Ian’s replies to the questions below.

Q: Can you please explain how there has been an improvement in cure rates for people with breast cancer over the last few decades?

A: The improvement in cure rates mainly refers to early breast cancer. It has come about largely because of the use of what we call adjuvant medical therapies. These are given after surgery ( or in certain circumstances before surgery in which case it is called neoadjuvant therapy). The type of medical treatment depends on the subtype of breast cancer and could be endocrine therapy (sometimes called hormone therapy), chemotherapy or sometimes antibody treatment with a drug called trastuzumab (Herceptin). Sometimes a combination of these options is required. The idea is to mop up hidden microscopic cancer cells (micrometastases) that have escaped through the bloodstream to other parts of the body before surgery.

There has also been an improvement in survival for secondary or metastatic breast cancer, because of a whole series of new drugs which have become available over the years. And we are beginning to think that a few of these patients may also be cured. This is a big topic and I’ll deal with it in a blog. 

 

Q: During this crisis, the Denosumab injections I was receiving as part of my breast cancer treatment have been stopped but other parts of my treatment (palbociclib and letrozole) have continued. I have concerns about the long term implications of not having Denosumab.

I am also extremely concerned about how long the clinically vulnerable will be asked to shield. I’ve been very anxious the few times I’ve needed to leave the house and with consults being done remotely, I fear that isolation and associated psychological issues will become a very real problem. Are these issues being taken into consideration?

A: This is a very common worry at present. When the Covid-19 crisis broke, One and a half million people received the same ‘clinically vulnerable’ message without any selectivity and it caused a great deal of anxiety. Having active cancer is indeed associated with some increased risk of having serious Covid-19 complications. We don’t have specific data yet for patients on palbociclib but in my estimate this increased risk is only moderate rather than severe. And the incidence of the disease is in itself now fortunately falling. So I think it would be reasonable for you to start to get out and about as the general lockdown lifts, go for walks, meet friends and family when it becomes allowed, but be cautious and sensible. I do not think you need to continue to cut yourself off entirely.

 

With regard to denosumab, this should be started again soon (the Covid crisis in hospitals has passed), and I doubt very much whether any harm has been done by the delay in receiving this. Some patients are being taught to self administer this.

 

Q: I had breast cancer 4 years ago and have been well since finishing chemotherapy and do not take any medication relating to the cancer. As I understand, I am not classed as vulnerable but I would appreciate clarification and any other advice/information you could give.

A: Having cancer is a risk factor for getting serious complications from Covid-19, and this has understandably caused some concern for people like yourself. But you do not have active cancer, you have been free of it for 4 years. So I agree that you should not be classed as vulnerable.

 

Q: My chemotherapy for breast cancer started in January and I am on my 3rd (and final) round of Docetaxel 148 mg (dose reduced due to Covid-19). Also due to Covid-19 I have had a break in my treatment of 3 weeks (all cancer treatment was stopped). During this time I was given Letrozole for a period of 2 weeks. When treatment restarted I was given Docetaxel 148 mg (a reduced dose due to the effect on my immune system and the prevalence of Covid-19). I am due to have 1 week of radiotherapy (instead of 3 weeks) soon and then recommencing the Letrozole for 10 years.

What will the long term effect be on the re-occurrence of the cancer due to the reduced treatment? What follow up should I be expecting after the completion of the radiotherapy? Due to reduced doses of medication should I be having any extra treatment at any time?

A: I think the decision to reduce your dose of docetaxel was a sensible one in the circumstances, and I doubt very much that it will adversely affect your long term outcome. Personally, I think that we sometimes push the doses of these drugs higher than necessary anyway. The 3 week delay was covered by letrozole, also very sensible. And a recent large trial has shown that for many patients, 1 week of radiotherapy (with a bigger dose per fraction than in the past) is as effective as 3 weeks with smaller doses. So no problem there either. 

 

If you have any queries or comments please email the team at Breast Cancer Haven and I will answer these in my next blog.

 

Ian E Smith

Professor of Cancer Medicine

Royal Marsden Hospital and Institute of Cancer Research, Londo