Hello again. Fortunately many fewer people now have Covid 19 than when I wrote my first blog post, but this still remains a big challenge for us all, and I want to talk about the specific issues this raises for people with breast cancer.

Am I at high risk because of my breast cancer?
When Covid 19 first arrived in the UK, one and a half million people who were considered to be at high risk received a letter advising them to take extra precautions including staying at home at all times and shielding themselves from other members of family or anyone else living at home with them.

This may have included you. Certainly large numbers of people with breast cancer received this letter, whether or not they were on treatment at the time. This has understandably caused widespread uncertainty and anxiety.

I am frequently being asked ‘do I have to remain in lockdown indefinitely even after it stops for everyone else?’, or ‘am I really at a big risk of getting seriously ill from this virus?’, or sometimes ‘my outlook from my breast cancer is uncertain, I want to make every minute count, and I am so upset that I can’t see my children, my grandchildren, my close friends with no end in sight’.

So let’s try to sort this out.

The background

A diagnosis of cancer was reported early on as one of the high risk factors for serious complications from Covid 19. But of course cancer covers a huge range of conditions. There are many different types, different stages from early to advanced, and many different treatments, some intensive and likely to suppress immunity, and others mild. And then there is a big distinction between patients with active cancer on treatment, and those in remission and hopefully cured.

Most of the hard data on this so far come from China following their big initial outbreak. They reported that patients with cancer tended to have more severe Covid 19 symptoms and to do less well than those without. But the number of patients in their early studies was small, and they often had advanced so-called Stage 4 (metastatic or secondary)disease. Furthermore lung cancer seemed to be the commonest type in their reports, and it’s easy to see that this could make Covid 19 a lot worse.

Breast cancer in remission

So how about breast cancer? Well, the first thing to say is that if you have had breast cancer in the past and are currently in remission, there is no good evidence that you are at increased risk from Covid 19. This remains true even if you are on what we call adjuvant endocrine (hormone) therapy with for example tamoxifen, letrozole or anastrozole, which is usually continued for several years. It also includes if you are on adjuvant antibody therapy with Herceptin (trastuzumab) for so called HER2-positve disease, which can go on for a year.

So for the many thousands of you in this category my advice is that you do not need to lock yourself away. Take care obviously, wash your hands regularly, keep social distancing and avoid large crowds. But within that framework, I believe it’s good for you to get out of the house, enjoy the summer weather, take regular exercise and generally follow the guidelines for the general population.

Breast cancer: early disease

Most patients who develop breast cancer are treated first with surgery and sometimes also radiotherapy. Initially there was the suggestion that surgery increased the risk of serious Covid 19 complications. And as you will have read or heard in the media, there has been a large drop off in breast cancer referrals, partly because of this. This shouldn’t be happening. Breast cancer surgery is usually relatively easy for the patient in that it doesn’t involve a major surgical procedure like going into the chest or abdomen, and there is no good evidence that it puts you at increased virus risk (providing of course you have a negative test for Covid and you don’t have other comorbidities). In addition to this, NHS Trusts have created Covid 19 free hubs for cancer surgery and other treatments locally.

The same is true for radiotherapy. My colleagues who specialise in this treatment say this doesn’t seem to put patients at increased risk of serious Covid complications. And this is because radiotherapy like surgery is targeted at the breast, and sometimes-adjacent nodes, without the kind of risk associated with treatment to deeper sites in the body.

Some patients with early breast cancer require chemotherapy given for a few months after surgery. Unlike with endocrine therapy, some types of chemotherapy can be quite immunosuppressive in the short term. So if you are on this treatment, or have recently had it, you have to be very cautious. But even here I don’t think it’s necessary to be completely locked away. It’s reasonable, and likely to be good for you, to go outside for some fresh air daily, providing you use your common sense, scrupulously stick to social distancing and keep washing your hands.

Breast cancer: recurrent disease

If you have recurrent disease then this also requires more caution, but with the exception of some types of chemotherapy most of our treatments are not particularly immune-suppressive. Many patients with this type of disease are treated with endocrine therapy, as discussed above. Nowadays, many are also on so-called CD4/6 inhibitors including palbociclib, ribociclib or abemociclib. These drugs have been a big breakthrough in treatment and merit a blog of their own soon. They are usually safe and well tolerated. Some including the widely used palbociclib do suppress neutrophils, a type of white cell that specifically fights bacterial infection. These are new drugs and we are still studying whether they might increase the risk from Covid, but so far there is no strong evidence that they do. So my current advice for patients on a CD4/6 inhibitor is similar to that for those in remission. I do not think you need to lock yourself away. Get out of the house, enjoy a walk or a cycle, but remain very cautious and stick closely like everyone else to current guidelines.

So I hope this has provided some reassurance. Bear in mind that what I’ve said only applies if you who are otherwise healthy and do not have any of the co-morbidities which predispose serious Covid complications.

Stay safe and let’s hope for a continuing rapid decline in this horrible infection.

Ian E Smith
Professor of Cancer Medicine
Royal Marsden Hospital and Institute of Cancer Research, London

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