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FAQs on Cancer and COVID-19

By Dan Veljovich, MD

Dr. Dan Veljovich is a Gynecological Oncologist with Swedish Cancer Institute. Dr. Veljovich is also a member of the Rivkin Center Board of Directors. Questions were submitted by members of the Rivkin Center patient and survivor community.

The ongoing COVID-19 pandemic has created a lot of worry and questions from our cancer patient and survivor community. Below I have addressed some frequently asked questions on how to best manage cancer care during the outbreak. Please note that these are general guidelines and you should consult your personal healthcare provider for questions specific to you.

What are some tips for managing exposure and risks for going into busy medical facilities for regular chemotherapy treatments and appointments?

In general, the most important strategy to avoid exposure to COVID-19 for patients either in cancer surveillance or active cancer treatment is to AVOID HEALTH CARE FACILITIES. Unless absolutely necessary, cancer patients should minimize contact points with the health care system as much as possible, including not going into their physicians’ offices unless a physical exam is needed.  In our practice, a few guidelines are as follows:

  • TELEHEALTH visits are being utilized for ALL standard pre-chemotherapy visits, with laboratory results and imaging study results reviewed with the patient on a virtual visit using FaceTime, Google Duo, or Zoom so as to avoid the patient making any contact with an outpatient office. This minimizes exposure both to the patient and provider.
  • Liberal hand washing as often as possible, minimization of any hand-to-face contact, and maintaining appropriate social distancing even in the doctor’s office to the extent possible.
  • NO PHYSICAL EXAMINATION unless imperative to do so, as this is yet another contact point in the system.
  • Ensuring that white blood cell, absolute neutrophil, and lymphocyte counts are appropriate before proceeding with chemotherapy or immunotherapy or biological therapy.
  • Avoiding doctor visits for surveillance until after the pandemic has blown through Seattle/King County, with emphasis on tumor markers and imaging as needed, but again avoiding doctor visits.
  • Avoiding contact with ANY health care facility to the extent possible during the surge of coronavirus, which is difficult to predict at this time.

What do patients who have low white cell/neutrophils need to watch for to monitor for infection?

The most important symptoms to report immediately are FEVER, SHORTNESS OF BREATH, or COUGH. In an immunocompromised patient with a low absolute neutrophil count, these symptoms should be reported immediately to their physician and currently the most common course of action would be to NOT go to the oncologist’s office so as to avoid potential spread to other oncology patients, but to contact her primary care physician and have testing done at one of the mobile testing centers. The idea is to keep patients who have COVID-19 out of the hospital and office setting and remain quarantined at home if not ill, but a primary care physician should make the final decision about whether the patient should be seen in a medical facility for evaluation.

Do patients who are currently in chemotherapy treatment but have normal white counts and neutrophils need to take special precautions beyond the current guidelines in place for the general population? 

Patients undergoing any form of anti-cancer therapy are by definition more immunocompromised relative to the general population and therefore should be ultra-vigilant regarding the usual precautions utilized by the general population, including frequent hand washing with soap and hot water for 20 seconds at a time, minimizing contact with others (avoiding any public store or setting to the extent possible), practicing the 6 foot rule, and immediately reporting any symptoms consistent with coronavirus. LYMPHOCYTES typically fight viral infections and patients with normal absolute neutrophil counts can have lymphopenia which put them at increased risk of viral infection. Again, only having touch points in the medical system for infusion appointments and pre-chemotherapy labs is advisable (i.e. NOT seeing your doctor in an outpatient setting and using telehealth visits instead).

How should patients in remission handle regular oncology checkups and/or their oncology health in general if their oncologist’s office is not seeing low risk patients and/or the labs are not taking low risk people because of COVID-19?  

Delay surveillance visits until AFTER the pandemic as cited above. The risk of a surveillance visit at this time is higher than any benefit and unless patients have symptoms that are worrisome for recurrence I would recommend avoiding the doctor’s office. Most labs are still operational so tumor marker studies can still be done.

Are the risks for someone in remission any greater than they were before they had cancer?

Typically patients who have completed therapy more than 3 months ago with normal lab counts and have no significant increased risk. However, the most significant risk factors for COVID-19 infection in the general population are increasing age (generally greater than 65 years old), multiple co-morbidities (i.e. hypertension, diabetes, cardiac disease), and any underlying pulmonary disease, including a history of asthma, smoking or COPD. Given that many cancer patients are older and have multiple co-morbid medical conditions, these factors generally put cancer patients at higher risk even in those women who have completed therapy and are not classically immunocompromised secondary to low white blood cell counts.

Talk to your Family

Talking to your family and identifying cancer in your family tree can be a good indicator of your health risks. Download our Family Tree Worksheet here.  Be sure to include yourself, children, parents, siblings, aunts, uncles, and grandparents.

Get Educated

Know your body and be proactive about your health. Learn about your breast and ovarian health. Learn about the risk factors and signs & symptoms for breast and ovarian cancer.

Trusted Healthcare Provider

Having a relationship with a health care provider you know and trust is one of the most important decisions you’ll make about your health care. Click here to find a provider

Higher Risk in the Ashkenazi Jewish Population

In the general population, around 1 in 400 people carry a BRCA1 or BRCA2 mutation. People of Ashkenazi Jewish ancestry have a 1 in 40 chance of carrying a BRCA mutation, making them 10 times as likely to carry a BRCA mutation as someone in the general population. Whether you’re a man or a woman, if you have a BRCA mutation then there is a 50% chance of passing the mutation on to your children, whether they are boys or girls. It’s important to note that these mutations significantly increase risk, but are not a guarantee a person will get cancer.

Why is the Ashkenazi Jewish population at higher risk?

Over 90% of the BRCA mutations found in the Jewish community are one of three “founder mutations”. A founder mutation is a specific gene mutation in a population that was founded by a small group of ancestors that were geographically or culturally isolated. Because the population was isolated, the rate of founder mutations in descendants is much higher than it would be if the population were larger and co-mingling with more genetically diverse populations. A large expansion in the population caused the current high frequency of the mutations in the Ashkenazi Jewish population. If you are of Ashkenazi Jewish ancestry, the chance of carrying a BRCA gene mutation compared to the general population is increased tenfold. BRCA mutations can be passed down from either your mother’s or father’s side, and may be associated with any of the following cancers:
  • Breast cancer
  • Ovarian cancer, fallopian tube, peritoneal cancer
  • Male breast cancer
  • Prostate cancer
  • Pancreatic cancer
  • Colon Cancer

Ready to take action? Knowledge is power. Take this short quiz to be proactive about your health.

Genes 101

Our bodies are made of many tiny building blocks called cells. Our cells contain a copy of our genome – all of the DNA genetic code we inherited from our parents. Our genome is organized into 46 chromosomes, 23 inherited from mom and 23 from dad. Each chromosome has hundreds or thousands of genes. Each gene has the instructions to make a protein that may control the structure or function of cells, can determine many things including how tall we are or the color of our eyes. Genes also contain instructions for many things inside of us that we cannot see, such as how our bones are formed or how our heart works. Each gene is made up of molecules called nucleic acids (A, T, C, and G). The specific sequence of the nucleic acids holds the instructions that control all the components and their functions in cells.

If the DNA sequence is changed, like a spelling mistake, the instructions may not make sense. The technical term for this change is “mutation,” meaning there is a change to the usual genetic code that may change the instructions stored in the gene. A mutation in a gene that repairs DNA damage or controls cell growth can increase the risk of developing cancer.

Sporadic vs Hereditary Cancers:

Ovarian and breast cancer can be either sporadic or hereditary. Sporadic cancers make up the vast majority (85-90%) of ovarian and breast cancers and are not associated with family history of either cancer or inherited cancer-associated mutations. Sporadic cancers arise from genetic mutations acquired in some cells of the body by events part of normal metabolism and environmental factors. This type of cancer can happen to anyone. Most acquired gene mutations are not shared among relatives or passed on to children.

Hereditary (also known as inherited, or familial) cancers are those that occur due to genetic mutations that are inherited from mom or dad. Other blood relatives may also share these same gene mutations. Parents give one copy of each gene to their children. If a parent has a genetic mutation in a gene, each of their children have a 50% chance of inheriting that mutation. Therefore, even in families with hereditary cancer, not all family members inherit the mutation that is causing cancer, and their risk of cancer is similar to the average person in the general population. Individuals who are suspected to have a family history with high incidence of ovarian, breast, and other cancers may be offered genetic testing to try to find the specific genetic mutation that may put them at risk. Importantly, individuals who do not have a known genetic mutation but have high incidence of ovarian, breast, or other cancers in their families are still considered at higher risk for developing those cancers.

Hereditary cancers often occur at an earlier age than the sporadic form of the same cancer, so experts often recommend starting cancer screening at a younger age for individuals at high risk for hereditary cancer. Hereditary cancers can also be more aggressive than the sporadic form of the same cancer. Individuals who have inherited a gene mutation may be at a higher risk for more than one type of cancer.

BRCA 1 and BRCA 2: Most Common hereditary breast and ovarian cancer

The genes that are most commonly involved in hereditary breast and ovarian cancer (HBOC) are BRCA1 and BRCA2. These genes are named for their link to breast (BR) cancer (CA), but they are also linked to ovarian cancer risk as well as other cancers. Both women and men can inherit mutations in these HBOC genes. BRCA1 and BRCA2 are tumor suppressor genes that have a usual role in our body of providing instructions on repairing DNA damage and preventing cancer. When a family has an inherited mutation in BRCA1 or BRCA2, this leads to an increase in cancer risk. Not every man or woman who has inherited a mutation in the BRCA1 or BRCA2 gene will develop cancer, but people who have a mutation do have a significanlty increased chance of developing cancer, particularly cancer of the breasts or ovaries.

While breast and ovarian cancers are the most common cancers diagnosed in people with BRCA1 and BRCA2 mutations, the risk of some other cancers is also increased. Men with BRCA1 and BRCA2 mutations have a higher risk of early-onset prostate cancer than men without mutations in either gene. Other cancers seen at increased rates, particularly in individuals with BRCA2 mutations, include pancreatic cancer and melanoma. Researchers are continuing to find new genes that are involved in hereditary breast and/or ovarian cancer so it is important to follow up with a genetic counselor on a regular basis if hereditary breast and ovarian cancer is likely in your family.

Talk to your family about your health history and take the Assess Your Risk quiz here

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