CORONAVIRUS: DELAYS FOR ROUTINE SURGERIES, VISITOR RESTRICTIONS + COVID-19 TESTING.

As one of most common cancers among women in the United States, it's vital to receive annual breast cancer screenings and necessary treatment, even during a global pandemic. Halle Moore, MD, Director of Breast Medical Oncology and Co-Director of the Comprehensive Breast Cancer Program at Cleveland Clinic Cancer Center, joins Butts & Guts to discuss how Cleveland Clinic has adapted its breast cancer program to maintain care for patients during COVID-19.

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Breast Cancer Screening and Treatment During the Coronavirus Pandemic

Podcast Transcript

Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Hi, everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio, and we are very pleased to have Dr. Halle Moore, who's the Director of Breast Medical Oncology and the Co-Director of the Comprehensive Breast Cancer Program here at Cleveland Clinic Cancer Center. Halle, thanks so much for joining us here on Butts & Guts.

Halle Moore: You're welcome. Thank you for having me.

Scott Steele: As just a little bit of introduction and background to set the tone before we jump in, next to skin cancers, it's always important to remember that breast cancer is the most common cancer among women in the United States. And what we're going to focus on here today is to discuss the importance of continuing breast cancer screening, as well as treatment, and how the Cleveland Clinic has adapted its breast cancer program to maintain our care for patients, including during this COVID-19 pandemic.

Halle, with that kind of context, as all of our listeners on Butts & Guts know, I always like to first start out and say, tell me about yourself. Where are you from? Where'd you train? How did it come to the point that you're here at the Cleveland Clinic?

Halle Moore: I am a medical oncologist. I actually grew up in Vermont. I went to medical school not too far from here at Case Western Reserve University and did my oncology training at the University of Pennsylvania, and then came to the Cleveland Clinic over 20 years ago and since then have been specializing in the care of breast cancer patients.

Scott Steele: And so can you talk a little bit about breast cancer overview? How does it develop? What are its symptoms? Is this a disease that affects all age ranges? Or just kind of set the tone and the background for what we're going to discuss today.

Halle Moore: Sure. Well, like most cancers, breast cancer seems to result from some combination of factors, including a person's genes, their environmental exposures. , including hormonal exposures, which is why women are more prone to breast cancer than men. And then there's probably just some component of bad luck in terms of cancer development.

The symptoms of breast cancer may include a lump or a firm area in the breast. Less often, people can have pain or swelling in the breast or a swollen lymph node in the underarm area. And often, there are no symptoms from breast cancer, which is why screening with mammography is so important, as this is a common way for breast cancers to be diagnosed.

As the risk of breast cancer increases as you get older, with breast cancer in women under the age of 40 being less common than women over the age of 40. But really, it can occur at any age in an adult, especially if there's a family history or other risk factors for breast cancer.

Scott Steele: As many of our listeners of Butts & Guts are aware, we've touched on breast cancer in the past, and this time, we're going to specifically focus a little bit about the importance of continuing breast cancer screening during this time of COVID-19. Let's start right there. It's a pandemic. We all know that people are worried about going anywhere. And sometimes, one of the things that can take kind of a seat on the back burner is actually going to the doctor or doing self-checks or anything like that. Let's start. Is it safe to come and go and see your doctor, safe to come here to the Cleveland Clinic during COVID-19?

Halle Moore: Yeah, well, as have you, I'm sure, I have been coming to work every day here at the hospital, and I feel very safe, and I think this is a very safe place for our patients to come. Even prior to the pandemic, the Cleveland Clinic has always been committed to safety. And in the current times, there are numerous procedures in place to keep both patients and caregivers safe.

Scott Steele: In addition to coming in and seeing patients and getting a breast examination from your local provider and anything, one of the things that often happens with screening for breast cancer or even kind of breast examinations is a mammography or an ultrasound. Do you still recommend getting either one of these tests during COVID-19?

Halle Moore: Yeah, so there's been a lot of mixed messaging, which has led to a lot of confusion in many aspects of what we do for our health during the pandemic. And certainly, in the early peak of the pandemic, when we were trying to keep people home as much as possible and trying to preserve medical equipment because of the uncertainty about supplies and protective equipment and needing to keep ORs closed, we were telling people for a brief time to delay their screening mammograms in the absence of any symptoms or any concerns with the breasts.

Now, that did not apply to anybody who had symptoms or was actively being evaluated for a new problem. However, now that it's clear that A, we have plenty of supplies to be back to our full loads, but also that the pandemic is going to be with us for a while yet, and what we really do not want to do is put off screening for many months. And so it is important that people get back in and have their routine exams and screening, including mammography.

There was one study that looked at modeling individuals, if people were, if everybody were to delay their mammogram by a year, five years from now, we could see about an eight to 9% increase in breast cancer mortality, potentially, simply by not doing screening for a year.

Scott Steele: Halle, you kind of mentioned this in the last answer, but I think it's worth kind of taking note. Can you walk patients through, what is the difference between screening and diagnostic type testing?

Halle Moore: Yeah, so screening is what we do because you are of an age where you're at risk for breast cancer. You have no symptoms, and this is going in and basically looking for trouble, versus diagnostic imaging is done to evaluate a concern. So if you have a lump, if you have pain in the breast, if you have breast changes that are of concern, then diagnostic imaging would be done to investigate that problem.

Scott Steele: And kind of going into cancer treatment and specifically breast cancer treatment in the era of COVID-19, how has COVID-19 changed breast cancer care in general?

Halle Moore: Currently, we're really back to most of our usual care, but we have made some modifications to try to reduce the number of visits that people need to be here. Again, during the peak, we made some changes to allow for people to start perhaps on hormonal treatments before surgery, in the case that surgery needed to be delayed. So there are definitely ways that we could modify our treatment. We have been quick to adapt some of the newer radiation protocols that allow for a shorter course of radiation and fewer visits. Some of our treatment regimens have been modified to use longer-acting agents, again, to allow fewer visits. But for the most part, our treatment has still included surgery, when appropriate, chemotherapy, when appropriate, radiation, when appropriate, and then hormonal and other treatments. We have not really skimped in terms of the management of cancer during this time, because obviously, this is another very important health concern.

Scott Steele: Truth or myth: Patients with breast disease or concerns about breast cancer need to always come in for an in-person visit versus can they get a virtual visit?

Halle Moore: Yeah, so it kind of depends on the concern. It is very hard to do a breast exam or a mammogram virtually, so we may need to bring you in. But an initial visit could be done virtually or a consultation to discuss that concern. And we have done many more virtual visits since the pandemic, so that may be an option for some individuals.

Scott Steele: What can a patient expect when they come in and visit Cleveland Clinic's breast cancer program?

Halle Moore: For those that are coming in for routine mammograms, they may not even need to interact with our cancer program. We have screening mammography available at all of our family health centers. For somebody who is diagnosed with breast cancer, you can expect a pretty quick referral to our multidisciplinary team. That will often involve meeting with a surgeon, a medical oncologist like myself, a radiation oncologist, perhaps a genetic counselor, a variety of specialists to help determine what the best path forward is for the management of that cancer.

Scott Steele: Is it okay if you're otherwise healthy to receive chemotherapy and radiation therapy during this time?

Halle Moore: In general, if there's an indication for these treatments, it's a good idea to receive those. So for patients that require chemotherapy, we have not been avoiding it simply because of the pandemic. We have encouraged very strict safety measures, which, honestly, most of us should be following pretty strict safety measures anyway. And we've been able to safely give chemotherapy to many patients.

Scott Steele: Let's change that question just slightly now. Let's say that you were infected or you are overcoming COVID-19. Is it okay to delay your therapy, or should we proceed with chemo and radiation therapy?

Halle Moore: Yeah, well, somebody who's sick with COVID, we wouldn't want to contribute to their immunosuppression with chemotherapy until they've recovered from the illness. But there may be other treatment options that can continue. For instance, some of our hormonal treatments can be safe to give, especially if that person has mild illness. Of course, we also, with things like radiation, while that might be simple enough to give in somebody who has active COVID, we want to also be safe for our providers, so these things need to be individualized. And certainly, if there is an active illness, whether it be COVID or other active illness, sometimes out of safety, we do have to delay our treatments.

Scott Steele: Yeah, that's a great point. And as a colorectal surgeon, there's been some emerging data about the importance of getting care, even during this pandemic, whether or not you're infected with COVID-19. But in the breast cancer world, how safe is it to delay your cancer care? If you are somebody out there that's said, I got to put this on hold for whatever reason, is there anything out there that would suggest that there's a certain time period that can happen or is that should be individualized?

Halle Moore: I think it really needs to be individualized because we have seen people who maybe had a problem. January, February of this year, they were a little slow in getting follow up. And then by the time they did reach out, there may have been restrictions where they lived in terms of seeing patients, and so there was further delay. And sometimes we are seeing breast cancers presenting at a higher stage than it may have been initially had it been diagnosed six months ago. So we certainly don't want to delay evaluation of symptoms. Higher stage disease may mean more aggressive treatments and potentially higher risk for future spread of that cancer. But again, we don't want to put people in danger, and if you're actually sick, then that's a valid reason for delay.

Scott Steele: What's a final take home message for listeners in regards to this talk of breast cancer screening and treatment during COVID-19?

Halle Moore: I think that the major message is that we're living with this, the COVID-19, and it's going to be going on for a while yet. It is important that we stay safe, but that does not mean neglecting your other health needs, including screening mammography. We're encouraging people to continue to do that.

Scott Steele: Okay. So for all of our guests, we'd like to have a couple of quick hitters to line up to get to know you a little bit better. What's your favorite sport?

Halle Moore: Rowing, crew.

Scott Steele: Wonderful. What's your favorite food?

Halle Moore: Oh, probably chocolate.

Scott Steele: Fantastic. That's one of the major food groups. What is the last non-medical book that you've read?

Halle Moore: The last non-medical book? I'm trying to remember the name of it. It was written by an author who'd lived in Shaker Heights for a little while. Do you know the book that I'm talking about? Little Fires Everywhere? Something like that.

Scott Steele: Little Fires Everywhere. Yeah.

Halle Moore: I like easy light reading or historical fiction.

Scott Steele: And then finally, what is something that you like about living here in Cleveland?

Halle Moore: The Metroparks are great. I love being in the outdoors.

Scott Steele: Well, that's fantastic. And so thank you so much for taking the time to join us. And in times like these, it's important for you and your family to continue to receive medical care, and I hope that you got that out of this interview today. And for your empowerment and your peace of mind, please take the time to schedule the appropriate examinations and to include scheduling a mammogram, visit ClevelandClinic.org/walkinmammo. That's ClevelandClinic.org/walkinmammo, W-A-L-K-I-N-M-A-M-M-O to view all mammography locations, hours, and phone numbers, including those offering walk-in screening appointments and mammograms for women with no breast symptoms.

Rest assured, here at the Cleveland Clinic, we're taking all necessary precautions to sterilize our facilities and protect you, our patients, as well as our caregivers. Halle, thanks so much for joining us on Butts & Guts.

Halle Moore: Thank you so much.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.

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Butts & Guts

A Cleveland Clinic podcast exploring your digestive and surgical health from end to end. You’ll learn how to have the best digestive health possible from your gall bladder to your liver and more from our host, Colorectal Surgery Chairman Scott Steele, MD.
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