Experts from Penn Medicine’s Abramson Cancer Center in oncology, imaging, and women’s health discuss updates in breast cancer care and imaging during the time of COVID. They elaborate on vaccines, screening, and course of treatment.
Treating Cancer Patients During the COVID-19 Outbreak: Penn Experts Offer Guidance and Recommendations Cancer and COVID-19 Vaccination | Penn Medicine Anthony Fauci on COVID-19 Public Health and Scientific Challenges |Penn Medicine Twitter @PennMDForum Good afternoon, everyone. I feel really privileged to talk with you today about care of our patients With regard to their breast health. During the COVID-19 pandemic breast cancer is the most common cancer in women and one in eight women will be diagnosed with breast cancer in their lifetime. Screening for breast cancer is thus a really important part of health care for women. Additionally, timely care of patients diagnosed with breast cancer is important to ensure their good outcomes. When the COVID-19 pandemic started, we were really concerned about how it could affect our ability to deliver care to our patients with breast cancer. We quickly employed a number of mitigation strategies during the initial phase of the pandemic, including increased use of preoperative hormonal therapy and appropriately selected patients. This allowed patients with lower risk cancers to delay their surgeries During the initial COVID-19 surge without compromising their outcome. We also increase the use of our multidisciplinary tumor board where physicians discuss and recommend next steps for patients as a group from 1 to 3 times a week in order to ensure that new cases were triaged quickly and closely tracked for outcome. Finally an expansion of the pen cancer care at home program allowed for home administration of hormonal therapies that were injections that previously had required a clinic visit. These are just some of the examples of how we maintain quality of care for our patients. We were actually fortunate to publish a paper and J. C. O. Oncology practice that described our experience. And thankfully our findings showed that patients with newly diagnosed breast cancer treated at penn during the initial covid 19 pandemic did not wait longer to start therapy compared to previous years. That was something that we were very proud of. As the pandemic has progressed. We have now adapted to provide care and modified ways. We feel confident in our ability to keep patients safe in our clinic and in our treatment infusion center. We're all really encouraged by ongoing efforts at vaccination and dropping COVID-19 case numbers. However, a number of questions about what the long-term effects of the pandemic will be on women with regard to their breast cancer risk. We have assembled today an excellent panel of four physicians who will share their thoughts with you today and answer questions that you may have during this difficult time. Please feel free to submit questions via the Q and a tool throughout our presentation and we will also reserve 15 minutes at the end of our session to take your live questions for our panelists. Our first Panelist is doctor an Steiner. Dr Steiner is a clinical professor in the department of obstetrics and gynecology. She has worked within penn medicine for 24 years at Penn medicine Radner and as a resident educator at the Helen Dickens Center for Women at Hope. She is founder and director of the Menopause Clinic and the Center for Women. A year ago, when we did this webinar, she described herself as quote hunkered down at home with her family, Including her 96 year old mother, her husband and her dog while doing plenty of telemedicine visits with her patients and remote resident. Teaching. Her current update for us is that although she is an avid cook and has always made meals for her family while working, the pandemic has broadened her culinary horizons. She's now ordering meals a couple of days a week and going to the gym rather than going to the gym like she previously did, she's using a home stationary bike which has facilitated more exercise for her and she's in very good shape, So welcome Dr Steiner, we're so glad to have you here today to update us about how this year has gone for you. And the first question that I have for you and is what has been your personal professional journey in the last year. First I would like to acknowledge the stress loss, fear, isolation, pain, and trauma that this pandemic has heaped on and continues to heap on humanity worldwide. There isn't one of us that hasn't been personally affected by COVID-19 or doesn't know someone who has been personally affected. I have colleagues whose lives and careers have been derailed by covid related illness, but the impact on our west philadelphia patients for whom we care has been magnitudes greater and highlights the disparities in our health system. During this pandemic. Our patients face challenges of food and shelter insecurities, increased job loss, increases in domestic and gun violence, Virtual schooling responsibilities and stress, increased risk of serious complications and death with covid due to health care, disparities, increased mental illness, suicide and substance struggles. They have also barriers to follow up getting appointments and contacting providers as the oldest person in my practice. And with my soon to be 1880. Excuse me and my soon to be 98 year old mother living with me. I was panicked in March of 20 on March 13, I left the office saying I would not be back in person for For visits until we have this virus figured out. Our department began telemedicine visits around March 20 with one practitioner in the office at a time for emergencies and non differentiable problems and procedures. Are nurses and staff were available through phone to triage refill medications and put in imaging orders By one July. Thanks to the vigilant use of PPE and distancing. The number of new cases in philadelphia and surrounding counties fell to a more manageable level. I became convinced it was safe to return to our outpatient practice without putting myself and my family at risk. Now, more than a year into the pandemic, I am often seen women who come out of their bubble for the first time to our office to visit with me. They haven't seen family members knew grandchildren and close friends for over a year and are only now emerging due to more available vaccinations. Our department is doing 12.5% telemedicine visits now and G. Y. N. Is only doing 58% of their visits through telemedicine. Dr Steiner, thank you for your comments so far. What are some of the challenges to well being and self care that people have faced during the pandemic crisis? A research team looked at nearly 7500 weight measurements from 270 participants between February and June one of 2020. According to their research from um healthy heart study. And measurements were taken from Bluetooth connected Smart Scales. On average, they gained about £0.6 every 10 days or £1.8 per month during shelter in place orders, giving new meaning to covid 19. The author said that the implementation of shelter and place orders correspondent with a decrease in daily step counts and an increase in self reported overeating during lockdown. Many have turned to high calorie foods like pizza or sweets to relieve stress when there's little else to do or look forward to. And working from home allows us to be right next to the kitchen and have food in the refrigerator within reach all day long. The food delivery system saw boom. They saw five years worth of growth in a matter of five weeks and they grew over 300% during the year. There's now more than 500,000 Instacart. Shoppers cruising more than 4 45,000 Stores across the US. and Canada and their revenue hit 15 billion. It's estimated that the U. S. Gym and health club industry lost 13.9 billion from Mark mid March to august 31st of 2020 and at about 25% of gyms closed by the end of 2020. On the other side of that, 40% of respondents exercised at home for the first time because of COVID-19. And during the quarantine, 47% of Americans used at least one fitness app Pallet time, for example, is estimated to have made 1.8 billion in sales for 2020 doubling their sales from 2019. But on the dark side, the COVID-19 pandemic and the resulting economic recession have negatively affected many people's mental health and created new areas for people already suffering from mental health and substance use disorders. During the pandemic. About four and one adults in the US. have reported symptoms of anxiety or depression disorder. Up from one in 10 adults, 36% saw increase in difficulty sleeping, 32% in changes in their eating and 12% increased use of alcohol or substance use. 12% reported worsening of their chronic conditions, their chronic medical conditions due to worrying and stress over the virus. Throughout the pandemic, women have been more likely to report poor mental health compared to men. 47% of women reported symptoms of anxiety or depression, compared to 38% of men by December of 2020. Some populations were particularly at risk for experiencing negative mental health or substance abuse consequences during the pandemic, including young adults, people experiencing job loss, parents and Children, communities of color and essential workers. During the pandemic, adults. In households with job loss or lower incomes reported higher rates of symptoms of mental health of mental illness than those without job loss or income loss. Early 2020 data showed that the drug overdose deaths. Drug overdose deaths were pronounced from March to May of 2020 coinciding with the start of the pandemic related lockdown and history has shown that mental health impact of disasters outlast the physical impact, suggesting today's elevated mental health need will continue well beyond the coronavirus outbreak itself. For example, an analysis of the psychological toll on health care providers during outbreaks found that psychologic distress Can last up to three years after an outbreak. There was an interesting interview recently April seven in the Philadelphia Inquirer and Margaret Savoy, Chair of the Department of Family Medicine and Community Medicine at Temple was interviewed. She said that people are waiting so long to make their well visits their health well visits that by the time they do come back they're hearing all the horrible news they didn't want to hear because their chronic illnesses are so far out of control. Well, she said time is up people, it's time to go back to the doctor really, it's okay to resume your checkups. Doctors did a good job telling us to stay away from their offices and clinics. But the medical community community did a really lousy job letting people know it was safe to come back. But now we have entirely different protocols. We space people out in our offices and waiting rooms. And at this point most of the medical staff has been vaccinated. So when you make that doctor's appointment, you are taking back your power. So our second Panelist is Dr Emily Conan, um Dr Cannon is a professor of radiology and she's actually served as the chief of breast imaging at the Parliament Center for Advanced Medicine since 1997. She has published numerous articles on topics ranging from novel breast cancer imaging to us, to assessment of disparities with imaging and quantitative imaging to guide personalized breast cancer screening. And uh a year ago she was intermittently sheltering in place with her husband john and her dog lucy. Uh and thankfully now that she and her Children, her three Children are vaccinated, they've enjoyed venturing out into the world again. Tour of her kids are in new york city, they've been actually able to eat in a restaurant and her medical student, um she has one child who is a medical school student in philadelphia and happy to be back in the clinics. Thanks for joining us Emily. And and we we have a lot of questions for you I know today, so I'm gonna go ahead and let you get started. Great, thank you so much, Rachel and kevin. It's really a privilege to be here with uh with this team of experts. Um so so much has happened in the last year I thought and did an amazing job of summarizing so many aspects of what our patients are going through and also our workers. Um I think we have to appreciate that it's been stressful for workers as well. So in terms of breast imaging care, um as you probably know when we spoke before, we shut down our services for routine screening in the middle of March 2020. And we were actually shut down for routine, you know, screens until June one, which was a very long time. During that time, we were triaging patients individually, actually looking up their records and sometimes even calling them uh to see why they were coming in for diagnostic imaging, meaning, you know, they felt a lump or had nipple discharge or something was going on. That wasn't quite right symptomatic patients. And we were certainly seeing them throughout that time. I want to share with you and I'm going to try to share my screen now some national data and here you go. Hopefully you can see that now about what this did across the nation. And this is a summary report um from the Electronic Medical Record Group. Epic. Looking at their sites that they sort of throughout the country um modeling the mist screening. So it's a little complicated. But you've got the purple line which is 2020 and maybe you can even see my marker. And you can see the rate of screening pretty much average compared to the dotted black line, which is the weekly screening mean across 2017 to 2019. Across there, the purple line, All these other lovely lines, the green, the orange and the light. The turquoise show screening over time and how it varies by season slightly. However, look at the purple line, it dips down and this is the beginning of the pandemic stays down and this is screening mammograms. Just routine asymptomatic. Please come every year mammograms Um and then begins to come back. But the estimated number of MS screens, as you can see is almost 300,000. And that's only in that time. We have continued to see um, some reduction in screening. Um, and this is really impacted uh, care. Women have delayed their screens, skip the whole screen and that's quite worrisome now. Certainly, you know, we encourage all women to come in and not miss those screens, but there has been a delay of screening and women are still concerned about coming to our site. I think we have, as I think we talked about on the last last spring's webinar um social distancing in place. Our technologists are cleaning, our rooms were having a new format for where one changes, you change out of your clothes into your, down in the room and then one way traffic changing on the way out, wiping down all the equipment. Um, So in terms of transmission within the clinic, we haven't really seen that we really have a very safe environment. Um, so my message is, don't, don't fear coming in. Please do come our volumes. However, have resurged significantly. Um, after I think around the fall really is when we saw our volumes really going up in women delaying multiple months and then saying, I just really need to come in and certainly being encouraged by their health care providers, like and was saying, and steiner. Um and so right now we are seeing those women who have been delayed and we are seeing some issues. Um women who say they've had a look now for eight months, but it's getting worse. Um, so I encourage you all. I'm certainly happy to take any questions regarding that I want to move on now to a particular entity that we're seeing that has had a lot of press. One of my colleagues was just on NBC News the other night and we published articles on this and this is the ADN apathy that we see related to Covid. And so what I have here and I hope you can see these images is a woman's mammogram. one view of her left breast 2019 images on the left. And you can see this is a normal mammogram. There's some blood vessels coming from the upper aspect of the breast. Her nipple is here. All of this is just lovely and normal. Up at her axillary as you know, live the lymph nodes. And these are very nice and normal looking. They have these little fatty Heilemann them and they're just they're quite normal here. She comes back two weeks after her second vaccine and I'm going to magnify these. And what I want you to do is compare those lymph nodes. Now the lymph nodes are enlarged, She couldn't feel these but we saw them on her screening mammogram. Of course we are very interested in the timing of her vaccination. This is a normal response to vaccine. But the problem is there can be an overlap in this appearance and things that can be worrisome like lesions in the breast. That could be causing problems with the lymph nodes, enlargement of the lymph nodes or things like lymphoma from elsewhere. So it can be quite confusing. And this can prompt extra imaging, ultrasounds, extra ma'am. A graphic views and even biopsies sometimes to make sure that this is just a normal response to the recent vaccination. Another case I think now that you know where to look for the lymph nodes, you can see that up here. This woman also got her injection in her left deltoid just a few weeks. The second injection of her too. I believe this was a moderna vaccine. It doesn't really make a difference day. Um, approximately 16% of recipients um, will have this mammographies appearance of enlarged lymph nodes. We see it even more on cts mris that are performed higher up towards the neck, even into the neck. If one gets an injection in one sky. For some reason, we can see the ADN apathy in the groin. So what we've tried to do is number one ask all of our patients about when they were vaccinated, Their first vaccination and their second vaccination. And we put that in your medical record. And what type of vaccination if possible? If a woman has not delayed her screening and she can schedule her screening her routine study around her vaccination, meaning ideally before she gets vaccinated or now that so many of us are vaccinated. About six weeks or so after the second shot, we see less of this. AdN apathy. But most importantly, and I really, really can't emphasize this enough is please do not delay if you have any symptoms, that means lump, dimpling discharge, anything that is new or different that you feel, um, that's concerning to you. That's what we're here for and we need you to come and do not delay that care because um, as I think Rachel said, and an said that uh, isn't going to help. Um, and hopefully we'll have good news for you. We'll do all sorts of imaging and hopefully everything is just normal. But we do want you to come in for your regular screening mammograms, ideally if you can schedule around your vaccination. Um, but certainly if you have symptoms, please do come in. So that's what I've got. Let me stop sharing and we'll move on. Thanks Rachel. Thanks so much Emily. So I heard you say essentially six weeks after the second shot would be optimal in terms of doing a routine screening screening mammogram. Uh So are you okay with six weeks after the second shot if patients are a little bit late or I mean so how it just makes a question like everybody is a little bit late this year, it seems like. Uh huh. Yeah, that's a tough question. I I think most importantly is please don't delay your mammogram by six months to you know, skip a whole cycle. And we're actually seeing a lot of that um and we're willing to work around you. But be prepared that we do see some times this ADn apathy and someone will feel it and be concerned and we want you to come in in that case we may do an ultrasound and then follow you with an ultrasound in you know, two months or so. Um But it is one of those things that comes along with this whole pandemic and it's a good normal response. We'd like to see uh this immune response to the vaccine. Um but we just want to make sure there's nothing else going on. And I guess it would suffice to say that if it's a diagnostic mammogram, you would not want them to know. No, no delay. And we will work around and if we see lymph nodes, but we really want to make sure that the symptoms that a woman has that she's coming to see us for um are really just, you know, the nine changes. Maybe assist or just normal tissue and some tenderness, things like that. Um So the diagnostic patient symptomatic patients, patients who go to their doctor and there's a lump felt on exam, please please come in as quickly as you can. And then finally we have a question in the chat line already about how long the lymph nodes stay enlarged after the vaccine. Is that variable? Or have you seen it? It's incredibly variable. And as more data develops it's looking like they do stay in large for longer than the 6 to 8 to maybe 10 weeks, particularly when we're looking at scans like cat scan cts mris but there largest in that first phase and they are larger after the second injection than the first injection. Um Which is just the mounting immune response to the vaccine. Um So yes, we do see them later. But if they're only mild being large and we know when your injection is, you know, we don't start doing all sorts of things. Um They get smaller over time. Good question thanks Emily. We did have one good point made by one of the participants in the chat box here saying barriers to screening are not always about our location and our ability to to provide safety at our location. Um The participant noted that some people are worried about the trip to and from from the doctor and how they're going to get there safely. Public transportation, things like that. So that that's also a valid point. We have been trying to work with social work if patients need rides for treatments and things as best we can. But they're just as an talked about a number of of social stressors that can play into this as well. Totally understandable. Yes. Okay. So um our next speaker that I am going to introduce is dr Julia chew and uh dr chu is a professor of clinical surgery in the department of surgery at the Hospital of the University of pennsylvania here. She has actually been a faculty member at Penn Medicine for over 17 years and she served as the section Chief of Breast Surgery since 2016. Her practice is centered here at the runaround breast center in philadelphia, but she also sees patients at penn cancer centers at Valley Forge and and Radner right Julia as well now. And um to be honest doctor to never really slowed down during the pandemic. She's one of the hardest working surgeons I know. Um but any extra time she has she likes taking long walks with her husband and her dog and she enjoys cooking for her two teenage sons. So I'll let you uh take over Julia. But one thing that we hope to hear from you is where we are in terms of testing for procedures and surgeries. Um and what is the status of, do patients need to get covid tested, etcetera? And um what have you seen in your own patients in terms of delaying visits and screening and diagnostic studies. Thanks for being here. Thank you Rachel. Thank you for allowing me to join this panel. Um It's been a year that we were here before and thank you to all the participants in joining this. Uh really remarkable group of people on the panel. Um So a lot has happened in the last year, so right from the beginning um in March, uh we uh in the surgery department we were very uncertain about what policy we have to be put in place to make everybody safe. So the first two months during the pandemic, we did shut down the surgery center only allowing the most emergent cases to be done. So. And we opened back up in May when we got a better picture of what to do and how to keep patients safe, such as testing all patients coming in for surgical procedure uh for covid 19 testing using PcR test um at our designated locations. So the way we kept our patients safe in the clinic would be every all the staff and health care providers will be masked and have uh eye protection. And visitor policy was restricted in the beginning to no visitor. Uh allowed uh We do allow visitors to join the conversation virtually such as on telephone or facetime. So that has been working quite well. And we were doing telemedicine for quite some time for new patients and return patients and then for emergent for patients that need to be seen in person. We are, we were always there. We have always been there for them in person. So, um we resume our surgical schedule pretty much back to full schedule, starting May uh last year. And we've seen our patients returning to the clinic uh gradually and actually almost two full schedule uh more more so in the suburbs. Because as one of the uh uh participant has raised the travel time and how to get to clinic might be difficult or a lot of our patients might have felt safer in the suburbs because of the shorter commute time than to come into the city. So, um the location of our clinics in the suburbs have been very valuable for our patients in all in the pennsylvania and New Jersey suburbs. Um So we we have seen a growth, tremendous growth in the suburbs and in the philadelphia region. We said we've seen a steady steady state of patients in terms of how Are we testing patients who are who are coming for surgical procedures? Who uh in patients who have been fully vaccinated. The short answer is yes. We are still testing all patients having surgical procedures, uh testing them for COVID-19. Policy might change in the future. But I do not I have not heard any change in the near uh in the in the next few in the next couple of months. Um We have not seen any transmission of COVID-19 from health care providers to patients. So just to emphasize that we are uh making sure that the patients are being taken care of in the safest manner. And finally, I think Rachel asked me, have I seen any delayed in care of patients having delayed in screening for and diagnostic imaging and coming to the clinic with more advanced breast cancer. We do see some patients who are delayed in their care, but I thankfully I think a lot of patients are getting the message and coming to screening and having diagnostic work up and um uh we are uh we are ready to take care of all the patients that need to be taken care of in the safest manner. Thank you. Thank you Julia. Um our final panelists today is dr Tracy D'Entremont. Dr D'Entremont was born and raised locally. She attended Canastota High School As an undergraduate, she studied biomedical engineering at Duke, she attended medical school at Penn State and did internship, residency and fellowship at the University of pennsylvania. So she's kind of a homegrown pen person after fellowship. She had a very busy private practice for 10 years but then was recruited back to Pen to open the Abramson Cancer center of Valley Forge, where she's been director of oncology services ever since. Her special interests are breast and gastrointestinal cancers. Um and she enjoys teaching residents and fellows as well as lecturing patients and community members. She lives with her husband and her three Children in bryn mar during the height of the pandemic. She enjoyed expecting, spending unexpected time with her Children and instead of rushing for one sport to another, they had more family dinners and even started a routine of daily crossword puzzles. And by the end of the summer, as her two older Children went back to college, they decided to rescue a dog Penny, who is now a good addition to their family and helps keep her saying on on long walks. Um Now that schedules have become more hectic hectic again. Welcome dr D'Entremont. Let's get started um with a couple of questions for you. So as a medical oncologist, how did your practice change um to keep patients safe and allow for their treatments to keep going during the pandemic? Thank you Rachel. Um And thank you all the other panelists for allowing me to participate today. Um I think just as everyone else was saying certainly there were a lot of changes in the beginning of the pandemic for our practice. Um Initially there was a lot of uncertainty clearly in terms of what the pandemic was going to play out as. Um and there certainly was probably about at least a month period of time where even patients on active treatment were choosing to delay their therapies. Um But once we realized that unfortunately the pandemic was here to stay um we were able to really shift gears, make the clinic safe um Change our waiting room, change our flow in terms of getting patients directly in check in into the lab and then into the exam room with minimal um contact with other patients and little wait time so that we were able to keep our patients on schedule and on treatment even during the height of the pandemic. So I would say from our perspective and medical oncology perspective, fortunately um very few delays in terms of patients on active therapy, certainly patients who were in routine follow up and needing six month or annual physical exams. Um They definitely did delay their visits initially, and we also incorporated more telehealth visits for those patients, which has been a real asset, I think for that for certain patient population. Uh And as Julia mentioned, we also have been using more telehealth to incorporate family members um who maybe can't come to the clinic because of covid restrictions, but also it allowed us to incorporate family members who live a distance from the patient and allow them to be a much more active participant in the patient's care, which I think has been one of the good outcomes in terms of covid and some of the things that we've learned in terms of taking care of our patients, that's really allowed family members who live further away to be more actively involved in their family members care. Um As we've mentioned previously, we also have shifted some of our treatments to more home infusion, specifically um some hormonal injections as well as some. Um This fascinating injections and bone strengthening agents, which allowed many of our patients who would be coming in monthly for an injection to get that at home and only have to come in for a visit maybe every three months for lab work or physical examination. So that really helped decrease um the throughput through our office and decrease the exposures that patients would have to other patients and to um office personnel. Um I think that you know really um we also had very few incidences of covid within our practice um and within um you know, unaware of any exposures between staff members and patients. Um and I think in talking To my colleagues, very few of our patients in general contracting COVID-19 through all of this, which I think is a testament to our oncology patients who are very used to unfortunately being immuno compromised, being immuno suppressed and being at high risk or infection in general and therefore used to taking care of themselves following rules being willing to wear masks. Excuse me. And um also following vaccination guidelines which I think has been helpful in terms of their um them staying healthy through the pandemic. Um I think that becomes one of the questions that I'm frequently asked more recently is in terms of vaccination and is there a specific vaccine that we recommend for our patient or when should patients get vaccinated with respect to their cancer treatment? Um there certainly is a lot um in the literature now suggesting that some patients who are immuno compromised on cancer therapy unfortunately are not mounting as much of an immune response from covid vaccination as we would like. Um That data is mostly in the uh lymphoma population or the multiple myeloma population and the human to logic malignancies and less so in our solid tumors or breast cancer population. Um And in those patients, the human logic malignancy patients, unfortunately, some of the antibody response rates to the vaccine can be as low as 50% and obviously that's unfortunate. But from our perspective, we do feel strongly that it's important for patients to still get vaccinated. Whatever antibody response they may be able to get from the vaccine is important. Um In my experience we have not seen patients have worse outcomes or more toxicity from vaccination um if they are on treatment or have histories of cancer, which is a good thing, there's obviously a lot about the johnson and johnson vaccination and the clotting that's occurred. Um I think the take home message from my perspective in that regard is that um although certainly concerning the incidence is quite low. Um the last Reading that I did was about 28 cases out of eight million patients who received the Johnson and Johnson vaccine. Um and from what I saw also, there was no clinical indication that that is more prevalent in patients who otherwise have a high clotting risk. Um Sometimes we think about our cancer patients as being a high risk for thrombosis either because of medications that we're giving them or because of recent surgery or active cancer. Um but actually the patients who received the johnson and johnson vaccination and had clotting episodes um actually didn't have other risk factors for clotting. So I don't believe that our patients should be at more risk for poor clotting outcomes related to that vaccination. And I tell my patients um to just get whatever vaccine they can as soon as possible. Fortunately I think access to vaccinations has become a lot easier lately and I think that's about it. I think at this point our patients unfortunately are all coming to the office and I think from the perspective of um telehealth, I think one message I would give is that um you know, the office is a safe place to be just like Emily was saying and I would encourage patients to be willing to come in for their visits. Um Certainly like I said, some patients who are on routine follow ups, we were deferring and doing telehealth visits, but there's certainly no um substitute for a physical examination which obviously can't be done over video. And so I encourage women who maybe have not seen their doctor for a full year to come in and have that physical examination because we don't want to be missing things. Thank you. Thanks Tracy. So yes, I mean I think that there is a question coming in already um just in general terms, patients who have completed chemotherapy for breast cancer um and then go on to get fully vaccinated are wondering, you know, are they going to be fully developed full immunity the way a patient would who had not received chemotherapy? Um And I would be hopeful that that would be the case. You know, I know that our drugs do not stay in the system very long after the last administration. What is your opinion about that with I think you touched on that with solid tumors but just to to dr yeah I think I agree exactly. I mean I think um sort of broached on it but I didn't say specifically with regard to the timing of the vaccination. Um I think certainly if a patient has completed their chemotherapy in um you know, certainly more than three months ago their ability to mount an immune response to the vaccine should be completed. Um I think in our patients who are undergoing active treatment, there's always that question of when should I get the vaccine? Um You know there for a while in the height of the pandemic when they access to the vaccines was so questionable. Um, in a patient who was maybe getting defined treatment and was going to be done in a month or so, there was the question about um, you know, should I wait until my chemotherapy is complete and then get the vaccine so I can have a better response. You know, Unfortunately, we didn't really have a luxury of waiting there at some point in time because the ability to get the vaccine I think was limited. Um, and for patients who are going to be on ongoing treatment. Um, the best analogy that we have really is for the flu vaccination, which we've always encouraged our patients to obtain every year even though they're on active treatment and they've been getting immunity to against influenza and haven't been getting sick from that. So, I think in general and answer to your question, patients should not be having long term difficulty responding to the vaccines if their chemotherapy is over. Yeah. And I guess I would have to I appreciate that answer because I think it was a very thorough one. Um I would have to say that partial immunity is better than no immunity and it's possible, you know, that these vaccines could continue to evolve over time, Right? And that we all may unfortunately have to get another vaccine at some point. So, yeah, I too have just encouraged people to get it as soon as they can. Thank you. Um so we had another question coming about what to do if a patient has breast symptoms and they've had the vaccine in the last six weeks. So in other words, if there are positive lymph nodes, but they also have a calm commitment breast abnormality. Um what the next steps and management would be. I think either Julia or Emily could could feel that question. Um Emily looks like she's on the screen so we'll go for her. Um but certainly love to hear what Julia has to say definitely come in um because we want to work that up and evaluate what's going on. So no question if someone symptomatic and has you know, concerns about a finding in their breast, a lump, you know, focal tenderness, um discharged thickness, things like that. We really want to do additional evaluation that may just be an ultrasound if they've had a mammogram within the near you know recent past. Um but I wouldn't delay that kind of evaluation just because you know, you had your vaccine two weeks one week yesterday beforehand we really want to evaluate those. Um those findings don't know Juliet. Yeah, I completely agree with Emily. So the breast imaging portion of the work up to me is the most important. So do come in for the breast imaging part and then for a clinical breast exam will be also important. Um So that we can evaluate further just to collaborate with the imaging findings. There's an interesting question Rachel that since Julia is on and I'm on to about soreness around the lumpectomy site after vaccine. Um And I I think that's really interesting. I think it depends a little bit where that site was and how far out after definitive surgery and therapy if there was therapy. Um I think that uh certainly if someone sore in there axel a and their arm we start groping and examining and that's all good. But sometimes you know we feel more things because our attention is drawn there. But again, any kind of symptom that's new or different um should be evaluated Julia. You have anything else to add? Um Yes, I agree with Emily. I always agree with. So yeah, the symptoms are related to the it could be because of the enlarged lymph nodes from the vaccine, but the soreness in the breast is uh most likely due to the surgery. And if you have had radiation is possibly some of the side effects of long term effects of the radiation plus surgery that you may have. So, but do come in and get checked out and and just in terms of um soreness and breast tenderness, it's one of the most common symptoms that we do see women coming into the clinic and it certainly needs to be evaluated, but I just want to make it clear that in general intermittent pain, diffuse pain Really is rarely associated with any abnormality. We get more concerned when it's vocal, like right here if you can put your finger on it. Um but intermittent waxing and waning breast pain is extremely common. We did a survey years ago and 70% of women coming into our clinic said they had pain every now and then. Um and again. Pain unfortunately. And I think is rarely associated with anything abnormal, you know, abnormal. If there's not also a lump, I wish that pain would help us find things but rarely does it without a lump that's felt. Usually cancers are painless slumps unless they're very, very large. So pain is quite common but still should be evaluated with your health care provider Julia, Anything to add to that pain? Oh, um so yeah, I agree with Emily paying a cyclical pain by a lot of pain in both breasts are benign. So we usually just say keep an eye on it and if uh if it waxes and wanes is usually nothing to worry about. But focal pain is something that we do want to work up uh with further imaging and breast exam. Emily there's been a couple of questions come in about number one. Does three D. Mammography or thomas synthesis look like a regular mammogram or to the patient or does it look different and is it less comfortable and to the that same topic? Um patients are wondering or providers I'm not sure who's writing the questions about dense breast tissue. Any updates about breast density? I mean this isn't covid specific but I know that three D. Mammography is helpful for that. So could you briefly comment? Sure. So you might not be able to tell the difference between the machine if you just look at it from afar because it looks like a standard mammogram machine. The kicker is that when you're in there in compression say like this the head or the we call it the head or the part where the X rays come from actually moves slightly. And so what it's doing is acquiring multiple low dose mammograms across an arc. And then because it's um processed with digital information were able to reconstruct what quasi three D. Sort of three D. That allows us to look through different layers of the breast so that we can scroll through and remove things that are just normal and better see abnormalities. So improve detection and less false positives is what that's all about. The only thing you might notice with the machine is this moving part above you and that you're in compression a couple seconds longer than you would be otherwise. And that's no fun because you gotta hold still and don't breathe please. Um But other than that, I don't think you've noticed in terms of the breast density question, That's such a hot topic and quite a conundrum right now in terms of management, um we know that women who have more glandular tissue, very dense breasts on the mammogram have a higher risk of developing breast cancer, almost as if there is more of a garden for cancer to grow in. And it can be significant, a woman who has very, very dense breast that can be almost four times risk compared to a woman who has entirely fatty breasts. So one side is increased risk for developing breast cancer. And then the other one is that with all that breast density. And there's sometimes even with thomas synthesis, we have a hard time finding the cancers because they're the same density on the mammogram as the regular breast tissue. And so if they're surrounded by regular breast issue and we may not be able to see them. And that's when the question comes up about supplemental screening. Should you be doing something beyond chest a mammogram? And that's an extremely hot topic. We're required by laws I'm sure you know across all states and U. S. Territories to tell you about your breast density. And that's that funny paragraph that I find very confusing in the report. It talks about breast density. Um If you are interested in supplemental screening I think it's a question to take up with your health care provider and the pros and cons of it. The I think reasons to go through it. Um And that's either ultrasound or we actually have a very um uh rigorous and I think an impressive supplemental abbreviated M. R. Program. But that means getting an M. R. Getting an injection going in one of those tubes. Um That has the highest detection rate Added on with three D. Mammography. Um The problem is the more you look the more you see. So while we find significantly more cancers like 4 to 5 times more cancers um with MRI we also have more false positives. So it's a risk benefit balance if you're willing to have that balance because you're concerned about your breast density and you talk to your doctor. Um That's something you may consider doing. And we certainly offer that throughout the pen system. But what I would recommend it if you want supplemental screening abbreviated M. R. Is definitely the way to go. I have them mm You're muted Rachel. Sorry I'm sorry and I think you made an important point in the chat box. I just like you to a verbally touch on in case everyone's not reading the chat box. So there was a question that came in about whether it's OK for pregnant women um to get vaccinated and it's an extremely important question. We get all the time. So remember these vaccines at the moment are approved for emergency use authorization. They're not fully FDA approved yet. I know that Pfizer is about to apply for full FDA approval. But what we have learned during the course of this pandemic is that pregnant women who acquire covid 19 the virus and the disease. Do they fare much worse than women their same age? Um, they're more likely to end up in the ICU.