The SARS-CoV2 pandemic has brought upon us a new normality as citizens. We as physicians and scientists are tasked not only with the difficulty of designing a new treatment for the SARS-CoV2, but also as global citizen we are also tasked to redesign our current health infrastructure and how do we deliver these resources to individuals who are diagnosed with cancer. The most common cancer in women is breast cancer. According to the American Cancer Society on 2020 in the United States, about 276,480 new cases of invasive breast cancer will be diagnosed in women, 48,530 new cases of Carcinoma In Situ (CIS) will be diagnosed and about 42, 170 will die from breast cancer .
There are strong considerations to address such as ethical issues, epidemiological aspects, medication shortages and fear of patients. There is a call to tear down barriers within nations and to work together in a design of a new vaccine, a new treatment for the global cause of survival. There is no doubt that individuals who possess cancer are at an increased risk of infection with the SARS-CoV2 .
The social, now called physical distancing strategy is now promoting cancer patients to get sicker, as fear of entering their hospital or doctors will likely infected them as they are immunocompromised by their disease and their treatment (avoiding/delays). Therefore, a need for education toward individuals who are diagnosed with cancer is needed, by all sectors of the healthcare community (doctors, nurses, physician’s assistants, and naturopathic physicians). The order of the day would be to provide instructions to patients about doctor’s appointment, and to strategize the delay of life-saving treatment through peer-reviewed algorithms.
Telemedicine is a strategy that bridges patients with new ways of direct contact with Primary Care Physicians (PCP). In addition, it provides the first part of a full evaluation for patients, and broadens the time to provide healthcare to patients beyond the 15-minute consult. It is considered a way around the imposition of EHRs (Electronic Health Records). The EHR although provide a limited amount of benefits also increases costs in medical offices and hospitals.
Education toward patients is key. During the pandemic patients are at risk of not complying with their treatment protocols as guided by the National Comprehensive Cancer Network (NCCN) because of fear of catching COVID-19. Therefore, many of these protocols are altered by noncompliance. The most common used protocols are dependent on the presence of biomarkers such as Human Epidermal Growth Factor-2 (HER-2), Estrogen Receptor (ER), Progesterone Receptor (PR), staging of the disease and biopsy.
An example of a general therapeutic agent for breast cancer is Trastuzumab which is a recombinant humanized IgG1 monoclonal antibody against the HER-2 receptor. Although adverse effects are ventricular dysfunction and congestive heart failure, patients on this chemotherapy are regularly evaluated with echocardiogram and MUGA scan.
Individuals with breast cancer can also present with previously diagnosed diabetes mellitus and have end-organ damage such as atherosclerosis, congestive heart failure and should be monitored with echocardiogram when undergoing chemotherapy with agents such as trastuzumab. High risk populations are in need of information because of their co morbidities therefore patients shift their attention toward social media that is not validated by healthcare experts. Therefore, they start asking: Is my cancer treatment an essential thing? Well yes, it is.
The patient fears are normal, but that should challenge us to broaden our services. Family members play a key role in the treatment of patients and have a regular follow-up with the healthcare provider.
In addition, the guidance of the use of mask for individuals with cancer is strongly recommended, and which masked is appropriate. Their use is now the new norm for a regular medical visit. The constant use of masks is guided toward decreases in hospitalization and decreasing morbidity. For individuals with cancer, the N95 is the most appropriate. Although there are some drawbacks, such as cost, hard to find and hard to use, especially if the patient has breathing problems and most don’t like to use them.
As the United States is preparing to reopen, a reality check should take place. A new norm has taken place in order for the protection of the virus. Doctor’s appointment need a maximum of patients in their reception area (2 or 3) with a minimum of distance between patients, patient would need to wear a mask or some mask made of cloth, in order to provide a sense of security for themselves and for the office personnel that surrounds them. In term of outpatient clinic, long lines will now be the norm as well for entry into outpatient clinics and/or a swab test before entering the building.
In terms of patients that are hospitalized, although the general rules is one (1) family member per patient, a stricter enforcement of this rule is necessary, and security check points for temperature checks and screening for risk factor would need to be installed at the doors.
The pandemic presents a unique scenario for the oncology ward, as a heavier screening should be installed for individual who possess cancer, and their chemotherapy, radiotherapy and surgery.
For patients who are scheduled, individual rooms for immunocompromised patients are necessary, in order to prevent contact with suspected COVID-19 patients. This has a direct impact, especially on individual who have lung cancer, and need surgical intervention. The same would apply to individuals who have breast cancer and women who possess gynecologic cancer as well and need to be intervened.
Surgeons who are operating as leaders of the operating theater should use the most restrictive PPE, in order to protect their personnel inside and outside the operating room and key personnel, such operating room nurses and surgical technologist, which clean and sterilize instruments.
Patients in the United States and territories such as our Puerto Rico are using complementary, alternative and integrative medicine (although there is no data on the uses in Puerto Rico). Increases were seen from 2012 to 2017 in the use of complementary health approaches in the past 12 months among U.S. adults for all modalities. The use of yoga increased from 9.5% to 14.3%, while the use of meditation increased more than three-fold from 4.1% in 2012 to 14.2% in 2017. The use of chiropractors increased from 9.1% to 10.3% .
The new normality in our healthcare system includes Complementary, Alternative Medicine plus Integrative Medicine (CAM + IM), and we need more data in states and territories on the use of these modalities in our healthcare system.
There is no cure for the SARS-CoV2, through the whole spectrum of medicine (CAM+IM), and as global citizen we are called to work together to mitigate the deadly effects caused by the pandemic. Therefore, instead of working on our differences, we should work on our similarities for the benefits of patients and healthcare personnel. Increasing the immune response, for not only our patients but also our health care providers and maintenance personnel is not only key for controlling the virus but the humane thing to do.
A couple of examples we should embrace: sharing research freely across countries, document therapeutic modalities and their outcome, and focusing on mechanism of action of each of the therapeutic approaches.
Initially, “social distancing” now “physical distancing” has indeed flattened the curve, in some areas not to the optimal level we would expect and definitely with consequences in all economic sectors such as public and private school, the manufacturing and construction industry and mayor sports events. Although the term essential service is now the termed coined for some economic sectors to remain open such as supermarket, gasoline stations, pharmacy and hospitals in a global context of “shelter in place”. However, our naturopathic medicine doctors kept providing services to patients through alternate modes of delivery, ensuring patient safety for their conditions.
In the US, in population dense areas, the healthcare system is overwhelmed, daily news on the New York crisis is the order of the day, from shortage of ventilators to shortage of PPE (Personal Protective Equipment), the ethical problem is who has the right to a ventilator? From a rapid review of the local press the young and those with more of potential life years are getting treatment while those in critical conditions are getting more of a palliative treatment. Compounding this problem is the shortage of life-saving medicines to treat hypertension in hospitalized settings such as Epinephrine, Dobutamine, Enaliprat at this date according to the FDA Drug Shortages .
Individuals with breast cancer have increased risk of metastasis due to the proximity of lungs and highly organized lymphatic vasculature. As the usual organ of metastasis, individuals with breast cancer, which have a decreased immunologic system, are seeking more information to increase their health while waiting for treatments and surgery. Although there are two scenarios, we are addressing the patient that is resistant to compliance to chemotherapy and the patient that seeks complementary medicine, but is adequately informed about safe practices that promote chemotherapy, on the basis that some alternative medicine can mitigate the effects of chemotherapeutic agents.
Naturopathic Medicine Doctors, who specialize in Oncology, are also well prepared in providing information that complements oncologic treatment [5-9].
These are serious considerations to find another way to tackle preventive medicine and how can we insert a different healthcare system into our population. A more preventive medicine approach is highly needed to stop the up scaling of dangerous diseases such as cancer. A door of opportunity is in sight for CAM+IM to open, and provide the necessary tools from a technology driven medicine.
Patients with Chronic Disease such as Cancer, have a new factor to take into account, the fear of acquiring the disease by entering into a Hospital or outpatient clinic. Providers are racing to attend the growing necessity of telemedicine and long distance health provision under extreme circumstances by passing essential diagnostic maneuvers such as physical examination, therefore providing continuity of care in an emergency-war like scenario, where life-ending bullets are not the cause of death but slow chronic and undertreated diseases.
How do we approach these patients? A dire need to reopen medical offices of all the spectrum of medicine is needed to rescue patients from their shelter in place homes.