Five Questions With: Dr. Theresa A. Graves

Breast surgeon Dr. Theresa A. Graves is director of the Breast Cancer Center at the Lifespan Cancer Institute and director of the Center for Breast Care at Brown Surgical Associates Inc.

Graves discusses what impacts the COVID-19 health crisis has had on the practices, and explains how cancer patients were able to continue to receive care even as virus cases surged in Rhode Island.

PBN: How has the COVID-19 crisis affected day-to-day routines at the Breast Cancer Center?

GRAVES: The COVID-19 pandemic has transformed the way we conduct our medical practice, but we are not compromising the quality of care that is being delivered. We have further sharpened our attention to the individual needs of each of our breast cancer patients.

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The daily routines of the Center for Breast Care at the Brown Surgical Associates and the Breast [Cancer] Center at the Lifespan Cancer Institute have become a mixture of tele/videoconferencing with patients for routine checks and face-to-face consultations with new patients, patients in active treatment, or patients with new complaints.

Management of our patients, often virtually, is optimized to provide the best oncologic care while not compromising outcomes due to COVID-19 restrictions. The phases of the pandemic have required continuous adaptation according to the conditions as they arise. We continue with two weekly, multidisciplinary tumor boards at the Lifespan Cancer Institute, which are conducted through videoconference. These are conducted with the same attention to detail to determine the best course of action for the patient’s cancer treatment.

We then layer the constraints of the pandemic restrictions to modify, if necessary, our recommendations for patient safety, constraints of hospital resources, and staff precautions. Many of our patients have been enrolled in well-established plans of medical treatment that can safely avoid surgery for up to six months if necessary.

There is a consortium of national societies addressing breast cancer treatment recommendations in detail, to be modified based on the various stages of the pandemic, and individual community and hospital constraints. We are currently initiating a reentry to treatment phase to maximize our breast cancer patients’ access to definitive management while still maintaining strict precautions for exposure and minimizing patient risk.

PBN: Do you expect that having to adapt to the health crisis will result in any lasting changes in daily procedures, patient care, or services at the center?

GRAVES: We are using more telemedicine, reducing patient visits, delaying or eliminating treatments or tests; we are reducing risks while conserving resources. We are providing care in outpatient settings and remaining connected as a multidisciplinary team in innovative ways. Many of these modifications may prove to be efficient while maintaining excellent outcomes.

The widespread use of videoconferencing allows us to decentralize our care beyond the pandemic, providing an opportunity to offer specialized multidisciplinary services in the communities where our patients live and work.

Heightened awareness of infectious risk in our potentially immune-compromised cancer patients is likely to remain even in the post-COVID environment. As we reenter the real-time treatment phase for our patients, we remain dedicated to minimizing patient risk in these vulnerable patients. There will be no compromise to the quality and personalized patient care.

PBN: Has the Breast Cancer Center been able to continue caring for seriously ill patients even while the state’s response to COVID-19 meant postponement of most medical procedures?

GRAVES: Throughout the COVID-19 pandemic, cancer care has been classified as non-elective and triaged as necessary surgery/treatment at Lifespan [Corp.] and the Lifespan Cancer Institute Breast [Cancer] Center. The critically ill patients, or patients in the top tier of medical necessity, have been cared for throughout the pandemic while remaining highly sensitive to the increased risk these treatments and surgical procedures may introduce to the patient. They have been assessed carefully for risk/benefit of definitive treatment.

We have carefully considered the recommendations for prioritization, treatment and triage of breast cancer patients that were proposed by a consortium of national breast and cancer societies. These guidelines assist with uniform and well-researched plans of care.

Many of our breast cancer patients are triaged to medical management with little or no risk to the patient, unchanged clinical outcome and no expenditure of resources. This is especially true in the majority of our patients who present with estrogen receptor positive breast cancers.

PBN: Will it be harder for patients to get appointments at the center as restrictions ease and daily life begins to return to normal?

GRAVES: Patient appointments at the Brown Surgical Associates Breast Center and the Lifespan Cancer Institute Breast [Cancer] Center continue to schedule via telemedicine or in-person office visits, weighing the needs and associated risks to the patient. As we reenter into real-time patient care, we do not anticipate delays in access to care.

With this dedication to returning to a normal schedule, we are prepared to increase hours and operative scheduling as needed to accommodate any backlog of patients diagnosed during the pandemic and those new patients diagnosed as screening opportunities continue to increase.

PBN: Are you concerned that some breast cancer patients may have gone without treatment over the past few months?

GRAVES: Patients who were diagnosed with breast cancer immediately preceding and during the COVID-19 pandemic crisis were carefully assessed in a multidisciplinary team setting with detailed treatment recommendations formulated and outlined with the patients.

We have kept careful records of each patient and their course of treatment with anticipated plans for reevaluation. Frequent telemedicine contact with each patient has allowed the Breast Center to evaluate the effectiveness and compliance with the recommendations and alter plans accordingly.

With frequent evaluations, we were able to determine those patients who have required more-immediate definitive care. Those patients who were unable or reluctant to obtain screening or diagnostic tests to identify cancers during this time frame are strongly urged to seek medical attention now to assist with diagnoses which can be safely treated.

Elizabeth Graham is a PBN contributing writer.