Three days before a scheduled mastectomy to reduce her risk of breast cancer, Merritt Sage's doctors said the surgery was off.
Sage, 18, inherited a gene mutation from her grandmother which makes it more likely she'll get cancer at a young age. She hoped to have the prophylactic surgery this month so she could recover before starting college this fall.
But the coronavirus changed her plans, causing her doctors to cancel the procedure -- a decision Sage said she's come to terms with.
"At first I think I was like, really disappointed -- and kind of frustrated," said Sage, who lives in Little Rock.
"But there are bigger problems going on in the world right now that I need to put more energy toward, and not think of it as something that was taken away from me. ... My time is going to come."
The global spread of a new coronavirus, which has infected more than 715,000 people worldwide, is quietly reshaping cancer-related care in Arkansas.
What's still on, oncologists and administrators say: active treatment such as chemotherapy, urgent surgeries and some bone-marrow transplants, appointments for new diagnoses and enrollment in clinical trials.
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What's off or postponed: Preventive surgeries like Sage's, and some follow-up appointments and scans. Visits from family and supporters -- including a "sitter" to accompany patients receiving infusions -- have been temporarily phased out at some sites.
At CARTI, a cancer treatment center with more than a dozen locations across Arkansas, president and chief executive officer Adam Head said overall patient population is down by about 30% to protect those with "delicate" immune systems.
Trying to reduce traffic in clinics, the group's doctors are reviewing files to determine which individuals may not need to be seen right away, such as people receiving maintenance care and check-ups.
"We've had to look at those types of visits, scans, procedures, and so forth, and push all those out for several weeks," Head said.
"If they're doing pretty well right now, there's no reason to have [them] leave the house, and risk exposure."
Dr. Michael Birrer, who leads the Winthrop P. Rockefeller Cancer Institute at University of Arkansas for Medical Sciences, said the urgent timelines of cancer treatment mean they are keeping most current patients on track with their therapies.
"Patients are expressing a concern about, can I see you? Will I get my chemotherapy? And will it be business as usual?" he said.
"Where we're making changes would be primarily in the less-critical visits ... such as for breast cancer patients who are multiple years out of treatment, and they have no evidence of disease."
It's a balance, Birrer said, of providing needed oncology care and being reasonable about who really needs to come into the hospital.
VULNERABLE PATIENTS
Even outside a pandemic, cancer patients are vulnerable to infection. Chemotherapy reduces white blood cell counts, making it hard for the body to fight sickness. Surgical wounds get infected easily, and some patients who have had transplants take immunosuppressant drugs.
Additionally, "liquid tumor" cancers, like multiple myeloma and leukemia, themselves affect cells that are part of the immune system, Birrer said.
That par-for-the-course vulnerability has made oncologists cautious as the coronavirus continues its march across the world.
"Oncologic common sense tells us that it's unlikely that covid-19 infection in cancer patients is going to be kinder and gentler. It likely might be worse," Birrer said, referring to the disease caused by the virus.
On Friday, the federal Centers for Disease Control and Prevention published a guide urging cancer patients and their caregivers to closely monitor for symptoms of covid-19 and take steps such as washing hands, limiting social contact and laying in a supply of other medicines in case they get sick and have to stay home.
Fortunately for doctors, cancer patients tend to be receptive to advice, and guidelines to prevent infection are familiar, said Dr. Gregory Oakhill, a partner with Highlands Oncology Group in Northwest Arkansas.
"We're preaching this to the patients all the time," he says.
"They're well aware of the importance of ... good hygiene and avoiding infection risk ... they're probably better-prepared than most other people in the general population."
What's not clear, people involved in cancer care in Arkansas said, is what will happen in their practices moving forward.
All said they've been thinking about the issue since earlier this year. More intense preparations, staff screenings and visitor restrictions ratcheted up as the first cases were discovered in Arkansas this month.
WEEK-TO-WEEK EVALUATION
Head expects CARTI to reevaluate from week to week what to do next. For example, the center last week added restrictions banning most visitors, except for those accompanying first-time, physically challenged or surgical patients.
For people working in health care, “you don’t want a situation like this to happen — but when it does, you’re ready to rise to the occasion,” he said.
Rockefeller Cancer Institute’s Birrer said most conversations about what will unfold in the long term are taking place at UAMS. A major concern is not the length of the outbreak, but its peak, and the pressure that will place on health systems, he said.
One area under review is bone-marrow transplant schedules, looking at who may not have a readily available match or whose disease is not progressing quickly, to see if those visits can be staggered.
Highlands Oncology Group’s response is also “in flux,” changing almost by the day, Oakhill said.
“The thing that’s most awkward, I think, for me over the last week, is kind of not hugging my patients, and shaking their hands when they come in,” he added.
“It’s probably affected me more than anything else, because they’re like our family.”
Trust built with her provider is part of why Sage was able to accept her doctors’ decision, she said. If she can’t have the surgery later this spring, she’ll probably have to wait until next summer, after the school year.
Maha Witherington said she hasn’t received any news about her upcoming annual appointment, which is set for June. The 63-year-old from Bryant was diagnosed with breast cancer in 2013.
She said she isn’t concerned yet, and is trying to remain optimistic during the outbreak.
“Hopefully we’ll hear good news soon, and hopefully this will be over, and people will get back to their lives,” she said. “It couldn’t be worse than cancer.”