What your doctor reads on Medscape.com:
8 APRIL 2020 — The guideline on COVID-19-related triage of patients with breast cancer was published on March 24, 2020 by the COVID 19 Pandemic Breast Cancer Consortium, which consists of representatives from the National Accreditation Program for Breast Centers (NAPBC), the Commission on Cancer (CoC), the American Society of Breast Surgeons (ASBrS), and the National Comprehensive Cancer Network (NCCN)..[1]
As a general suggestion, the rules advise that patients' case status (ie, risk of death and time-frame) needs to be determined by a multidisciplinary team, ideally in a multidisciplinary setting (breast tumor conference). This multidisciplinary discussion needs to be documented within the medical record.
Phase I – Semi-urgent situation (preparation phase)
In this setting, the hospital has few COVID-19 patients, its resources will not be exhausted, it still has ventilation capability within the intensive care unit and the COVID-19 evolution will not be in a phase of rapid escalation. Here, the rule of thumb recommends limiting surgery to patients whose survival is more likely to be in danger if their procedure will not be performed inside the subsequent 3 months.
Phase I cases that have to be handled as quickly as possible (taking into consideration that the hospital status is more likely to change in the subsequent few weeks) include the next:
- Patients completing neoadjuvant treatment
- Patients with estrogen receptor (ER)-positive/progesterone receptor (PR)-positive/HER2-negative tumors in clinical stage T2 or N1
- Patients with triple negative or HER2-positive tumors
- Patients with discordant biopsies are more likely to be malignant
- Excision of a malignant reoccurrence
Note that in some cases of ER+/PR+/HER2-, triple-negative, or HER2-positive tumors, institutions may decide to perform surgery reasonably than subject a patient to an immunocompromised state with neoadjuvant chemotherapy. These decisions depend upon institution resources. The guidelines recommend performing breast-conserving surgery each time possible and recommend postponing definitive mastectomy and/or reconstruction until after the COVID-19 pandemic has subsided, provided radiation oncology services can be found.
Cases that needs to be postponed include the next:
- Excision of benign lesions (e.g. fibroadenomas, nodules)
- Duct excisions
- Discordant biopsies are probably benign
- High-risk lesions (e.g. atypia, papillomas)
- Prophylactic surgery for cancer and other diseases
- Delayed sentinel lymph node biopsy for cancer identified by excisional biopsy
- cTisN0 lesions – ER positive and negative
- Re-resection surgery
- Tumors that reply to neoadjuvant hormone treatment
- Clinical stage T1N0 ER+/PR+/HER2- tumors (these patients can receive hormone therapy)
- Inflammatory and locally advanced breast cancer (these patients should receive neoadjuvant therapy)
Alternative treatment approaches to think about (where resources permit) include the next:
- Patients with tumors in clinical stage T1N0 ER+/PR+/HER2- can receive hormone therapy.
- Patients with triple-negative and HER2+ tumors may receive neoadjuvant therapy before surgery.
- Some women with clinical stage T2 or N1 ER+/PR+/HER2- tumors may receive hormone therapy.
- Patients with inflammatory and locally advanced breast cancer should receive neoadjuvant therapy before any surgery.
The guidelines indicate that many ladies with early-stage, ER+, breast cancer don’t profit substantially from chemotherapy. Generally, these are women with stage 1 or limited stage 2 cancer, particularly those with low- to intermediate-grade tumors, lobular breast cancer, low OncotypeDX scores (< 25), or "luminal A" signatures. There is high-level evidence of the protection and efficacy of 6 to 12 months of primary endocrine therapy prior to surgery in such women, which can allow for delay of surgery.
Phase II – Urgent situation
In this setting, hospitals have high numbers of COVID-19 patients, ICU and ventilator capability is restricted, supplies are limited, or hospital COVID-19 evolution is in a phase of rapid escalation. Guidelines recommend limiting surgery to patients whose survival is more likely to be in danger if their procedure will not be performed inside the subsequent few days.
Cases that require treatment as soon as possible (taking into consideration that the situation within the hospital is more likely to change in the subsequent few days) include the next:
- Incision and drainage of a breast abscess
- Evacuation of a hematoma
- Revision of an ischemic mastectomy flap
- Revascularization/revision of an autologous tissue flap (nonetheless, autologous reconstruction needs to be postponed)
All breast surgery needs to be postponed. In appropriate cases, neoadjuvant therapy needs to be considered; within the remaining cases, statement is protected.
Phase III
In this case, all hospital resources are getting used for COVID-19 patients, there isn’t a ventilator or intensive care capability, or supplies are exhausted. Guidelines recommend limiting surgery to patients whose survival is more likely to be in danger if their procedure will not be performed inside the subsequent few hours.
Cases that require treatment as soon as possible (taking into consideration that the situation within the hospital is more likely to improve inside a couple of hours) include the next:
- Incision and drainage of a breast abscess
- Evacuation of a hematoma
- Revision of an ischemic mastectomy flap
- Revascularization/revision of an autologous tissue flap (autologous reconstruction needs to be postponed)