Breast cancer treatment in the COVID 19 pandemic
EUBREAST offers access to relevant literature and recommendations for physicians and patients
General recommendations on cancer patient care (ASCO)
- Due to a strong association between anticancer therapy in the past 14 days and severe effects of COVID-19 infection, interrupting anti-cancer treatment in patients with active COVID-19 should be strongly considered.
- Cancer screening procedures that require clinic/center visits such as screening mammograms should be postponed for the time being.
- Routine surveillance in asymptomatic patients considered to be at relatively low risk of recurrence should be postponed.
COVID-19 Guidelines for Triage of Breast Cancer Patients (American College of Surgeons)
- Triage details depend on the regional/institutional circumstances (Phase I – Semi-Urgent Setting; Phase II – Urgent Setting; Phase III – all resources routed to COVID19 patients)
- In Phase I most breast cancer surgeries take place as planned (especially high-risk cases, recurrent BC, neoadjuvant patients finishing treatment), others may be postponed (such as SNB for cancer identified on excisional biopsy, cTisN0 lesions); in T1N0 ER/PR pos HER2 neg patients consider neoadjuvant endocrine therapy!
- In Phase II and III no elective breast surgeries, i.e. surgery restricted to patients likely to have survivorship compromised if not performed within next few days (breast abscess, hematoma, ischemic mastectomy flap etc.)
International Guidelines on Radiation Therapy for Breast Cancer During the COVID-19 Pandemic
- Consider shorter schedules or omitting radiation therapy altogether in low-risk patients (e.g. patients ≥ 65 years and tumor ≤ 30mm with clear margins, pN0, grade 1 or 2, ER+ HER2-)
- Consider delivering radiotherapy as in the FAST and FAST Forward trials for cN0 patients that do not require a boost (options include 28-30Gy once weekly over 5 weeks or 26Gy in 5 daily fractions over 1 week)
- Omit boost in the vast majority of patients unless ≤ 40 years or with significant risk factors for local relapse
- Nodal radiotherapy can be omitted in post-menopausal women requiring whole breast radiation following SLNB in case of T1, ER+ HER2-, G1-2 tumors and 1-2 pos sentinel nodes
- Moderate hypofractionation should be used for all breast/chest wall and nodal radiation therapy (40Gy in 15 fractions over 3 weeks)
Resource for Management Options of Breast Cancer During COVID-19 (SSO – Society of Surgical Oncology)
- Consults and surgeries in case of atypia, benign disease, prophylactic or reconstructive procedures can be deferred for at least 3 months
- Consider endocrine therapy for ER+ DCIS and invasive BC stage I-II with re-assessment every 4 weeks (invasive BC) or 8-12 weeks (DCIS)
- TNBC/HER2+ patients with T2 N0-3 M0 or T0-4 N1-3 M0 tumors should begin neoadjuvant chemotherapy; those with T1 N0 M0 disease should be considered high priority for surgery
- All surgeries amenable to same day discharge and/or 23 h observation should be performed as such
- Consider telemedicine for postoperative and surveillance visits and second opinion consultations
Recommendations for Prioritization, Treatment and Triage of Breast Cancer Patients During the COVID-19 Pandemic: Executive Summary (The American Society of Breast Surgeons / NCCN)
- Three priority categories based on patient’s condition: Priority A – immediately life threatening, clinically unstable; Priority B – non-critical but delay beyond 6-8 weeks could potentially impact overall outcome; Priority C – stable enough that services can be delayed for the duration of the COVID-19 pandemic.
- Priority A surgeries: abscess, hematoma, ischemic flap
- Priority B surgeries: e.g. neoadjuvant therapies finishing treatment; TNBC/HER2+ tumors (in some cases institutions may decide to proceed with surgery versus subjecting a patient to an immunocompromised state); T2 / N1 ER+ HER2- (some may receive endocrine therapy)
- Priority C surgeries: e.g. BC stage I ER+ HER2-, DCIS, atypia, benign lesions, prophylactic surgery
COVID-19: Considerations for Optimum Surgeon Protection Before, During, and After Operation (American College of Surgeons)
- Have minimum number of personnel in the operating room.
- Use smoke evacuator when electrocautery is used.