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 advice, the rules advise that patients' case status (ie, risk of death and time-frame) must be determined by a multidisciplinary team, ideally in a multidisciplinary setting (breast tumor conference). This multidisciplinary discussion must 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 usually are not 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 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 should be handled as quickly as possible (making an allowance for 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 relatively than subject a patient to an immunocompromised state with neoadjuvant chemotherapy. These decisions rely upon institution resources. The guidelines recommend performing breast-conserving surgery at any time when 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 must 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 security 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 (making an allowance for 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 must be postponed)
All breast surgery must be postponed. In appropriate cases, neoadjuvant therapy must be considered; within the remaining cases, remark is secure.
Phase III
In this case, all hospital resources are getting used for COVID-19 patients, there is no such thing as 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 (making an allowance for that the situation within the hospital is more likely to improve inside a number 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 must be postponed)