Recommendations for prioritization, treatment, and triage of breast cancer patients during the COVID-19 pandemic. the COVID-19 pandemic breast cancer consortium

Abstract

The COVID-19 pandemic presents clinicians a unique set of challenges in managing breast cancer (BC) patients. As hospital resources and staff become more limited during the COVID-19 pandemic, it becomes critically important to define which BC patients require more urgent care and which patients can wait for treatment until the pandemic is over. In this Special Communication, we use expert opinion of representatives from multiple cancer care organizations to categorize BC patients into priority levels (A, B, C) for urgency of care across all specialties. Additionally, we provide treatment recommendations for each of these patient scenarios. Priority A patients have conditions that are immediately life threatening or symptomatic requiring urgent treatment. Priority B patients have conditions that do not require immediate treatment but should start treatment before the pandemic is over. Priority C patients have conditions that can be safely deferred until the pandemic is over. The implementation of these recommendations for patient triage, which are based on the highest level available evidence, must be adapted to current availability of hospital resources and severity of the COVID-19 pandemic in each region of the country. Additionally, the risk of disease progression and worse outcomes for patients need to be weighed against the risk of patient and staff exposure to SARS CoV-2 (virus associated with the COVID-19 pandemic). Physicians should use these recommendations to prioritize care for their BC patients and adapt treatment recommendations to the local context at their hospital.

Management of early breast cancer during the COVID-19 pandemic in Brazil

“…Cancer patients are at an increased risk of contagion, infection, morbidity and death [9][10][11]. Emergency guidelines for breast cancer treatment [13][14][15]32,33] have suggested postponing surgery when the risk of progression is low (luminal tumors), initiating NET, extending the application of NACT and/or target therapies to subtypes of adverse biology (TN and HER2), minimizing the extent of surgery, including avoiding the use of autologous tissue in breast reconstruction, and postponing prophylactic surgery.…”

“…The pandemic and the emergency recommendations for EBC treatment impacted on the management strategies of Brazilian breast specialists. According to these recommendations [13][14][15]24,32,33], HRpositive EBC should preferentially be treated using NET. Some societies have suggested that recommendations for the treatment of EBC should be classi ed by degree of priority according to the advice provided in the Ontario Health Pandemic Planning Clinical Guideline for Patients with Cancer [37], with cases of luminal tumors being classi ed as Priority B and surgery being postponed for 3-6 months.…”

“…In HER2 and TN tumors, considerable variations were found in the protocols from the different organizations. In one, TN and HER2 tumors are classi ed as Priority B1, suggesting NACT for tumors over 2 cm or with affected axillae [13]. Others also suggest NACT without specifying the cut-off point for treatment [32,33].…”

“…Cancer patients are at a greater risk of acquiring COVID-19, of developing severe symptoms and of dying compared to the rest of the population, possibly due to their state of immunosuppression resulting from cancer treatment [9][10][11]. Consequently, expert groups have drawn up novel protocols [12][13][14]. The treatment of EBC with a low risk of progression such as ductal carcinoma in situ or invasive hormone-positive tumors could begin, for example, with neoadjuvant endocrine therapy (NET) during the pandemic [15], with surgery being postponed with no negative effect on disease outcome [16][17][18].…”

“…Although the Brazilian medical societies drew up recommendations [24,25], little is known regarding how Brazilian breast specialists have complied with these guidelines. This online survey study aimed to evaluate how Brazilian breast specialists have managed EBC (stage I/II and clinically negative axilla) following publication of emergency treatment protocols [12][13][14]24,25], both at the beginning and during the COVID-19 pandemic, as a function of EBC molecular subtypes [26] and with regards to oncoplastic surgery.…”