When the World Throws You a Curve Ball: Lessons Learned in Breast Cancer Management

Abstract

In the care of patients with operable breast cancer, there has been a shift toward increasing use of neoadjuvant therapy. There are benefits to neoadjuvant therapy, such as monitoring for response, as well as an increased rate of breast conservation and reduction of potential morbidity associated with breast surgery, including axillary management. Among patients with highly proliferative tumors, such as HER2-positive or triple-negative breast cancer, those with residual disease are at higher risk of recurrence, which informs the recommended systemic therapy in the adjuvant setting. For instance, in patients with residual disease after neoadjuvant chemotherapy and HER2-targeted therapy, there is a role for adjuvant trastuzumab emtansine for those with residual disease at the time of surgery. The same holds true regarding the role of adjuvant capecitabine in patients with residual disease after neoadjuvant chemotherapy. With the added complexities of treating patients in the era of the COVID-19 outbreak, additional considerations are critical, including initiation of surgery within an appropriate time from completion of neoadjuvant therapy. National consensus guidelines on time to surgery must be developed to improve measurement and comparison across systems. In addition, there is emerging radiation treatment management research addressing a number of factors, including hypofractionation, role of proton beam therapy, safe omission of radiotherapy, and preoperative radiotherapy with or without drug combination. In this article, the multidisciplinary approach of treating patients with operable breast cancer is highlighted, with updates and future considerations described.

The effect of COVID-19 on breast cancer care and treatment in North America: A scoping review

“…Again these findings were more pronounced in patients with stage I or II cancers. 18 Contrary to these findings, other studies have shown no association between delay in surgery (>30days) and overall or disease-specific survival. 18 These inconsistent findings may in part be due to different studies that lack established benchmarks that define time to surgery.…”

“… Retrospective cohort study 100% Johnson et al 17 Time to surgery - 12 weeks Delaying surgery for 12 weeks may decrease overall survival (OS) in BC (HR 1.46, 95% CI 1.28–1.65). OS was decreased in stages I (HR 1.27, 95%CI 1.16–1.40) and II (HR 1.13, 95%CI 1.02–1.24), but not in stage III (HR 1.20, 95% CI 0.94–1.53) Systematic review and meta analysis 100% Obeng-Gyasi et al 18 Time to Surgery - 4 weeks 6–8% increased risk of mortality for each 4-week delay in time to surgery. Delays in BC surgical care for up to 12 weeks could result in 6100 excess deaths in the US.…”

“…However, another study showed that patients undergoing surgical management within 21 days of completion of neoadjuvant therapy had better overall survival and relapse-free survival. 18 More recent data shows that surgery within 6 weeks of chemotherapy may improve recurrence-free survival. Results accumulated from these multiple studies suggest that patients receiving neoadjuvant therapy may benefit from treatment within 3–6 weeks of completion of systemic therapy.…”

“…Results accumulated from these multiple studies suggest that patients receiving neoadjuvant therapy may benefit from treatment within 3–6 weeks of completion of systemic therapy. 18 …”

“… 17 Thus, in future waves of COVID-19, guidelines for surgery delays according to tumor stage should be revisited. 13 , 15 , 17 , 18 Another study showed a reduction in overall survival and disease-specific survival with each 60-day increase in time to surgery reported. Again these findings were more pronounced in patients with stage I or II cancers.…”