For breast cancer care during the COVID-19 pandemic, a panel of experts has recommended that patients be divided into one of three categories based on the severity of their condition and the potential effectiveness of treatments.
Top priority are patients who require urgent care immediately because of life-threatening conditions, while the second group includes those who do not need immediate treatment but should start it before the pandemic is over. The remaining patients are those for which treatments can be safely delayed.
The recommendations come from experts from the American Society of Breast Surgeons (ASBrS), the National Accreditation Program for Breast Centers, the National Comprehensive Care Network (NCCN), the Commission on Cancer, and the American College of Radiology.
“As hospital resources and staff become limited, it is vital to define which breast cancer patients require urgent care and which can have delayed or alternative treatment without changing survival or risking exposure to the virus,” said Jill Dietz, MD, president of the ASBrS, in a press release.
The recommendations are detailed in an article titled “Recommendations for Prioritization, Treatment and Triage of Breast Cancer Patients During the COVID-19 Pandemic,” which has been accepted for publication in an upcoming issue of Breast Cancer Research and Treatment.
“Doctors should use the recommendations to prioritize care for these patients and adapt treatment recommendations to the local context at their hospital,” said William Gradishar, MD, chair of the NCCN NCCN Clinical Practice Guidelines in Oncology Panel for Breast Cancer.
The multidisciplinary team of experts collaborated by teleconference to define three priority levels (A, B, and C) based on the severity of a patient’s condition and the potential efficacy of treatments.
Priority A patients are defined as those with a condition that is immediately life-threatening, clinically unstable, or completely intolerable where a short delay in treatment would significantly change patient outcomes. According to the panel, “these patients are given top priority even if resources become scarce.”
Patients in the priority B category — which represents most breast cancer patients — are those who do not have immediate life-threatening conditions but require treatment or services that cannot be delayed until the end of the pandemic. A short delay in treatments of six to 12 weeks “would not impact overall outcome for these patients.”
Priority C patients are those that can indefinitely delay certain treatments or services until the pandemic is over without affecting prognosis.
For outpatient visits during the pandemic, “the majority of encounters should be conducted remotely via telemedicine,” the team wrote. The decision to conduct in-person visits must weigh the risk of viral infection with the need for direct evaluation.
For priority A patients, an in-person assessment may be conducted for unstable post-operative patients or those with cancer-related emergencies.
Priority B patients — those who are newly diagnosed, develop new problems such as infection or side effects from therapy, are on intravenous chemotherapy or treatments needed for surgery, are post-operative, or are recommended for radiation therapy — “should be evaluated by at least one member of the multidisciplinary team in-person or remotely depending on need.”
Patients in priority C can be seen remotely or delay clinical visits until after the pandemic.
While priority A patients would normally not require breast imaging, priority B patients may need diagnostic imaging for an abnormal mammogram or suspicious breast symptoms, certain biopsies, and breast MRI to measure the extent of disease or pre-chemotherapy assessment. Patients returning for short-term follow-up mammograms, ultrasounds, or routine breast exams should be postponed after the COVID-19 pandemic.
“All screening exams including mammography, ultrasound, and MRI should be placed in Priority C,” the panel said. Those under the age of 40 who carry BRCA mutations may need screening if delays longer than six months are expected.
Although deferring surgeries may help minimize the use of operating room resources, delays may impact outcomes for breast cancer patients.
Patients with invasive breast cancer should be assessed with “multidisciplinary input” to determine if they are eligible for neoadjuvant therapies such as chemotherapy, radiation therapy, or hormone therapy during the pandemic.
Those who have completed neoadjuvant chemotherapy can delay surgery for up to eight weeks and should not be adversely affected. If limited resources do not allow surgery, “additional non-surgical therapy should be considered.”
Short-term surgical delays for those with hormone receptor-positive breast cancer taking hormone therapy should not adversely impact patient survival.
Patients who have breast cancers that are estrogen receptor-positive (ER+) or HER2 negative who also receive hormone therapy can delay surgery for six to 12 months. Those with triple-negative breast cancer should receive standard chemotherapy.
For patients with advanced, metastatic breast cancer, adjustments to treatment dose and schedule “are reasonable to reduce clinic visits, bloodwork, and development of significant side effects.” Those without signs of tumor progression may defer scans for routine restaging.
Patients receiving chemotherapy may require supportive care to reduce side effects and “should remain a high priority.”
The majority of patients needing radiation therapy fall into the priority B category. Treatment delayed more than eight weeks can affect those with locally-advanced or inflammatory conditions after chemotherapy while, in contrast, delaying radiation therapy by 20 weeks in early-stage, ER+ patients should not affect outcomes.
“This information should be used to organize a process of structured decision-making for the care of patients with breast disease during the COVID-19 pandemic,” the experts wrote.