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The American Society of Breast Surgeons has released an executive summary of recommendations for prioritizing, treating, and triaging patients with breast cancer during the COVID-19 pandemic.
"The COVID-19 pandemic poses unprecedented challenges for patients, clinicians and health care systems," write the authors, led by Jill R. Dietz, MD, FACS, President of the American Society of Breast Surgeons.
Written by representatives from multiple cancer care organizations with expertise in the multidisciplinary management of breast cancer, the document provides preliminary recommendations for the triage and treatment of patients with breast cancer during the COVID-19 pandemic. The executive summary was released "in order to get the information out as quickly as possible prior to publication."
"These are recommendations, and are not intended to supersede individual physician judgement, nor institutional policy or guidelines," write Dr. Dietz and colleagues. "These recommendations should be taken in the context of each institution's resources and prevalence of the COVID-19 pandemic in their region. The consortium highly recommends multidisciplinary discussion regarding priority for elective surgery and adjuvant treatments for your breast cancer patients."
The authors note that the recommendations "are subject to change with changing COVID-19 pandemic severity."
Recommendations are presented in a table format and are divided into three categories: Priority A, for patient conditions that are imminently life-threatening and unstable; Priority B, for situations that, while not critical, could have the overall outcome negatively impacted by a delay of more than six to eight weeks; and Priority C, for situations that are stable enough to delay services for the duration of the pandemic.
Outpatient visit situations classified as Priority A include potentially unstable situations such as a hematoma or infection, as well as a new diagnosis of invasive cancer, which the authors suggest could be done over a telemedicine visit. Priority B situations include the new diagnosis of noninvasive cancer, for which the authors recommend telemedicine visits; postoperative patients; and established patients with new problems or symptoms from treatment, for which telemedicine is recommended whenever possible. For breast disease-focused imaging, Priority B situations include diagnostic imaging for breast symptoms or a Breast Imaging Reporting and Data System (BIRADS) 4-5 screening mammogram, as well as biopsies for abnormal mammograms or breast symptoms.
For surgical oncology, Priority A situations include incision and drainage of a breast abscess, evacuation of a hematoma, revision of ischemic mastectomy flap, and revascularization/revision of autologous tissue flap; the authors state that autologous reconstruction should be deferred. Priority B includes neoadjuvant patients finishing treatment, as well as stage T2 or N1 estrogen receptor (ER)-positive/progesterone receptor (PR)-positive/human epidermal growth factor receptor 2 (HER2)-negative tumors, with a note that some of these patients can receive hormonal therapy. For patients with triple-negative breast cancer (TNBC) and HER2-positive disease, the authors note that in some cases, institutions may opt to proceed with surgery instead of subjecting a patient to an immunocompromised state, depending on the resources at hand. Priority B also includes reconstructive surgery (limited to tissue expander or implant placement), discordant biopsies that are likely malignant, and excision of malignant recurrence. The authors state that eligible patients should have breast conservation, provided that they will have access to radiation oncology services and that the risk of multiple visits or deferred radiation is acceptable.
For medical oncology, Priority A situations include neoadjuvant or adjuvant chemotherapy for TNBC and HER2-positive cancer; early-line chemotherapy likely to improve metastatic disease outcomes; completion of previously initiated neoadjuvant or adjuvant chemotherapy, with or without anti-HER2 therapy; continuation of standard adjuvant endocrine therapy with oral agents such as tamoxifen or aromatase inhibitors; and luteinizing hormone-releasing hormone (LHRH) agonists in the adjuvant or metastatic setting to optimize endocrine therapy.
For medical oncology, Priority B situations that are higher priority include the use of neoadjuvant therapy to enable deferral of surgery by six to 12 months for clinical stage I or II breast cancers.
"Many women with early-stage, ER-positive breast cancers [tend] to not benefit substantially from chemotherapy," state the authors. "In general, these include women with stage I or limited stage II cancers, particularly those with low-intermediate grade tumors, lobular breast cancers, low OncotypeDX® scores (<25), or 'luminal A' signatures. High-level evidence supports the safety and efficacy of six to 12 months of primary endocrine therapy before surgery in such women, which may enable the deferral of surgery."
An additional higher-priority situation is adjuvant antibody treatment for HER2-positive cancer, which the authors say may be curtailed after seven months instead of 12 months of treatment, based on clinical trial evidence.
Lower-priority situations in the Priority B category for medical oncology include later-line palliative chemotherapy that is less likely to improve outcomes, as well as antibody treatment (trastuzumab or pertuzumab) for metastatic HER2-positive breast cancer beyond two years of maintenance in patients with minimal disease burden, whom the authors note should be followed for progression every three to six months. In stage I HER2-positive cancer, clinical trial data supports the substitution of trastuzumab-DMI for paclitaxel/trastuzumab for the sake of patient safety or convenience. The authors suggest delaying the addition of CDK4/6, mTOR, or PIK3CA inhibitors to endocrine therapy, especially in the first-line setting and in situations where endocrine therapy alone is providing good tumor control.
Chemotherapy schedules can be modified in order to reduce clinical visits when appropriate. When possible, dexamethasone use should be limited to reduce immunosuppression, and patients should receive granulocyte colony-stimulating factor (G-CSF) growth factor support to minimize neutropenia. Patients receiving LHRH agonists can be given long-acting doses every three months to reduce visits; alternatively, home administration could be considered when possible.
For radiation oncology, Priority A includes bleeding or painful inoperable breast masses, patients already on treatment, and patients with spinal cord compression, brain metastases, or other critical metastatic lesions. Priority B is divided into two categories: Category 1, which involves adjuvant postoperative breast cancer patients within 16 weeks of their last surgery or chemotherapy who have high risk indications for radiation, and Category 2, which involves adjuvant postoperative breast cancer patients within three to six months of their last surgery or chemotherapy who have low-intermediate or intermediate risk indications for radiation.
All of the authors have provided their email addresses for urgent questions related to the treatment of patients with breast cancer during the pandemic.
For More Information
The full text of the executive summary can be viewed here:
Dietz J, Yao K, Kurtzman S, et al (2020). The American Society of Breast Surgeons: recommendations for prioritization, treatment and triage of breast cancer patients during the COVID-19 pandemic: executive summary. Version 1.0. Available at: https://www.nccn.org/members/committees/bestpractices/files/The_COVID-19_Pandemic_Breast_Cancer_Consortium_Recommendations_EXECUTIVE_SUMMARY.pdf
Image credit: National Cancer Institute