How should cancer care providers balance the needs of treatment against the risk of COVID-19? A group of representatives from multiple cancer care organizations with expertise in the multidisciplinary management of breast cancer has sought to answer this question through their set of recommendations for prioritizing, treating, and triaging patients with breast cancer during the pandemic. In this interview with i3 Health, Jill R. Dietz, MD, FACS, President of the American Society of Breast Surgeons (ASBrS) and first author of the recommendations, which are soon to be published in Breast Cancer Research and Treatment, explains the reasoning behind the recommendations and shares advice for physicians involved in breast cancer care as they seek to manage treatment during the COVID-19 pandemic.
To what extent does breast cancer place patients at increased risk from COVID-19?
Jill R. Dietz, MD, FACS: I'll start by saying that I'm not an expert concerning patients who have COVID. The guidelines that we wrote deal with how to take care of patients who don't have COVID and who do have breast cancer. That being said, this pandemic started several months ago in China, so we're starting to see data out of China. What we're finding out is—and this isn't specific to breast cancer—that patients who have cancer have an increased risk of developing COVID-19.
There are a lot of reasons why that could be. One is because patients with cancer are coming to the hospital frequently for treatment and they have higher exposure; another is that this phenomenon could possibly be related to the patients being immunocompromised or stressed from their cancer treatments. No one yet knows, but patients who have cancer have a higher chance of getting COVID, and patients with cancer who get COVID have a higher chance of dying from COVID than COVID patients who don't have cancer, so as health care advisors, we worry about exposing our patients to the virus.
Can you speak to the significance of this publication?
Dr. Dietz: The goal of this multi-society, multidisciplinary recommendation is to help us in making these really, really difficult choices. The purpose is to have medical oncologists, surgeons, radiologists, and radiation oncologists all get together and look at the data that's already available, not necessarily from COVID, and help people to make decisions in order to triage each patient.
Everything we offer to a cancer patient in terms of treatment is a discussion of risks versus benefits: the risks of this treatment are these, and the benefit is this. Then we help the patient to make a decision. Well, now we have to add in the risks of COVID. Patients are coming to the hospital and getting exposed, and we know that for patients with cancer, the rate of having a complication or dying from COVID is higher than if they did not have cancer. We also have to balance the risks not only to the patients but also to the health care workers and the community.
That's why the recommendations are tiered, especially for a place like New York where the concern is that they'll have to turn people away because they don't have ventilators and are running out of personal protective equipment (PPE). In New York, they have moved to only operating on Tier A patients because they are in the heart of the pandemic. That means that anyone who has recently been diagnosed with breast cancer is not getting operated on and is put on medical treatments or, if indicated, observed. Where I am, in Cleveland, we have a very aggressive governor who was the first to close down schools in the country, and we've had a stay-at-home order for a very long time; we have also initiated early testing for the virus. Because of these actions, fewer people are getting and spreading the virus. I think we're predicted to see our peak this week instead of at the end of April, and we're not going to run out of PPE, and we're not going to run out of ventilators. We may continue to be able to treat high-priority Tier B patients.
We also know that for women who have small, low-grade estrogen receptor–positive tumors, there's no impact or detriment to their survival if we put them on a pill and say, "I'll see you when the pandemic is over in a few months." It keeps them safe and does not cause any decrease in their survival. At University Hospitals, we stopped screening mammograms weeks ago in accordance with the Society of Breast Imaging recommendation, and now we're not doing any elective surgery at all; we are limiting our surgeries to those patients who have a higher Tier B priority.
Is there any concern that implementing these recommendations to reduce patients' risk of COVID exposure could increase the risk of negative outcomes from their cancer?
Dr. Dietz: The answer to that question varies according to the priority. If you're not taking people who have urgent Tier A problems to the operating room, those people could die. In contrast, patients with Tier C problems will not have their survival impacted in any way by delaying, and that's why they're in priority C. For Tier B, the answer is maybe; it depends on how long you delay. There's some information out there about the timing of various procedures. At some point, you're really weighing the extent to which we might start to see a difference in local recurrence if we delay that radiation or surgery any longer against the risk of exposure or the use of PPE.
The manuscript is more detailed than the online executive summary that we distributed based on our society members' pleas for guidance during this crisis. The tiered tables and additional text in the manuscript provide a guide to help providers even further, breaking the information down to various tumor types in different situations.
We just opened a registry with the ASBrS to keep track of changes in management due to COVID. In the end, we'll be able to determine answers to the questions you're asking. Maybe we will find that by deferring treatment, we have impacted local recurrence and maybe even survival in some patients, but we may also find out that by following these recommendations and keeping people away from the hospital, we were actually able to improve patients' survival because they weren't developing COVID-related complications.
That's the idea behind the registry that the ASBrS is doing and the idea behind the priority charts. Is this recommendation perfect? Probably not. We've pulled it together in five days, but it needed to get out there. It's a guide, and hopefully it will help providers to make very difficult decisions during the pandemic.
What advice can you give to surgical, medical, and radiation oncologists as they consider how to best implement these recommendations, given their situation and the current status of the COVID pandemic in their region?
Dr. Dietz: The paper discusses some of the issues that physicians should be aware of, depending on where their region is in the curve. For example, how many hospital beds are full, and what's the ability of the institution to take on patients? The answers to these questions essentially depend on where a physician's region is in the COVID crisis. If the cancer providers can get that feedback from their hospital, then that helps them to know where they should be in the triage process.
It really should be the institutions that are guiding the providers, by saying, for example, that while we're certainly not doing any Tier C procedures, now we're in a bind and we're not going to do any B3s or B2s, and we'll reassess in three weeks. This process involves working together with senior administration to figure out the overall COVID situation for the region and how it affects the hospital, and then use the guidance to help determine care.
Something else that can help providers is the ASBrS registry we just opened to keep track of changes in management due to COVID. If providers put their information into the registry, they'll actually be able to determine if they're doing similar things to the rest of surgeons entering data.
Is there anything else you'd like to add?
To me, the biggest success of this effort was that various societies realized that we were all making our own guidelines, so we decided to combine efforts, 19 of us from five different societies. Additional societies were interested in joining as well, but the process was so fast that time didn't allow. I was pleased by how collaborative the group was and how well everyone worked hard together to get the help out there as soon as possible.
About Dr. Dietz
Dr. Dietz is the Director of Breast Center Operations at University Hospitals Cleveland Medical Center and is an Associate Professor of Surgery at Case Western Reserve University School of Medicine. She is the President of the ASBrS and chairs their patient-reported outcomes committee. In addition, she serves as the ASBrS representative and Vice Chair of the Standards and Accreditation Committee of the National Accreditation Program for Breast Centers (NAPBC). She is the former Chair of the Breast Fellowship Program Directors' Committee of the Society of Surgical Oncology (SSO) and is a current member of the SSO Breast Disease site working group. Dr. Dietz has been the principal investigator of multiple research studies focused on understanding breast cancer. Her areas of research have included the effects of radiation on reconstruction, patient-reported outcomes and value-based care, oncoplastic techniques, and the role that genetic factors play in developing breast cancer. Dr. Dietz has authored or coauthored numerous peer-reviewed publications and textbook chapters related to her expertise, and she has served as an expert consultant for multiple organizations.
For More Information
Dietz JR, Moran MS, Isakoff SJ, et al (2020). Recommendations for prioritization, treatment and triage of breast cancer patients during the COVID-19 pandemic. Available at: https://www.breastsurgeons.org/docs/statements/ASBrS%20NAPBC%20CoC%20NCCN%20ACR%20BC%20Covid%20MANUSCRIPT%20BCRT%20Rev1-4_7_2020%20_1022amEST.pdf
Society of Breast Imaging (2020). Society of Breast Imaging statement on breast imaging during the COVID-19 pandemic. Available at: https://www.sbi-online.org/Portals/0/Position%20Statements/2020/society-of-breast-imaging-statement-on-breast-imaging-during-COVID19-pandemic.pdf
ASBrS Board of Directors & ACR Board of Directors (2020). ASBrS and ACR joint statement on breast screening exams during the COVID-19 pandemic. Available at: https://www.breastsurgeons.org/docs/news/2020-03-26-ASBrS-ACR-Joint-Statement.pdfTranscript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of i3 Health.