Management of Breast Cancer During the COVID-19 Pandemic: A Stage- and Subtype-Specific Approach

Abstract

The COVID-19 pandemic has rapidly changed delivery of cancer care. Many nonurgent surgeries are delayed to preserve hospital resources, and patient visits to health care settings are limited to reduce exposure to SARS-CoV-2. Providers must carefully weigh risks and benefits of delivering immunosuppressive therapy during the pandemic. For breast cancer, a key difference is increased use of neoadjuvant systemic therapy due to deferral of many breast surgeries during the pandemic. In some cases, this necessitates increased use of genomic tumor profiling on core biopsy specimens to guide neoadjuvant therapy decisions. Breast cancer treatment during the pandemic requires multidisciplinary input and varies according to stage, tumor biology, comorbidities, age, patient preferences, and available hospital resources. We present here the Johns Hopkins Women’s Malignancies Program approach to breast cancer management during the COVID-19 pandemic. We include algorithms based on tumor biology and extent of disease that guide management decisions during the pandemic. These algorithms emphasize medical oncology treatment decisions and demonstrate how we have operationalized the general treatment recommendations during the pandemic proposed by national groups, such as the COVID-19 Pandemic Breast Cancer Consortium. Our recommendations can be adapted by other institutions and medical oncology practices in accordance with local conditions and resources. Guidelines such as these will be important as we continue to balance treatment of breast cancer against risk of SARS-CoV-2 exposure and infection until approval of a vaccine.

The Impact of the COVID-19 Pandemic on Breast Imaging

“…The American College of Surgeons (ACS) and the Society of Surgical Oncology released triage guidelines recommending an interim cancellation of most routine surgeries, while still performing breast surgeries for those in more urgent cases 19 , 20 . Some centers, such as Magee-Breast Cancer Program and Johns Hopkins published multi-disciplinary algorithms of how best to triage breast cancer patients, broken down by sub-types program 21 , 22 . Other published tools suggested risk-stratifying patients for breast surgery with the purpose of causing few deleterious effects in patients recommended for postponement 23 .…”

“…In one study from Wuhan, China, over half of patients receiving radiation therapy were unable to complete their regimens during the lockdowns 54 . The pandemic increased the use of neoadjuvant and hormonal therapies prior to surgery, as well as increased genotypic profiling, secondary to deferrals of surgeries 55 . In another study from the Netherlands 1/3 of patients noted that the pandemic affected their cancer care, with most of these noting a shift to telehealth consultations 56 .…”

Changing trends in dermatology practice during COVID ‐19 pandemic: A single tertiary center experience

“…Prominent changes in the clinical practice of various medical disciplines have been observed during the pandemic 2‐5 . Postponing elective procedures, reducing the number of hospital admissions, effective use of telemedicine, implementation of strict triage protocols and obligatory use of personal‐protective equipment were some of the major regulations performed by the health authorities in this extraordinary period.…”

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

“…Likewise, in our understanding, the fact that one-third of respondents opted for NACT in cases of tumors < 1 cm may represent overtreatment, since there are safe options of de-escalating treatment, as occurs in cases of HER2 tumors [43]. A recent single institution guideline recommended upfront surgery for T1N0 HER2 and TN tumors [44].…”