Personalized Risk–Benefit Ratio Adaptation of Breast Cancer Care at the Epicenter of COVID-19 Outbreak

Abstract

Northern Italy has been one of the European regions reporting the highest number of COVID-19 cases and deaths. The pandemic spread has challenged the National Health System, requiring reallocation of most of the available health care resources to treat COVID-19-positive patients, generating a competition with other health care needs, including cancer. Patients with cancer are at higher risk of developing critical illness after COVID-19 infection. Thus, mitigation strategies should be adopted to reduce the likelihood of infection in all patients with cancer. At the same time, suboptimal care and treatments may result in worse cancer-related outcome. In this article, we attempt to estimate the individual riskbenefit balance to define personalized strategies for optimal breast cancer management, avoiding as much as possible a general untailored approach. We discuss and report the strategies our Breast Unit adopted from the beginning of the COVID-19 outbreak to ensure the continuum of the best possible cancer care for our patients while mitigating the risk of infection, despite limited health care resources. The Oncologist 2020;25:1-8 Implications for Practice: Managing patients with breast cancer during the COVID-19 outbreak is challenging. The present work highlights the need to estimate the individual patient risk of infection, which depends on both epidemiological considerations and individual clinical characteristics. The management of patients with breast cancer should be adapted and personalized according to the balance between COVID-19-related risk and the expected benefit of treatments. This work also provides useful suggestions on the modality of patient triage, the conduct of clinical trials, the management of an oncologic team, and the approach to patients' and health workers' psychological distress.

Impact of COVID-19 Outbreak on Cancer Patient Care and Treatment: Data from an Outpatient Oncology Clinic in Lombardy (Italy)

“…Six papers described the management of cancer patients during the COVID-19 pandemic in Lombardy’s hospitals where specialized centers (hubs) with dedicated multidisciplinary “hub teams” were identified to treat oncologic patients [ 3 , 15 , 16 , 17 , 18 , 19 ]. In particular, these works discussed the hospital strategies to ensure the continuum of the best possible cancer care by estimating the individual patient’s risk of infection based on both the epidemiological considerations and individual clinical characteristics (in particular age and number of comorbidities).…”

Hughes et al. (2020) 'I feel cancer patients have been neglected'.

“…All COVID-19 perceptions were associated with pre-COVID-19 depression, anxiety and optimism, which was supported by the qualitative data. Despite concerns of heightened COVID-19-related anxiety in the cancer population [15,18], these results suggest that women do not feel they are at high risk of COVID-19 illness.…”

“…infection and cancer prognosis are recommended [13,15] which postpones routine follow-up in the absence of symptoms. However, high COVID-19-related anxiety is associated with reporting more somatic symptoms [33], and so women with high cancer-related anxiety due to missed screening may report more symptoms, leading to unnecessary healthcare contacts and exposure to COVID-19.…”

“…Although data on the risk and outcomes of COVID-19 in breast cancer is currently lacking, advancing age, comorbidities and chemotherapyinduced immunosuppression present particular challenges [13]. Widespread measures have been implemented to reduce infection including postponement of surgery and routine followup, and switching to oral therapies where possible [14][15] which may have resulted in shortterm mental health and longer-term oncological implications [12,16] requiring further investigation.…”

“…It may be assumed that cancer survivors will experience higher psychological distress during the COVID-19 pandemic due to perceived vulnerability [15] and concerns around disruption of follow-up care [8], however the limited available empirical evidence is mixed [17][18].…”