Information on surgery and adjuvant chemotherapy for breast cancer is a vast amount of material in the medical literature, owing to the progressive evolution of care and improvement of outcomes based on reported/studied advances of that care. Thus, it is a daunting diagnosis for any physician, requiring an exquisite sensitivity to pathology, evidence-based information, knowledge of current protocols, and individualization of care due to age, cognitive ability, and quality of life.
COVID-19 complicating breast cancer and breast cancer complicating COVID-19
Breast cancer patients are particularly at risk with COVID-19 disease, either from how the virus affects their already-compromised health status or how their malignancy impacts their susceptibility to infection or their response to it. Thus, the relevance goes two ways:
1. how breast cancer impacts those with COVID-19 disease; and
2. how COVID-19 disease impacts those with a diagnosis of breast cancer.
Breast cancer impacting COVID-19 disease
The immunocompromise of current or planned adjuvant chemotherapy has relevance to the SARS-CoV-2 virus (that causes COVID-19 disease) in that it is a contagious organism that squarely interacts with one’s immunity. Thus, COVID-19 disease may prevent chemotherapy or surgery that would otherwise be indicated in a timely fashion. For those with advanced malignancy, an already compromised survival rate is compromised even more. Those with breast cancer are considered having “a pre-existing condition” which has been the factor increasing mortality in those infected.
COVID-19 disease impacting breast cancer
Simply put, the strain on hospital facilities and the shortage of PPE (personal protective equipment)1 have mandated all elective surgeries be postponed or cancelled altogether to conserve hospital resources as well as decrease exposure by decreasing the volume of patients. In relation to breast cancer, since the allotment of supplies that have been in short supply has centered on hospital beds, staff, and postoperative equipment (ventilators), all hospital-related services that normally are part of breast cancer protocols must be balanced against the war on the pandemic, adding yet another parameter to breast cancer treatment: facility capabilities.
Thus, a mandate to postpone all “elective” surgeries is a necessary component to the treatment plan, only allowing exceptions only for those in which any breast cancer surgery delayed for 3 months is likely to negatively affect survival.2 Considered non-elective and therefore indicated as needed and allowed:
· Chemotherapy patients finishing treatment
· Stage T2 or N1 (ERpos/PRpos/HER2 negative) tumors
· Triple negative or HER2 positive tumors
· Biopsies likely to be malignant
· Removal of tumor recurrence
Some breast cancers, for reasons that a 3-month delay won’t impact survival or for which hormonal (inflammatory or only locally advanced breast cancers) or adjuvant (CTisN0 lesions-ER (+) or (-) therapy has been shown to be effective, are considered elective and therefore indicated as deferrable:
· Benign lesions
· Duct lesions
· Biopsies likely to be benign
· Atypia, papillomas, etc.
· Preventative surgery
· Lymph node biopsy indicated for positive excisional biopsy
· Re-excision
The “Phase” gatekeepers
COVID-19 further impacts the breast cancer patient by the choice of hospital for such a patient that is based on the current supply shortage of PPE, ventilators, hospital beds, or staff:
1. PHASE I: SEMI-URGENT SETTING. This is the “preparation phase” for those institutions with few if any COVID-19 patients, ICU ventilator capabilities, and the COVID-19 trajectory “curve” not in escalation in an area. The decision to apply the above “electiveness” or “indicated” designations is tempered by the likelihood that Phase I is temporary and likely to escalate to a more advanced phase. The finer points of those surgeries (elective vs indicated) are put into a more granular perspective in the COVID-19 Pandemic Breast Cancer Corsortium.3,4
2. PHASE II: URGENT SETTING. This designation is for hospitals with many COVID-19 patients, only a limited capacity (beds, ICU, ventilators, PPE, or staff); or in an area identified as having a rapid escalating SARS-CoV-2 diagnosis/admission/mortality curve. In this setting, the 3-month window of assessing survival chances is narrowed to those in whom delay of surgery of only a few days would compromise their survival:
· Incision and drainage of breast abscess
· Evacuation of hematoma (blood clot), especially if it is contributing to continued bleeding
· Saving a tissue flap that faces necrosis without revascularization or revision
In all other patients, breast surgery should be postponed.
3. PHASE III. These are facilities in which all available resources have already been dedicated toward COVID-19 patients. The window of survival-without-surgery narrows even tighter, allowed only for those whose survival would be compromised if surgery is delayed by even a few hours. The list of indicated surgeries is the same as PHASE II, but with the narrower urgency window.
Conclusion
Until the pandemic is decreed “contained”—and how and when restrictions are reversed—the protocols of state-of-the-art breast cancer management are at the mercy of the global response to COVID-19 disease. Additionally, different states in the USA have different ideas of execution of reversal of such restrictions. Breast cancer treatment will not be “business as usual” for the near future. Likely, the “Phase I, II, III” designations will be refined or replaced. Thus, a physician treating breast malignancy must also include COVID-19 mandates into his or her treatment protocol.
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