COVID-19 Breast Cancer Patient Triage Guidelines (CPBCC, 2020)

COVID 19 Pandemic Breast Cancer Consortium

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

April 08, 2020

The guideline on COVID-19–related triage of patients with breast cancer was released on March 24, 2020 by the COVID 19 Pandemic Breast Cancer Consortium, which comprises representatives from the National Accreditation Program for Breast Centers (NAPBC), the Commission on Cancer (CoC), the American Society of Breast Surgeons (ASBrS), and the National Comprehensive Cancer Network (NCCN).[1]

As a general recommendation, the guidelines advise that determination of patients' case status (ie, risk of death time frame) be made by a multidisciplinary team, ideally in a multi-clinician setting (breast tumor board conference). This multidisciplinary discussion should be documented in the medical record.

Phase I – Semi-urgent Setting (Preparation Phase)

In this setting, the hospital has few COVID-19 patients, its resources are not exhausted, it still has ICU ventilator capacity, and the COVID-19 trajectory is not in rapid escalation phase. Here, the guideline recommends restricting surgery to patients whose survival is likely to be compromised if their procedure is not performed within the next 3 months.

In phase I, cases that need to be done as soon as feasible (recognizing that the hospital's status is likely to progress over next few weeks) include the following:

  • Patients finishing neoadjuvant treatment

  • Patients with clinical stage T2 or N1 estrogen receptor (ER)–positive/progesterone receptor (PR)–positive/HER2-negative tumors

  • Patients with triple negative or HER2 positive tumors

  • Patients with discordant biopsies likely to be malignant

  • Excision of malignant recurrence

Note that in some cases of ER+/PR+/HER2-, triple negative, or HER2 positive tumors, institutions may decide to proceed with surgery versus subjecting a patient to an immunocompromised state with neoadjuvant chemotherapy; those decisions will depend on institutional resources. The guidelines encourage use of breast-conserving surgery whenever possible and recommend deferring definitive mastectomy and/or reconstruction until after the COVID-19 pandemic resolves provided radiation oncology services are available.

Cases that should be deferred include the following:

  • Excision of benign lesions (eg, fibroadenomas, nodules)

  • Duct excisions

  • Discordant biopsies likely to be benign

  • High-risk lesions (eg, atypia, papillomas)

  • Prophylactic surgery for cancer and noncancer cases

  • Delayed sentinel node biopsy for cancer identified on excisional biopsy

  • cTisN0 lesions - ER positive and negative

  • Re-excision surgery

  • Tumors responding to neoadjuvant hormonal treatment

  • Clinical stage T1N0 ER+/PR+/HER2- tumors (these patients can receive hormonal therapy)

  • Inflammatory and locally advanced breast cancers (these patients should receive neoadjuvant therapy)

Alternative treatment approaches to be considered (assuming resources permit) include the following:

  • Patients with clinical stage T1N0 ER+/PR+/HER2- tumors can receive hormonal therapy.

  • Patients with triple negative and HER2+ tumors can undergo neoadjuvant therapy prior to surgery.

  • Some women with clinical stage T2 or N1 ER+/PR+/HER2- tumors can receive hormonal therapy.

  • Patients with inflammatory and locally advanced breast cancers should receive neoadjuvant therapy prior to any surgery.

The guidelines note that many women with early-stage, ER+ breast cancers do not benefit substantially from chemotherapy. In general, these include women with stage 1 or limited stage 2 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 6 to 12 months of primary endocrine therapy before surgery in such women, which may enable the deferral of surgery.

Phase II – Urgent Setting

In this setting, hospitals have many COVID-19 patients, ICU and ventilator capacity are limited, or supplies are limited or the COVID-19 trajectory within the hospital is in a rapidly escalating phase. The guidelines recommend restricting surgery to patients whose survival is likely to be compromised if their procedure is not performed within the next few days.

Cases that need to be done as soon as feasible (recognizing that the hospital's status is likely to progress over the next few days) include the following:

  • Incision and drainage of breast abscess

  • Evacuation of a hematoma

  • Revision of an ischemic mastectomy flap

  • Revascularization/revision of an autologous tissue flap (however, autologous reconstruction should be deferred)

All breast procedures should be deferred. Neoadjuvant therapy should be considered for eligible cases; observation is safe for the remaining cases.

Phase III

In this setting, hospital resources are all routed to COVID-19 patients, there is no ventilator or ICU capacity, or supplies have been exhausted. The guidelines recommend restricting surgery to patients whose survival is likely to be compromised if their procedure is not performed within next few hours.

Cases that need to be done as soon as feasible (recognizing that the hospital's status is likely to progress in hours) include the following:

  • Incision and drainage of breast abscess

  • Evacuation of a hematoma

  • Revision of an ischemic mastectomy flap

  • Revascularization/revision of an autologous tissue flap (autologous reconstruction should be deferred)

All other cases should be deferred. Alternative treatment recommendations are the same as for phase II.

For more information, see the Coronavirus Resource Center and Surgical Treatment of Breast Cancer. For more Clinical Practice Guidelines, please go to Guidelines.

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