Oncology Groups Issue Preliminary COVID-19 Triage Guidelines for Breast Cancer

The American Society of Breast Surgeons (ASBrS), the National Accreditation Program for Breast Centers, the National Comprehensive Care Network, the Commission on Cancer, and the American College of Radiology have joined forces to issue preliminary guidelines on how to treat patients with breast cancer during the coronavirus disease 2019 (COVID-19) pandemic.

Of particular note, the organizations said, is that resource availability and exposure risk should factor into these treatment decisions, which affect patients with breast cancer not infected with the virus. The goal of triage is to preserve scarce healthcare resources for those patients who are stricken with COVID-19, while not overriding physician decisions or institutional policies.

“As hospital resources and staff become limited, it is vital to define which breast cancer patients require urgent care and which can have delayed or alternative treatment without changing survival or risking exposure to the virus,” stated Jill R. Dietz, MD, FACS, president of the ASBrS, announcing the new guidance.

Following extensive discussions, the consortium of organizations and their representatives stratified patients with breast cancer according to 3 priorities:

1. Priority A patients have life-threatening conditions and require immediate treatment. These patients hold top priority status.
2. Priority B patients have serious conditions for which treatment is not urgent but should not be delayed to the end of the pandemic. Most patients with breast cancer fall into this category.
3. Priority C patients have a disease stage for which treatment can wait until after the pandemic subsides and their outcome will not be adversely affected.

“Decisions to conduct in-person visits must carefully weigh the risk of viral transmission to patients and healthcare providers with the need for an in-person evaluation,” the guidelines emphasize.

By stratifying the patients, the organizations were also able to address these areas:

Outpatient visits. In light of the present pandemic, telehealth has seen widespread implementation. In-person visits at present, therefore, should be reserved for clinically unstable postoperative patients, including those with medical oncologic emergencies.

Breast-focused imaging. Most imaging, which in these guidelines includes diagnostic imaging, biopsies for BI-RADS category 4 or 5 lesions, and breast magnetic resonance imaging (MRI), can be postponed, unless there is a postop complication. In addition, all screening exams (eg, mammography, ultrasound, and MRI) are recommended to be pushed to the postpandemic period.

Surgical oncology. Operating room use must be minimized. And because patients with invasive disease may be able to receive neoadjuvant therapies in the interim, their care team should assess possible risks, including immunosuppression, and comorbidities of deferring surgical solutions, especially in cases where a malignant lesion is unlikely.

Medical oncology. Again, the goal is to minimize unnecessary interactions and maximize resources, which means conserving them for only the most essential cases. For some patients this may necessitate a revision to their care plan with periodic assessments to track tumor progression, such as instituting an abbreviated treatment schedule or a dose-modified regimen.

Radiation oncology. According to the guidance, most patients who are referred for radiation are categorized as Priority B, so treatment can be deferred. Other suggestions include delaying radiation therapy for 20 weeks in patients with early-stage estrogen receptor—positive disease and considering hypofractionated regimens when possible.

Supportive care. Home administration is an option for endocrine treatments such as luteinizing hormone releasing hormone agonists. Accounting for adverse effects is a priority, especially neutropenia, for which granulocyte colony-stimulating factor is recommended. Bone-modifying treatments can be deferred.

“We acknowledge that there are limited prospective experiences to guide these recommendations. Furthermore, these recommendations are driven by the common goal to preserve hospital resources for virus-inflicted patients by deferring BC treatments without significantly compromising long-term outcomes for individual BC patients,” the authors noted. “However, as the pandemic rapidly evolves, we are increasingly learning about viral transmission and its impact on the health system, thus, these recommendations will evolve over time with continued updates.”

Reference

Dietz JR, Moran MS, Isakoff SJ, et al. Recommendations for prioritization, treatment and triage of breast cancer patients during the COVID-19 pandemic. The American College of Surgeons website. www.facs.org/-/media/files/quality-programs/napbc/asbrs_napbc_coc_nccn_acr_bc_covid_consortium_recommendations.ashx. Published April 13, 2020. Accessed April 14, 2020.