Introduction
Methods
Priority A category
Priority B category
Priority C category:
Results
Outpatient visits
Breast focused imaging
Surgical oncology
Priority | Patient description | COVID-19 treatment considerations |
---|---|---|
Priority A | ||
A | Breast abscess in a septic patient | Operative drainage if unable to be drained at the bedside |
A | Expanding hematoma in a hemodynamically unstable patient | Operative evacuation and control of bleeding |
Priority B | ||
B1 | Ischemic autologous tissue flap | Revascularize or remove flap |
B1 | Revision of a full thickness ischemic mastectomy flap with exposed prosthesis | Debride and remove expander/implant |
B1 | Patients who have completed neoadjuvant chemotherapy for Inflammatory BC | Operate as soon as possible depending on institutional resources* |
B1 | TNBC and HER2 + patients | Neoadjuvant chemotherapy or HER2 targeted therapy. In some cases, institutions may decide to proceed with surgery first versus neoadjuvant therapy. These decisions will depend on institutional resources and patient factors.* |
B2 | Neoadjuvant: -finishing treatment -progressing on treatment | Operate if feasible depending on resources or extend/change neoadjuvant therapy* |
B3 | Clinical Stage T2 or N1 ER + / HER2 – tumors | Consider hormonal treatment, delay operation |
B3 | Discordant biopsies likely to be malignant | Perform excisional biopsy when conditions allow |
B3 | Malignant or suspected local recurrence | Begin with staging when feasible. Perform excision when conditions allow if there is no distant disease |
Priority C | ||
C1 | ER–DCIS | Delay operation until after COVID-19 unless there is a high risk of invasive cancer (Move to B3) |
C1 | Positive margin(s) for invasive cancer | Delay re-excision until after COVID-19 |
C1 | Clinical Stage T1N0 ER + / HER2—cancers | Hormonal treatment; delay operation until after COVID-19 |
C1 | BC patients requiring additional axillary surgery | Delay operation until after COVID-19 |
C2 | ER + DCIS | Hormonal treatment; delay operation until after COVID-19 |
C2 | High-risk lesions | Delay operation until after COVID-19 |
C2 | Reconstruction for previously completed mastectomy | Delay operation until after COVID-19 |
C3 | Excision of benign lesions-fibroadenomas, nodules, papillomas, etc | Delay operation until after COVID-19 |
C3 | Discordant biopsies likely to be benign | Delay operation until after COVID-19 |
C3 | Prophylactic surgery-for cancer and noncancer | Delay operation until after COVID-19 |
Medical oncology
Priority | Patient description | COVID-19 treatment considerations |
---|---|---|
Priority A | ||
A | Patients with oncologic emergencies (e.g. febrile neutropenia, hypercalcemia, intolerable pain, symptomatic pleural effusions or brain metastases, etc.) | Initiate necessary management |
Priority B | ||
B1 | Patients with inflammatory BC | Neoadjuvant chemotherapy |
B1 | Patients with TNBC or HER2 + BC | Neo/adjuvant chemotherapy (Neoadjuvant for ≥ T2 or N1) |
B1 | Patients with mBC for whom therapy is likely to improve outcomes | Initiate chemotherapy, endocrine, or targeted therapy |
B1 | Patients who already started neo/adjuvant chemotherapy | Continue therapy until complete (if neoadjuvant and responding, can extend treatment if necessary to defer surgery further) |
B1 | Patients progressing on neoadjuvant therapy | Refer to surgery or change systemic therapy |
B1 | Patients on oral adjuvant endocrine therapy | Continue therapy |
B1 | Premenopausal patients with ER + BC receiving LHRH agonists (adjuvant or metastatic) | - If on aromatase inhibitor, continue LHRH agonist and consider long acting 3 month dosing or home administration - If on tamoxifen, consider deferring LHRH agonist |
B1 | Patients with clinical anatomic Stage 1 or 2 ER + /HER2- BCs | Neoadjuvant endocrine therapy for 6 to 12 months to defer surgery (may consider gene expression assay on core biopsy) |
B2 | Patients receiving treatment for Stage 1 HER2 + breast | Ado-trastuzumab emtansine may be substituted for paclitaxel/ trastuzumab |
B3 | Patients with ER + DCIS | Consider neoadjuvant endocrine therapy to defer surgery |
B3 | Patients with mBC for whom therapy is unlikely to improve outcomes | Consider deferring chemotherapy, endocrine, or targeted therapy |
B3 | Patients with HER2 + mBC beyond 2 years of maintenance antibody therapy (trastuzumab, pertuzumab) with minimal disease burden | Consider stopping antibody therapy with monitoring for progression every 3–6 months |
B3 | Patients with HER2 + BC receiving adjuvant antibody treatment | Consider curtailing antibody treatment after 7 months instead of 12 months |
Priority C | ||
C | Patients receiving zoledronic acid, denosumab | Discontinue bone antiresorptive therapy unless for hypercalcemia |
C | Patients with stable mBC | Interval for routine follow-up restaging studies can be delayed |
C | Patients with lower risk imaging findings needing follow-up (e.g., small pulmonary nodules) | Interval follow-up can be delayed |
C | Patients who are candidates for prevention measures (e.g. family history, LCIS or ADH, BRCA1/2 +) | Consider endocrine therapy (as appropriate), delay surgery and screening imaging |
C | Patients in long-term follow-up for early BC | Defer routine in-person visit |
C | Patients on aromatase inhibitors | Defer bone density testing (baseline and follow-up) |
Invasive BC—early stage
Invasive BC—advanced stage
High-risk lesions and pre-invasive BC
Supportive care and additional considerations
Agent | Dosing and scheduling considerations |
---|---|
Chemotherapy | Chemotherapy schedules may be modified to reduce clinic visits (using 2- or 3-week dosing, e.g.) or to reduce infection risk (using weekly dosing) for selected agents when appropriate |
For low-risk febrile neutropenia, outpatient regimens may be used | |
Selected patients (particularly with ER + disease), can consider radiation before chemotherapy if this facilitates patient safety | |
Targeted therapy | The addition of oral targeted agents (CDK 4/6, mTOR, or PIK3CA inhibitors) to endocrine therapy may be delayed in first-line treatment, or in situations where endocrine therapy alone is providing or is likely to provide effective tumor control |
Cardiac monitoring (Echo, nuclear) during HER2 antibody therapy can be delayed or discontinued if clinically stable | |
Consider reduced dose of oral targeted agents to optimize tolerability and minimize treatment-related toxicities | |
Trastuzumab and pertuzumab for metastatic HER2 + BC may reasonably be administered at longer intervals (e.g. 4 weeks) | |
Endocrine therapy | Oral endocrine agents (e.g. tamoxifen, aromatase inhibitors) are not immunosuppressive and can be safely continued |
Fulvestrant is not immunosuppressive but requires monthly clinical administration | |
Aromatase inhibitors are preferred over tamoxifen for neoadjuvant endocrine therapy (and LHRH agonists should be used for premenopausal women) | |
Supportive care | Extend venous access device (port) flush to 12 weeks or longer |
Consider peripheral venous access for IV chemotherapy if patient has sufficient veins and no existing port if institutional policies permit | |
Administer G-CSF growth factor support to minimize neutropenia | |
Limit dexamethasone when possible to reduce immunosuppression |
Radiation oncology
Priority | Patient Description | COVID-19 Treatment Considerations |
---|---|---|
Priority A | ||
A | Bleeding/painful inoperable local–regional disease, Symptomatic metastatic disease | Consider palliative HF regimens |
A | Progression of disease during NAC | Consider definitive HF regimens |
Priority B | ||
B1 | Inflammatory BC s/p mastectomy | Consider PMRT HF regimens |
B1 | Node positive: TNBC or HER2 + disease s/p BCT or mastectomy | Consider WBRT or PMRT HF regimens |
B1 | Postmastectomy with 4 or more tumor-positive nodes | Consider PMRT HF regimens |
B1 | Residual node-positive disease after NAC | Consider WBRT or PMRT regimens |
B2 | PMRT with 1–3 tumor-positive nodes | Consider PMRT HF regimens |
B2 | Node negative: TNBC or HER2 + s/p BCT | Consider WBRT HF regimens |
B2 | If tumor-positive margin after BCT for invasive BC with no alternative therapy options* | Consider WBRT HF regimens |
B3 | If tumor-positive margin after BCT for invasive BC with alternative therapy options | Consider WBRT HF regimens |
B3 | Young age (≤ 40 years) s/p BCT, node negative with ≥ 1 additional high-risk features (LVI + , PNI +) | Consider HF regimens |
B3 | ER- DCIS with a positive margin | Consider HF WBRT regimens |
Priority C | ||
C | DCIS** | Initiate endocrine therapy if ER + Defer radiation therapy until pandemic is over |
C | > 65 years early-stage, nodenegative ER + / HER2- taking adjuvant endocrine therapy s/p BCT | Omit radiation therapy or defer until pandemic is over |
Hypofractionated Regimens: | ||
Palliative Radiation | ||
4 Gy × 5 total 20 Gy | Meta-analysis [43] | |
8 Gy × 1 total 8 Gy | RTOG 97–14 [42] | |
Whole breast radiation therapy: | ||
2.67 Gy daily × 15 total 40.05 Gy | START B [45] | |
2.66 Gy daily × 16 total 42.56 Gy | Canadian [46] | |
5.7 Gy once per week × 5 total 28.5 Gy | FAST [52] | |
5.2–5.4 Gy daily × 5 total 26–27 Gy | FAST Forward [53] | |
Postmastectomy radiation therapy: | ||
2.5 Gy daily × 15 to chest wall total 37.50 Gy; 2.5 Gy daily × 14 to regional nodes (including IMN) total 35 Gy | British Columbia PMRT trial [49] | |
2.90 Gy × 15 daily to chest wall, SC & Level III axilla total 43.5 Gy No IMN or reconstruction | China PMRT Trial [50] | |
2.66 Gy daily × 16 to chest wall + regional nodes (with IMN) total 42.56 Gy | NCT03414970 | |
2.67 Gy daily × 15 to chest wall total 40.05 Gy, 2.67 × 14 to RNI total 37.38 Gy | NCT03422003 | |
Boost | ||
2.5 Gy × 4 total 10 Gy, consider additional 2.5 Gy fraction for positive margin | ||
Considerations for treatment interruptions | ||
No change to WBRT, PMRT dose. Adjust boost as follows: No boost in original treatment plan: Add boost 2.5 Gy × 4 Boost in original treatment plan: consider additional 2.5 Gy fraction to boost PTV total 12.5 Gy*** |