Breast Cancer Surgery in a Pandemic: What's the Best Approach?

Cindy Matsen, MD

The coronavirus disease 2019 (COVID-19) pandemic had a tremendous impact on the surgical care of patients with breast cancer, according to Cindy Matsen, MD, who added that practice patterns needed to be rapidly adjusted to continue to safely provide care during a time when resources were very limited.

“When the COVID-19 pandemic hit our country, especially during March [2020], when we went into lockdown, we saw huge impacts on surgical care,” Matsen said. “We were anticipating a big surge of patients who would affect our system's capacity to be able to [manage] these patients. As such, we very quickly had to start triaging patients into different groups to understand who needed [surgery immediately] versus who could [have their procedures] delayed safely.”

In an interview with Oncology Nursing News' sister pubilcation, OncLive® during an Institutional Perspective in Cancer webinar on Breast Cancer, Matsen, a breast surgeon and an assistant professor in the Department of Surgery at the Huntsman Cancer Institute, of the University of Utah, shared the protocols her institution put into place to ensure safe surgical practice for patients with breast cancer during the COVID-19 pandemic and how protective measures have evolved over the past year.

OncLive®: What were some of the main challenges that arose during lockdown with regard to surgery in patients with breast cancer?

Matsen: The main challenge was that we were asked to cancel all surgeries very quickly; it all happened basically over a weekend. We got an email on Friday, saying, ‘Hey, we think that we're going to need to cancel all surgeries.’ As such, over that weekend, we had to come up with lists of who we could cancel versus who we could not. There still was some operating room availability [at that time], but it was much more limited than it had been.

A lot of phone calls [were being made], with both our patients and our clinic staff. We were trying to get everything worked out and deal with the psychological consequences of having to cancel [these procedures]. Everyone was reeling from the idea of a lockdown. We were all hoping that by shutting everything down, we were going to be able to truly flatten the curve and return to normal in about 4 to 6 weeks; that obviously didn't happen. However, it did allow us time to plan a little better for when the surge did actually happen.

At that time, we were also dealing with a scarcity of personal protective equipment [PPE], which was very concerning. This was something that really impacts surgery specifically, because we need to wear masks, gowns, and gloves [for those procedures]. If that equipment is not available, then we can't do surgery. [Our concerns went beyond] seeing a big surge and not having enough beds. [We were worried about] whether we would have the basic equipment available to us to be able to perform any sort of surgery.

[We also had to figure out] who to have in the operating room. All of a sudden, all our residents, all our students, everyone is gone. Even if you went to the operating room, it was a very limited team, which is very different from how this normally works for us.

You mentioned that a lot of important decision making happened via phone over that weekend. What did you discuss and what are some of the solutions you came up with?

We used those phone calls among our group to come up with some protocols for canceling all non–time sensitive surgery. Who is time sensitive and who is not? Receptor status, the type of surgery that was scheduled, and the phase of treatment were all factors we took into account to come up with a triage system for who would be most at risk for having bad outcomes if we delayed their surgery, and who we felt could safely be delayed with strategies like neoadjuvant endocrine therapy.

That was probably the biggest shift: patients with estrogen receptor–positive, HER2-negative, early-stage disease, who would normally go to surgery first [turned to] other options. We're lucky in breast cancer that we have other options for these patients. Many received neoadjuvant endocrine therapy during that time period.

It's interesting because we don't have data for short-term neoadjuvant endocrine therapy, but it felt like that was the right thing to do, knowing that there was some uncertainty about when we would actually get these patients to the operating room. We knew that this would at least allow some window for us to be able to delay [surgery] safely, [while] still treating their cancer.

What are some of the steps that were taken as the lockdown started to lift?

During the lockdown, we saw fewer new patients. Fewer people were getting screened and fewer people were getting diagnosed with breast cancer during that time; that gave us a little bit of wiggle room. When we did reopen, our operating rooms were not already packed with patients who have been diagnosed during that time; that provided us with a little more flexibility to get the patients who had been delayed into [the clinic for their surgery].

During the months of June and July, things were very busy because we were trying to treat patients who were just diagnosed and also move all our patients who were on those lists that we made during lockdown into their surgical phase of treatment. It went fairly smoothly. We would talk to patients every week to determine when we might be able to get them in. Some of [these conversations were on] when reconstruction would be available; that was something we didn't start again until July 2020. Some patients were delayed longer depending on what kind of surgery they needed.

It took a lot of interpersonal communication with each individual patient to figure out what the plan was going to be for them. Our operating rooms didn't open up to full capacity right away; they kind of did a limited ramp up. This [decision was made] to protect staff and to figure out how much PPE we had; we still had concerns about those things. It took some time over the course of June 2020 and July 2020 to get everything ramped up to normal volumes. After that, things have been operating fairly normally.

What changes have been made with regard to managing patients around the time of surgery?

When we first opened up, there were no visitors of any kind; that was really hard for people. Patients had to get dropped off to have their surgery and then picked up; they were not to be able to have anyone with them during that time. That was a huge change for all of us.

Also, we now wear full PPE the whole time [that we are working]. I never take off my mask now. I always have on my goggles and I always have on my head covering. Not seeing people's faces or being able to shake their hand when you meet them [were] all things we had to get used to. That was a hard part of re-entry; it was a completely different way of practicing.

What changes were made in the operating room?

Our protocols around intubation and extubation evolved over time. When we first started up, we were very cautious, allowing only the anesthesiologist and 1 person to be at the head of the bed with full protective gear on. We would wait 15 minutes outside the room to let the circulation of the ventilation system happen before we would re-enter. Part of that had to do with the lack of availability of testing. It took some time to be able to get enough tests available that we could actually start testing all patients. Once we had more tests available, then we started testing all patients [who needed surgery]. Then we were able to feel more comfortable with adjusting some of those protocols around intubation and extubation.

In the very beginning, we were very cautious. We did a slow ramp up [until] we got back to full volume, which happened over time. We also had an increase in test capacity, which allowed us to start testing all patients. Then, things [started to feel] a little bit more normal. We also then felt safe having 1 visitor per person, which made a difference. However, a whole bunch of things changed. Nothing is truly normal about what we're doing. We get the surgeries done, but the way we do it, who's in the room, and who's not in the room—all of that is still evolving on a regular basis.

This article was originally published on OncLive as, "Matsen Spotlights Best Practices for Breast Cancer Surgery Amidst the COVID-19 Crisis."