COVID-19 Breast Cancer Recommendations Stratify Patients by Risk

Leading cancer organizations — the American Society of Breast Surgeons (ASBrS), the National Accreditation Program for Breast Cancers (NAPBC), the National Comprehensive Cancer Network (NCCN), the Commission on Cancer (CoC) of the American College of Surgeons, and the American College of Radiology (ACR) – came together to create joint recommendations for the treatment of patients with breast cancer during the coronavirus disease 2019 (COVID-19) pandemic.¹

The recommendations, which focus on prioritization, treatment, and triage, categorize patients with the disease into 3 priority levels — A, B, and C.

• Priority A: These patients have life-threatening or symptomatic disease, requiring urgent treatment. Under the assumption that treatment would be efficacious, priority A patients are, “given top priority, even if resources become scarce, requiring urgent treatment for preservation of life or control of progressing disease or symptomatic relief,” the recommendation says.
• Priority B: This group — which most patients with breast cancer will fall into – does not require immediate treatment, but should begin their treatment before the COVID pandemic ends. Most of these patients will not have outcomes affected if their treatment has a short delay of 6 to 12 weeks, but longer delays may impact their prognosis. Priority B patients are sub-categorized into B1 (higher priority), B2 (mid-level priority), and B3 (lower priority).
• Priority C: Patients in this group, patients’ treatment can be safely deferred until after the pandemic. The recommendations read, “Patients in Priority C category are patients for whom certain treatment or services can be indefinitely deferred until the pandemic is over without adversely impacting outcomes.”

“Additionally, the risk of disease progression and worse outcomes for patients need to be weighed against the risk of patient and staff exposure to SARS CoV-2 (virus associated with the COVID-19 pandemic),” the recommendations state. “Physicians should use these recommendations to prioritize care for their [breast cancer] patients and adapt treatment recommendations to the local context at their hospital.”

The recommendations stress the importance of telemedicine, stating that the majority of patient-provider encounters should be conducted remotely. Most Priority A patients, however, should be assessed in person, as they may be clinically unstable post-operative patients or have oncologic emergencies (such as febrile neutropenia, intractable pain).

Priority B patients should be seen by 1 member of the team, remotely or in-person, to be evaluated on a case-to-case basis. These patients include those with the following conditions: newly assessed breast cancer, established patients with new problems, such as breast infection, palpable findings, symptoms from therapy, patients on intravenous chemotherapy, patients completing neoadjuvant therapy preparing for surgery, postoperative patients, and those being planned for radiation therapy.

Finally, Priority C patients can either have their visit completely delayed or can be seen remotely. This includes: follow-up for benign or malignant conditions, survivorship visits, and high-risk screening.

“This information should be used to organize a process of structured decision-making for the care of patients with breast disease during the COVID-19 pandemic,” the recommendations say.

But the authors noted that situations — as well as the COVID pandemic – will continue to change.

“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. This consortium will continue to adapt these recommendations to the current pandemic severity including future waves of the COVID-19 pandemic. It is our hope that these current 16 recommendations will help clinicians provide the highest quality care for their patients during this evolving pandemic.”

Reference

Dietz JR, Moran MS, Isakoff SJ, et. al. Recommendations for Prioritization, Treatment and Triage of Breast Cancer Patients During the COVID-19 Pandemic. April, 2020. Accessed April 15, 2020