Breast Surgical Care in the Time of Coronavirus
COVID-19, also known as 2019 novel coronavirus, has transformed the way we are conducting our daily lives. For those of us who have dedicated our lives to healthcare and the well being of our patients, coronavirus is also completely upending how we deliver care.
Coronavirus has forced us to come face-to-face with deep flaws in our healthcare system. And physicians across every single specialty now have to triage, prioritizing urgent and emergent cases so that the delivery of services and resources is equitable and takes into account our sickest patients.
As a breast surgical oncologist, I am one of the first people a woman (and some men!) meet when they receive a breast cancer diagnosis. For the overwhelming majority of patients diagnosed with breast cancer, surgery will be the first hurdle along the treatment journey, in addition to chemotherapy, radiation therapy, and/or endocrine therapy.
At this time, my first priority is ensuring that in addition to keeping patients safe, I am ensuring that I am protecting my own health and safety, as well as that of my staff. With coronavirus currently at pandemic levels, affecting thousands of people around the world, surgeons have now been compelled to think long and hard about what is truly urgent or emergent. If a surgical case does not fall into either of these categories, it must wait for the greater good.
On March 17, 2020, the American College of Surgeons released a bulletin with guidance for how surgical cases should be prioritized based on acuity/severity. Most cancers fall between 2A and 3A, meaning surgery should not be delayed. Depending on specialty, this should be evaluated on a case-by-case basis. Based on my own practice, I’ve come up with the following template for factors to take into consideration when planning outpatient and OR time.
DELAY
§ Hormone receptor positive tumors, triple negative tumors >2 cm, N1+ disease, T2/N1 HER2 positive disease → neoadjuvant chemotherapy
§ ER/PR + DCIS
§ Benign masses (i.e. fibroadenoma)
§ High-risk lesions (i.e. ADH/ALH, LCIS, radial scar, radial scar, asymptomatic intraductal papilloma)
§ Prophylactic reconstruction
TREAT
§ Triple negative tumors < 2 cm (T1)
§ Mass-forming DCIS or DCIS with microinvasion on core biopsy
§ Failed neoadjuvant chemotherapy or partial response to chemotherapy
§ Positive margins status post surgical intervention
§ T1N0 disease
§ Phyllodes tumors and other angiosarcomas of the breast
§ Symptomatic intraductal papillomas (i.e. bloody nipple discharge), papillomas >1 cm, or papillomas with atypia or malignancy
§ Postop with complications (i.e. hematomas, large complicated seroma, abscess formation)
§ Axillary lymph node disease burden status post SLN biopsy (does NOT include micrometastatic disease or isolated tumor cells (ITCs) that can be treated with XRT)
OUTPATIENT: RESCHEDULE
§ Uncomplicated postop visits
§ Routine follow-up/surveillance
§ Breast pain/itching
§ Family history and/or high risk for developing breast cancer
§ Genetic mutation positive
OUTPATIENT: PROCEED WITH CAUTION/MAKE APPROPRIATE REFERRALS
§ Mastitis with abscess formation
§ Granulomatous mastitis
§ New breast rashes/skin changes
§ Inflammatory breast cancer
As we continue to receive new information and the COVID-19 pandemic evolves, I’m sure the recommendations and guidance for how to care for cancer patients will continue to change. Updated information will be posted to my websites and social media as it becomes available.
For up to date information on coronavirus, please visit trusted websites for health information:
The World Health Organization: www.who.int
The Centers for Disease Control and Prevention: www.cdc.gov
With Love,
Disclaimer: This article is not a substitution for seeking medical attention!