BreastSurgANZ & COVID-19: Guidance for Triage of Surgical Procedures

This guidance for Breast Surgeons should be considered in the context of your local resources and guidance provided by local Departments of Health and Individual Institutions, and on a case by case basis based on your knowledge of your patient, institution and available treatment options.

Based on The American College of Breast Surgeons ‘Recommendations for Prioritization, Treatment and Triage of Breast Cancer Patients During the COVID-19 Pandemic: Executive Summary v1.0’, The COVID-19 Pandemic Breast Cancer Consortium 24/3/2020 – see link

General Recommendations

Case status (i.e. risk of death time frame) determination should be made by a multidisciplinary team, ideally in a multidisciplinary meeting, which is documented in the medical record.

Guidance for treatment of breast cancer patients in Australia and New Zealand during the COVID-19 Pandemic is provided for two categories of semi-urgent (Stage 1) and urgent (Stage 2) settings, based on patient condition, prevalence of COVID-19 pandemic in your region and resource availability. These recommendations require update with changing severity of the COVID-19 pandemic.

Stage I. Semi-Urgent Setting (Preparation Phase)

Definition: Few COVID 19 patients, hospital resources not exhausted and COVID trajectory not in rapid escalation phase

Surgery restricted to patients likely to have survival compromised if surgery not performed within next 3 months.

Cases that need to be done as soon as feasible (recognizing status of hospital likely to progress over next few weeks):

• Neoadjuvant patients finishing treatment: consider shortening treatment if excellent clinical and imaging response
• Clinically operable T1- 2 N1 ER pos/PR pos/HER2 negative tumours.*
• Triple negative or HER2 positive patients *
• Discordant biopsies likely to be malignant
• Excision of malignant recurrence

*In some cases, institutions may decide to proceed with surgery versus subjecting a patient to an immunocompromised state with neoadjuvant chemotherapy. These decisions will depend on institutional resources.

Encourage use of breast conserving surgery whenever possible, defer definitive mastectomy and/or reconstruction until after the COVID 19 pandemic resolves provided radiation oncology services are available.

Cases that should be deferred

• Excision of benign lesions- fibroadenomas etc…
• Duct excisions
• Discordant biopsies likely to be benign
• High risk lesions- atypia, papillomas etc…
• Prophylactic surgery for cancer and noncancer cases
• Low and intermediate grade DCIS

Cases that may be deferred

• Delayed SNB for cancer identified on excisional biopsy
• Re-excision surgery
• Tumours responding to neoadjuvant hormonal treatment
• Clinical Stage T1N0 ER pos/ PR positive/HER2 negative tumours #
• high grade DCIS

Alternative treatment approaches to be considered (assuming resources permit):

• Triple negative and HER2 positive tumours can undergo neoadjuvant therapy prior to surgery
• Some Clinical Stage T2 or N1 ERpos/PRpos/HER2 negative tumours can receive neoadjuvant hormonal therapy©
• Inflammatory and locally advanced breast cancers should receive neoadjuvant therapy prior to any surgery
• If undertaking neoadjuvant therapy, please ensure primary tumour +/- positive nodes are clipped to facilitate later breast conservation and targeted axillary dissection

# Many women with early stage, ER pos breast cancers do not benefit substantially from chemotherapy. In general, these include women with stage 1 or limited stage 2 cancers, particularly those with low-intermediate grade tumours, lobular breast cancers, or “luminal A” signatures. High level evidence supports the safety and efficacy of 6 to 12 months of primary endocrine therapy before surgery in such women, which may enable the deferral of surgery.

Stage II. Urgent setting

Definition:Many COVID 19 patients, ICU and ventilator capacity limited, OR supplies limited or COVID trajectory within hospital in rapidly escalating phase

Surgery restricted to patients likely to have survival compromised if surgery not performed within next few days

Cases that need to be done as soon as feasible (recognizing status of hospital likely to progress over next few days):

• Incision and drainage of breast abscess which has failed repeated percutaneous drainage
• Evacuation of a hematoma
• Revision of urgent surgical complications

Cases that should be deferred:

• All other breast procedures

Alternative treatment approaches RECOMMENDED (assuming resources permit):

• Consider neoadjuvant therapy for eligible cases
• Observation is safe for the remaining cases