These guidelines for Breast Surgeons should be considered in the context of your local resources and guidance provided by local Departments of Health and Individual Institutions.
Please consider your own practice needs and developments with COIVD-19 in adopting or varying from these recommendations.
- Ensure you have remote access to your institution and use institutional email if possible, as forwarding to external emails may be problematic
- Set up a unit/HOU WhatsApp group for timely communication – see link to AMAinformation
Strategies to enable service provision under a shutdown of non-essential activity
- Move to Telehealth consultations for the majority of patients:
- http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-TempBB (e.g. follow up patients (105) telephone only 91833, videoteleconference 91823)
- Decrease the number of patients having face-to-face consultations
- Screen which of your routine patients need face to face review rather than phon. This is to enable an examination or more personal support for distressed patients
- Ensure careful documentation for bulkbilling; note specialists are no longer required to bulk bill telehealth services
- Provide in person consultations for
- Confirmed cancers
- Cases highly suspicious forcancer
- Post op – some may be able to be done with telehealth
- Consider deferring routine review of asymptomatic breast cancer patients, including their imaging, for 6 months or as appropriate. Keep a careful register of all deferred patients and enter a recall in your medical software system e.g.GENIE
- Triage of new referrals – deferral of all benign referrals except if the patent has high anxiety or uncertain.
In order to facilitate physical distancing in your practice/waiting room
- Limit the number of accompanying persons to one per patient and insist they wait outside the practice prior to the consult
- Place a barrier such as an empty blocked chair between patients
- Give patients option to wait in the car or an appropriate outside area & be called in when ready to be seen
- In multiple doctor practices, consider how many doctors consult at the same time
- Remove magazines, tea and coffee, toy boxes etc.
- SMS prior to appointment
Example:Appt with _ on_ _.If U have cold/flu symptoms pls delay yr apt by 2 weeks& call__ You can also ask all patients to ring and listen to a longer advice message on your answering machine.
Preop COVID Testing & Isolation
Screening of Elective Surgical Patients for Coronavirus (COVID-19)?
- All patients living or working in a stage 3 or 4 restriction zone or other known stay at home area require Coronavirus screening
- Surgery will not proceed unless a clear test is available prior to admission
- Patients should be instructed to isolate until testing results are available.
- Where feasible, patients should be asked to isolate throughout chemotherapy.
- The mortality and morbidity rates for both elective and emergency surgery in Corona Virus positive patients are higher than otherwise expected, even when such surgery is relatively minor. Therefore, it is usually safer to postpone elective surgery for someone who is symptomatic or who tests positive for COVID-19, even if they subsequently prove to be negative or a false positive, than to proceed and find out they are a true positive
- When a patient screens positive to any of the epidemiological and clinical risk factors of COVID-19 identified in the ‘Screening checklist for surgical patients not known to be coronavirus (COVID-19) positive’ (or a similar screening tool) , https://www.dhhs.vic.gov.au/clinical-guidance-and-resources-covid-19, emergency surgery should be deferred for as long as is feasible or until a coronavirus test result is available.
Consideration may need to be given to who is operated on & when
- Clip all new cancers sent for biopsy, in case their surgery may be delayed
- Consider neoadjuvant endocrine therapy for ER+ve cancers if surgery needs to be delayed
- Minimise time patients spend in hospitals – day case, HITH
- Limit complexity of surgery – consider deferral of immediate reconstruction, contralateral symmetrising surgery
- Deferral of all risk reducing surgery
- Only Cat 1 patients warrant surgery
- DCIS: low and intermediate grade defer
- Extensive high grade DCIS may be the exception
As treatment plans may differ from normal, frequent MDM & rigorous documentation
- Plan for multiple scenarios within your MDT
- Need to accurately quantify the value of (neo)adjuvant chemotherapy and CK4,6 inhibitors
- HER2 +: consider minimal chemotherapy/Subcut Herceptin
- TNBC: still overwhelming advantage in T2/N1 for chemotherapy
- If early apparent cCR may consider curtailing neoadjuvant chemotherapy and proceed early to surgery. See link to MJA article for more information
Look after yourself
- PPE: ensure you can comply with current recommendations, be up to date with training
- Rest and support yourself, family and colleagues
Look after your staff
- Put in place measures for your staff to work from home
- Remote access to practiceserver/software
- Diversion of phonecalls
BreastSurgANZ Council, 3 August 2020