It has been quite alarming reading about the current health pandemic (COVID-19). There is fear, gratitude, anxiety, and acceptance. There are plenty of emotions to go around in light of this global health pandemic. What's important to remember is that you are not alone in this. In fact, the entire world is in this with us (and us with them). They may not have breast cancer per se, but they may be dealing with an elderly parent. They may be dealing with a child who has asthma, they may be dealing with additional underlying conditions that we don't even know about because they are "invisible" illness.
When I first told my parents that some of my friends are being asked to postpone surgery, I don't think it actually resonated. Breast cancer is a piece of this health pandemic and everyone is on edge. But breast cancer is very much our world! It's what I read about, it's what I research, it's what I seek out on social media. So when I tell my parents that some of my friends need to delay treatment, what I am really saying is, I'm scared, we’re scared. I've always said we need to advocate for ourselves, to push for mammograms, to get second opinions and now, all of a sudden, this is on pause? All of a sudden is the message that I am getting, is that breast cancer treatment is no longer considered "essential”? No. Not at all. Yes, that's my gut reaction, my blood boils, and I cannot understand why we would delay removing a tumor in our breast. But thank goodness, after researching and reading the guidelines and hearing all of your questions, I actually feel quite confident about the state of breast cancer and COVID-19. The medical professionals and reliable and trusted medical organizations have moved swiftly to address our questions, concerns, and have published guidelines and recommendations for how we can navigate this unprecedented time.
This is what I found based on my scouring the sites of the Society of Surgical Oncology (SSO), the American Society of Clinical Oncology, (ASCO), the American College of Surgeons, and the American Society of Radiation Oncology (ASTRO). Please note that this information is not meant to substitute professional medical advice nor supersede individual physician judgement, institutional policy or guidelines. The American College of Surgeons suggest recommendations as follows based on priority categories:
Priority A: Patient condition is immediately life threatening, clinically unstable.
Priority B: Patient situation is noncritical but delay beyond 6–8 weeks could potentially impact overall outcome.
Priority C: Patient’s condition is stable enough that services can be delayed for the duration of the COVID-19 pandemic.
The Society of Surgical Oncology has provided these guidelines specific to breast cancer. What I find fascinating about the guidelines and the disruption to the typical sequence of treatment is that endocrine therapy is now being offered in a neoadjuvant setting. That is to say, if your tumor is estrogen driven, you may be asked to take Tamoxifen or an Aromatase Inhibitor in advance of your surgery. This is to protect you from needing to come to the hospital; yes, it will delay surgery, but given the situation, would you really want to expose yourself to COVID-19 when endocrine therapy could be a benefit? What excites me about this opportunity is that I am hopeful studies will emerge to investigate the effectiveness of endocrine therapy vs chemotherapy in the adjuvant setting and could potentially decrease the need for chemo for those diagnosed with breast cancer. (Of course, may other factors would need to be considered, but still a win in my book!) According to the American College of Surgeons, there are of course situations that need immediate attention:
Neoadjuvant patients finishing treatment
Clinical Stage T2 or N1 ERpos/PRpos/HER2 negative tumors*†
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. †Autologous reconstruction should be deferred. According to ASTRO, "patients with rapidly progressing, potentially curable tumors may outweigh the risks of COVID-19 exposure/infection, but patients receiving radiation for symptom control or at low risk of harm due to alteration of schedule for radiation treatment visits could potentially be safely delayed. Patients should check with their radiation oncologist to determine the most appropriate course of action for their treatment."
According to ASTRO, "patients with rapidly progressing, potentially curable tumors may outweigh the risks of COVID-19 exposure/infection, but patients receiving radiation for symptom control or at low risk of harm due to alteration of schedule for radiation treatment visits could potentially be safely delayed. Patients should check with their radiation oncologist to determine the most appropriate course of action for their treatment."
ASTRO states, "The overarching goal is to reduce the risk of transmission of COVID-19 and to allow cancer care to continue for those most likely to benefit.."
What's most important is to speak with your oncologist. It is important to recognize that this is a global issue and each hospital and institution is unique with their own set of guidelines.
As the Lancet Oncology mention, regarding regulatory impact, "the US Food and Drug Administration has issued guidance on managing clinical trials during the time of COVID-19, as have the US National Cancer Institute and the European Medicines Agency (EMA).
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