Invasive breast cancer patients should be triaged with multidisciplinary input and assessment of a patient's individual risks and co-morbidities to potentially receive neoadjuvant therapies during the pandemic.

If a woman (or man) suspects that they might have breast cancer, the first and most important step is to promptly seek medical advice. Currently due to the COVID-19 pandemic, there is a trend towards delaying any medical care. However, the fear of contracting COVID-19 should not lead to a delay in diagnosis of cancer. Hospitals are taking stringent measures to prevent exposure of cancer patients to COVID-19, through use of PPE, restricted entry, enhanced sanitization and disinfection.

If diagnosed in early stages, breast cancer survival rates are very high. As the disease progresses from early to late stage, the prognosis also gets significantly worse. This is evidenced by the 50% breast cancer related mortality in India that is mainly due to detection of breast cancer in Stage 3 or 4. A prompt investigation of the suspicious lump or mass can give oncologists a lot of information on how to proceed with treatment. They can also prioritize which cases need immediate treatment to ensure good outcomes, and in which cases treatment can be safely deferred based on treatment guidelines issued in the wake of COVID-19. Any delay is only justified if the risk of COVID-19 infection for a specific patient would be greater than the risk of deferring or modifying treatment.

Recommendations on changes to breast cancer treatment as per multiple bodies like the American Society of Breast Surgeons, USA, BASO and NHS, UK and ABSI plus IASO, India; ESMO, Europe are summarized below:

Recommendation for modifications to surgical interventions:

Invasive breast cancer patients should be triaged with multidisciplinary input and assessment of a patient's individual risks and co-morbidities to potentially receive neoadjuvant therapies during the pandemic. For example, triple negative breast cancer (TNBC) patients and HER2+ disease can get neoadjuvant chemotherapy (NACT) to defer surgery. However, T1N0M0 TNBC patients should be considered high priority and operated on immediately as they are not candidates for NACT. Patients with hormone receptor-positive breast cancer can get neoadjuvant endocrine therapy to defer surgery until after the COVID-19 outbreak. Patients with locally advanced disease may be offered NACT if they are hormone receptor negative. Surgery may be justified in poor responders to NACT or where neoadjuvant therapy is not an option.

Secondly, Patients who have completed neo-adjuvant chemotherapy should be operated after 4-8 weeks of completing their treatment. These patients should be considered high priority for operation.Thirdly, a negative pressure operating theatre (OT) is recommended. Where not available, the OT should meet the NABH requirements in terms of air changes, velocity, positive pressure, air handling and filtration, temperature and relative humidity. Lastly, Full protection including N95 face masks, face shields or goggles, and full body covers are strongly recommended for all OT staff.

Recommendation for modifications to systemic therapies:

Chemotherapy

In hormone receptor-positive, HER2-negative patients who are low-risk as per a prognostic test, prefer endocrine therapy alone. Here we have an Indian solution for Indian patients in line with the national policy advocating for local solutions and self-reliance. There is a prognostic test called CanAssist Breast offered by an Indian company called OncoStem Diagnostics based out of Bangalore is the only test that is validated on Indian patients, is affordable and has a quick turnaround time. The immune system of an individual with cancer is often weaker, especially during chemotherapy. Therefore, they may be more susceptible to the complications once an infection occurs with any virus, including seasonal coronaviruses and influenza viruses. CanAssist Breast can risk stratify the cancers and spare many patients of immunosuppression where the tumour biology indicates less aggressive disease. This can reduce the COVID-19 infectivity and fatality in a subset of patients.

For patients where chemotherapy is required, chemotherapy schedules may be modified to reduce visits to hospital (for instance, using 2- or 3-weekly dosing instead of weekly dosing for selected agents when appropriate).

Patients should receive G-CSF growth factor and, eventually, antibiotics support to minimise neutropenia, while dexamethasone use should be limited, as appropriate, to reduce immunosuppression. Oral chemotherapy agents should be prioritized, whenever possible, and managed via telemedicine, for the predictable and manageable toxicities

Endocrine therapy: Oral endocrine agents (e.g. tamoxifen, aromatase inhibitors) are not immunosuppressive and can be safely continued

Recommendation for modifications to radiation therapy:

If hypofractionated schedules are considered reasonable, they should be considered. Especially for early stage breast cancer, given the results of clinical trials like FAST-FORWARD, hypofractionated schedules of 1 week versus the traditional 3 weeks can now be offered to patients.Patients receiving radiation for symptom control or at low risk of harm due to alteration of schedule for radiation treatment visits could potentially safely delay their radiation therapy.

Other considerations for oncologists and patients:

As far as possible, visits should be converted to telehealth consultations done from the comfort and safety of the patients home to reduce exposure to the coronavirus. Patients and caregivers should both take all possible precautions including wearing masks, avoiding sick people and crowded spaces. Patients should be counselled by psycho-oncologists as they are experiencing increased anxiety and mental distress due to the dual challenges of coronavirus and cancer.