Breast Cancer Surgery in the COVID-19 Pandemic: Validation of a Preventive Program for Patients and Health Care Workers

Discussion

In the present experience, a specific preventive strategy was conceived according to national and international recommendations with the aim of performing a preoperative COVID-19 screening, thus avoiding any impairment of breast cancer patient’s outcome related to a delay of treatment planning, while preserving our clinical and surgical work-force. Seven out of 207 patients (3.3%) were temporarily suspended from the scheduled operation after the “Telephone Triage”, six of whom because of COVID-19 symptoms (3 patients) or hospitalization due to COVID-19 infection (the other 3 patients), while one received NAC after oncologic re-assessment. All patients that had been hospitalized for COVID-19 disease died. Thus, most of the patients underwent safe surgical procedures without any undue post-operative complication and without any demonstrated COVID-19 infection among patients and HCWs, notwithstanding the reduced availability of operating theatres and Anaesthetists. Hence, 163 patients with a preoperative diagnosis of breast cancer (80.3%) had the scheduled operation, 141 of whom for invasive cancer (69.4%) and 22 for ductal carcinoma in situ (DCIS) (10.8%). Worth of note, four of the latter group had invasive cancer at post-operative histological examination.

The rate of female patients coming from other Regional Breast Units was rather low (20 out of 203=9.8%), and this might be related to: 1) a delayed recruitment of patients coming from the other Breast Units; 2) doubts regarding the oncologic management by another team, far from home, while still hoping for a rather quick resolution of COVID-19 pandemic; 3) the fear of logistic obstacles for accomplishing adjuvant treatments (such as adjuvant medical treatment or radiation therapy) and, last but not least, the fear of acquiring COVID-19 infection during hospitalization (5).

In-hospital stay was strictly limited to the least for avoiding any unnecessary overload to health-care structures, with a mean length of stay of approximately one day more as expected in the pre-COVID pandemic due to the preventive measures that were required. All patients were regularly discharged with breast and/or axillary drainages as soon as they were clinically stable, and a systematic home tele-monitoring was developed and supervised by dedicated Breast Care Nurses.

Certainly, the most relevant issue regards the selection of the “Treating Group Patients”. In the present experience, patients with doubtful malignant potential tru-cut biopsy lesions (B3) were eligible for surgery. Hence, 26 patients (12.8%) with preoperative B3 diagnosis were surgically treated, and seven of them (26.9%) had a post-operative diagnosis of invasive cancer. This category was added to the eligible group of patients for surgery due to the delay in mammography screening from March 9^th to June 9^th. Hence, less breast cancer diagnoses were collected, and in less than two weeks, patients with a definite preoperative diagnosis of breast cancer could undergo surgical treatment; thanks to this addendum, these seven patients had a prompt surgical therapy thus, speeding the treatment planning and execution.

A great attention regards the possibility to choose, even in the early stage of disease, between surgery or primary systemic therapy. As suggested by Curigliano et al. (15), these two approaches should be considered based on local health-care resources and facilities, numbers of hospital accesses as well as the treatment-related effect on the immune system (16-19). Such decisions do not have a universal value because each situation might differ in a specific country and, also, in a peculiar town or hospital. This highlights even more the role of the multidisciplinary approach within the Institutional Breast Cancer Management Team in order to define the best treatment planning for “that” patient in “that” specific clinical contest. The main goal is to maintain a high quality of care while minimizing COVID-19 infection and treatment-related risks.

Last but not least, the pandemic scenario should be taken into account (i.e., early spread of COVID-19 infection onset as compared to mitigation or recovery phase). Therefore, although in the pre-COVID-19 era an early breast cancer patient might have been treated with primary systemic therapy, in the post-COVID-19 one surgery would be preferably adopted mostly if BCS might be performed in an outpatient setting. The opposite may be true in a post-menopausal patient with an early Luminal A/B disease who could undergo primary endocrine therapy instead of immediate surgery in order to delay hospitalization for more invasive procedures until the end of Covid-19 pandemic.

Regarding the psychological implications of COVID-19 disease, the fear of this new infective disease was perceived by patients as even worse than the diagnosis of cancer. As a matter of fact, in the recent clinical experience by Vanni et al. (20), both patients with suspected breast lesions or confirmed breast cancer assessed in the COVID-19 pandemic showed a significant higher rate of procedure refusal and surgical refusal as compared to the pre-COVID-19 period (p=0.0208, p=0.0065 respectively) and this was mostly related to the infection risk. Hence, COVID-19-related anxiety could negatively interfere with the patients’ decision-making process, and the availability of such data confirming the safety for both patients and HCWs may prevent any undue delay of treatment with an adverse effect on patient outcome.