Management of Breast Cancer During the COVID-19 Pandemic: A Stage- and Subtype-Specific Approach

Abstract

The COVID-19 pandemic has rapidly changed delivery of cancer care. Many nonurgent surgeries are delayed to preserve hospital resources, and patient visits to health care settings are limited to reduce exposure to SARS-CoV-2. Providers must carefully weigh risks and benefits of delivering immunosuppressive therapy during the pandemic. For breast cancer, a key difference is increased use of neoadjuvant systemic therapy due to deferral of many breast surgeries during the pandemic. In some cases, this necessitates increased use of genomic tumor profiling on core biopsy specimens to guide neoadjuvant therapy decisions. Breast cancer treatment during the pandemic requires multidisciplinary input and varies according to stage, tumor biology, comorbidities, age, patient preferences, and available hospital resources. We present here the Johns Hopkins Women's Malignancies Program approach to breast cancer management during the COVID-19 pandemic. We include algorithms based on tumor biology and extent of disease that guide management decisions during the pandemic. These algorithms emphasize medical oncology treatment decisions and demonstrate how we have operationalized the general treatment recommendations during the pandemic proposed by national groups, such as the COVID-19 Pandemic Breast Cancer Consortium. Our recommendations can be adapted by other institutions and medical oncology practices in accordance with local conditions and resources. Guidelines such as these will be important as we continue to balance treatment of breast cancer against risk of SARS-CoV-2 exposure and infection until approval of a vaccine.

Fig 1.

(A) Johns Hopkins recommended approach to multidisciplinary care for stage I-III triple-negative invasive breast cancer during the COVID-19 pandemic. (B) Johns Hopkins recommended approach to multidisciplinary care for stage I-III HER2-positive invasive breast cancer during the COVID-19 pandemic. (C) Johns Hopkins recommended approach to multidisciplinary care for stage I-III hormone receptor–positive invasive breast cancer during the COVID-19 pandemic. (*) See Table 1 for definitions of low- and high-risk biology. For patients with biologic risk features that are neither clearly high nor low risk, genomic profile may be performed on the core biopsy specimen to guide classification. In cases in which biologic risk features are neither clearly high nor low risk and genomic profiling is not performed, we recommend following lowbiologic-risk arm. (**) The preferred neoadjuvant regimen for postmenopausal women is aromatase inhibitor (AI). The preferrred neoadjuvant regimen for premenopausal women is ovarian function suppression with tamoxifen followed by transition to AI once estradiol is suppressed. (***) If surgery is not available after completion of planned course of neoadjuvant chemotherapy, may initiate neoadjuvant endocrine therapy (ET) until surgery is available. AC-T, doxorubicin and cyclophosphamide followed by paclitaxel; ASAP, as soon as possible; ddAC-T, dose-dense AC-T; H, trastuzumab; P, pertuzumab; T, paclitaxel; TCH, docetaxel/carboplatin/trastuzumab; T-DM1, ado-trastuzumab emtansine.