Should Breast Cancer Surgery Be Delayed Due to COVID-19?

Cancer, especially a new cancer diagnosis, is scary and urgent. COVID-19 poses a different kind of challenge – trying to balance both sets of risks. As we all know, hospitals have closed down elective visits, procedures, and surgeries. It is one thing to delay a six-month visit with the oncologist, or to move it to telehealth, and another to delay breast cancer surgery.

A reminder: although surgery is usually the first treatment for a new breast cancer, there have long been exceptions. For a range of reasons, sometimes the recommendation has been neoadjuvant chemotherapy before surgery. This means that the patient is given chemo or anti-estrogen therapy first and then moves to surgery, either a wide excision (lumpectomy or partial mastectomy) or a mastectomy. More often, however, surgery comes first.

Both the American College of Breast Surgeons and the American College of Surgeons have recently published guidelines that change the long-standing patterns of care. Hospitals are focused on keeping patients safe, and that means, right now, keeping people away when a delay is not a threat to their health. Another perspective is that hospitals are trying to keep their resources — staff, space, and equipment — available for large numbers of very ill COVID-19 patients. Some ORs have been repurposed as ICUs, and everyone is thinking about the best ways to be responsive to all needs while maintaining some flexibility.

Currently, the national recommendation establishes three phases of need:

• Phase 1 includes patients who are not likely to have compromised survival if the surgery does not happen within three months. This includes most patients who are diagnosed with clinical Stage 1 or 2 ER-positive breast cancer, those who are finishing a planned course of neoadjuvant chemotherapy, and some with triple negative breast cancers. This group also includes women for whom neoadjuvant anti-estrogen is administered to provide treatment for the cancer that is not yet removed.
• Phase II is patients whose survival could be threatened if surgery were not performed within a few days. These situations include someone with a breast abscess or experiencing serious complications from previous surgery, including breast reconstruction.
• Phase III means patients who could die within a few hours without surgery (this is a most unlikely scenario!).

Phases II and III are clear and brook no argument. The situation for Phase I patients is more challenging. I have not known very many, if any, women who are comfortable delaying breast surgery for several months after diagnosis. Even when the reason has been to immediately begin neoadjuvant (chemo) therapy, there are concerns. When a woman has needed to wait weeks or months because of the plan for mastectomy and reconstruction and the difficulties in scheduling, it can be very distressing. Through the years, I have talked with dozens of women in this set of circumstances, always reminding them that their doctors would not have made this plan if it were thought to be unsafe.

Right now, the recommendation is that newly diagnosed patients with Stage I or Stage II ER-positive breast cancer immediately begin neoadjuvant hormonal or endocrine therapy until it is safe to proceed with surgery. All of the available data suggests that this is just as effective as the more traditional schedule. At BIDMC, these decisions are being made on a case by case basis, with careful consideration and consultation, by the surgeons, medical oncologists and radiation oncologists. Learn more about BIDMC's Breast Cancer Services.