By Dr Raghavan Vidya MS, MD, FRCS, Honorary Senior Lecturer at Birmingham University and Consultant Oncoplastic Breast Surgeon at The Royal Wolverhampton NHS Trust. 

The recent onset of the global COVID-19 pandemic¹ has changed the practice of oncological breast surgery. It has significantly impacted the diagnosis and treatment of breast cancer due to the diversification of the medical work force and decision to focus on treating the critically ill. Clinical practice has changed overnight for doctors, with the need to prioritise patients and make difficult choices by offering less treatment - which has been contrary to routine practice previously.

UK practice follows a target-based strategy, which aims to achieve a diagnosis within 31 days and begin treatment within 62 days². New patients are triaged to identify possible cancers based on symptoms and eliminate the burden of benign breast disease. The results and follow-up clinics are conducted via telephone calls and virtual clinics for a majority of patients. The multi-disciplinary meetings (MDT) are carried out remotely via video link. The enforced novel practice, such as virtual clinics, remote MDT meetings and consultations has utilised these resources efficiently, could become the norm in the future.

Minimally invasive surgical procedures are preferred, with the exception of reconstruction and oncoplastic procedures. The oncological treatment is offered only to the least vulnerable patients, and neoadjuvant therapy is offered as a last resort.

Nevertheless, it is clear that patients on chemotherapy may be severely immunocompromised and therefore, vulnerable to the risks associated with COVID-19 exposure. The NHS Breast Screening Program has also been suspended to avoid anxiety associated with a breast cancer diagnosis, especially in light of the current pandemic.

In summary, oncologists are making difficult treatment choices based on individual risk assessment and stratification, tumour biology, progression and assumption of outcomes. Breast oncologists would have to follow these new clinical practices until the cessation of the pandemic. However, as a result, patients may not receive a timely diagnosis, and may require aggressive treatment with detrimental effects on their long-term survival. 

References:

1. Hui DS, I Azhar E, Madani TA, et al. The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health-the latest 2019 novel coronavirus outbreak in Wuhan, China. Int J Infect Dis. 2020; 91:264-266.

2. The Breast Surgeons Group of the British Association of Surgical Oncology. Guidelines for surgeons in the management of symptomatic breast disease in the United Kingdom. London: BASO, 1995