Adaptation of international coronavirus disease 2019 and breast cancer guidelines to local context

Table 5 Prioritization for early breast cancer

High priority	Medium priority	Comments
(1) General considerations: (a) All subtypes should complete their regimens that have already started[8]. Consider shorter regimens or dose-modifications (Yes: 100%, No: 0%); and (b) Patients with CS I-II (including N1) and those with intermediate/low grade, "low risk" genetic profile, or classified as luminal A subtype do not benefit from neo/adjuvant chemotherapy. They can receive endocrine therapy alone[9,10] (Yes: 100%, No: 0%); (2) TNBC EBC: (a) Chemotherapy neo/adjuvant is recommended. Sequential treatment with one agent reduces complications[11] (Yes: 100%, No: 0%); and (b) Adjuvant capecitabine is recommended in post-neoadjuvant residual disease (Yes: 100%, No: 0%); (3) HER2 (+) EBC: (a) Neo/adjuvant systemic therapy + targeted therapy anti-HER2 is recommended (Yes: 100%, No: 0%); (b) Complete neo/adjuvant chemotherapy (+/- anti-HER2 therapy) for HER2 (+) EBC (Yes: 100%, No: 0%); (c) Trastuzumab-based adjuvant therapy could be reduced from 12 mo to 6 mo without affecting outcomes[12,13] (Yes: 100%, No: 0%); (d) Consider the use of T-DM1 (+/- pertuzumab) in the neo/adjuvant scenario (reduces risk of neutropenia, hospital admissions, use of corticosteroids)[14-16] (Yes: 67%, No: 22%, Abst: 11%); and (e) Continue with T-DM1 in HER2 (+) patients as an adjuvant therapy for post-neoadjuvant residual disease[17,18] (Yes: 100%, No: 0%); and (4) Luminal EBC: (a) Neo/adjuvant endocrine therapy +/- chemotherapy for HR (+)/HER2 (-) BC is recommended (Yes: 100%, No: 0%); (b) Continue standard adjuvant endocrine therapy in pre and postmenopausal patients (use telemedicine to manage potential toxicities reported by patients) (Yes: 100%, No: 0%); and (c) Neoadjuvant endocrine therapy is an option for HR (+)/HER2 (-) BC patients allowing to defer surgery between 6-12 mo in BC with CS I or II (Yes: 100%, No: 0%)	(1) HER2 (+) EBC: Anti-HER2 therapy can be restarted after remitting SARS-CoV-2 infection, following a discussion, and approval by a multidisciplinary team (Yes: 78%, No: 22%); and (2) Luminal EBC: (a) In postmenopausal CS I patients with low/intermediate grade tumors or lobular BC, endocrine therapy may be started when surgery is deferred (Yes: 100%, No: 0%); and (b) For patients with low-risk genomic score/signature, endocrine therapy should be started alone (Yes: 89%, No: 11%)	(1) In patients with active infection due to COVID-19, stopping treatment is recommended; (2) Antihormonal therapy: Endocrine therapy (tamoxifen, AI, LHRH agonists) is safe (does not affect the immune system) and can be continued during the COVID-19 pandemic. LHRH analogs can be administered every 3 mo (although home administration of LHRH analogs is the preferred recommendation); however, fulvestrant requires intramuscular monthly application[19]; (3) Chemotherapy: schedules can be modified to reduce admissions (every 2 or 3 wks’ doses can be used instead of a weekly dose with selected agents). Consider the use of concomitant colony-stimulating factor (G-CSF), preferably pegfilgrastim for single-dose administration)[20]; and (4) Bone modifying agents (denosumab or bisphosphonates) can be deferred or administrated every 3 mo (without hypercalcemia), both for adjuvant therapy or in long-term treatments

AI: Aromatase inhibitor; BC: Breast cancer; COVID-19: Coronavirus disease 2019; CS: Clinical stage; EBC: Early BC; G-CSF: Granulocyte-colony stimulating factor; HER2: Human epidermal growth factor receptor 2; HR: Hormone receptor; LHRH: Luteinizing hormone-releasing hormone; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2.