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

Table 6 Prioritization for neoadjuvant medical treatment of breast cancer

High priority

Comments

(1) General recommendations: Patients with BC initiating therapy or ongoing neo/adjuvant chemotherapy and who present suspected symptoms of infection or contact history with an infected person is recommended to get tested (PCR) before starting or continuing it. In the case of positive results, defer treatment until confirmation of negative result with a new test (PCR) which could be performed between 2-3 wk later, and with previous evaluation from the Infectious Disease Department (Yes: 67%, No: 33%); (2) Neoadjuvant treatment according to subtypes: (a) A multidisciplinary team (using web platforms) should evaluate patients with invasive BC for the decision to initiate neoadjuvant therapy during the pandemic (Yes: 100%, No: 0%); (b) Neoadjuvant treatment in BC with “high risk” (TNBC, HER2 (+), luminal B with “high risk”) is recommended (Yes: 100%, No: 0%); and (c) In patients with HR (+) BC, neoadjuvant endocrine therapy allows deferring definitive surgery (Yes: 100%, No: 0%); (3) TNBC: (a) Standard neoadjuvant chemotherapy is recommended during the pandemic, although regimens that further reduce exposure and toxicity can be accepted (shorter duration, lower risk of immunosuppression and with an interval of every 3 wk) (Yes: 100%, No: 0%); (b) Consider the use of G-CSF (preferably pelfilgastrim for single-dose administration) in conjunction with chemotherapy (Yes: 89%, No: 11%); (c) The reduction of chemotherapy dose does not seem acceptable to reduce the risk of myelosuppression (Yes: 89%, No: 11%); (d) In older patients > 70 yr, the risk/benefit of neoadjuvant chemotherapy should be discussed. Initial surgery (as long as it is available) is an option, hoping that in 4-5 wk the situation improves to start chemotherapy (it should not be postponed more that period) (Yes: 89%, Abst: 11%); and (e) In patients < 70 yr who reject neoadjuvant chemotherapy for fear of COVID-19, initial surgery may be an option (if available) (Yes: 89%, Abst: 11%); (4) HER2 (+): (a) Neoadjuvant chemotherapy associated with anti-HER2 monoclonal antibodies is strongly recommended (Yes: 100%, No: 0%); and (b) A neoadjuvant regimen with dual anti-HER2 blocking for six courses without anthracyclines can be considered[26] (Yes: 67%, No: 11%, Abst: 22%); and (5) Luminal: (a) In those patients who do not accept surgery (initial therapy), the use of neoadjuvant endocrine therapy is considered to delay surgery until the pandemic is over, especially in patients > 70 yr, tumors with high expression of HR and low ki67 (Yes: 100%, No: 0%); (b) In luminal tumors, the benefit of adding neo/adjuvant chemotherapy to endocrine therapy can be estimated by clinic pathological factors: Tumors with histological grade 3, elevated ki67, or axillary involvement benefit more from chemotherapy (Yes: 100%, No: 0%); (c) Genomic platforms (oncotype, mammaprint, prosigna, endopredict) and online tools like ePrognosis provide additional value in establishing the need for chemotherapy (Yes: 100%, No: 0%); (d) In high-risk luminal tumors, neoadjuvant chemotherapy may provide benefits (e.g., an increased rate of conservative surgery) but not increased survival. This should be analyzed with the risk of SARS-CoV-2 infection and the availability of surgery (Yes: 100%, No: 0%); and (e) Recommendations of the use of neoadjuvant chemotherapy are the same as those described for TNBC subtype (Yes: 100%, No: 0%)

In patients with HER2 (+) EBC, trastuzumab can be restarted for up to 6 mo after stopping treatment

BC: Breast cancer; EBC: Early BC; HR: Hormone receptor; PCR: Polymerase chain reaction; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; TNBC: Triple-negative BC.