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

Table 7 Prioritization for adjuvant medical treatment of breast cancer

High priority

Comments

(1) General recommendations: (a) Recommendations in the neoadjuvant setting are similar to adjuvant therapy (Yes: 100%, No: 0%); (b) In patients > 70 yr, the evaluation of performance status for estimating the risk/benefit of chemotherapy is mandatory. Online tools (such ePrognosis) and genomic profiles can be useful (Yes: 100%, No: 0%); and (c) It is valid to defer the start of adjuvant chemotherapy until the pandemic is over, although decisions should be individualized according to the patient risk and tumoral subtypes (Yes: 100%, No: 0%); (2) TNBC: (a) Adjuvant chemotherapy must be administered in the most effective way (Yes: 100%, No: 0%); (b) It is recommended to initiate adjuvant chemotherapy up to 2 mo after surgery (Yes: 100%, No: 0%); (c) In patients with age > 70 yr, discuss risk/benefits of using adjuvant chemotherapy; consider a regimen less immunosuppressive to avoid hospital admissions (Yes: 100%, No: 0%); (d) Consider the use of concomitant G-CSF to reduce the risk of infections (Yes: 89%, No: 11%); and (e) The use of adjuvant capecitabine, during 6-8 mo, in patients with no PCR after neoadjuvant chemotherapy is recommended (Yes: 100%, No: 0%); (3) HER2 (+): (a) Adjuvant chemotherapy associated with anti-HER2 therapy is recommended (Yes: 100%, No: 0%); (b) Subcutaneous trastuzumab is an alternative to reduce time to hospital admission. (Yes: 100%, No: 0%); (c) In selected patients (low risk, CS I-II, with PCR after neoadjuvant chemotherapy and surgery), it is valid to consider a shorter time of treatment with adjuvant trastuzumab (6 mo) to reduce hospital admission (Yes: 100%, No: 0%); (d) In the case of completing neoadjuvant chemotherapy associated with anti-HER2 therapy, it is reasonable to continue anti-HER2 therapy until surgery (Yes: 89%, No: 11%); and (e) The use of T-DM1 in those patients who cannot reach pCR after neoadjuvant chemotherapy is recommended. Moreover, the use of T-DM1 can be delayed after surgery (Yes: 100%, No: 0%); and (4) Luminal: (a) In “high risk” luminal patients, it is recommended to assess a clinical risk and/or use of genomic platforms (including tumors with lymph node involvement) to limit the use of adjuvant chemotherapy, according to institutional clinical practice guidelines (Yes: 100%, No: 0%); (b) The assessment of clinical risk with online tools (such as Predict) to estimate the risk of recurrence and the benefit of adjuvant chemotherapy is recommended (Yes: 100%, No: 0%); and (c) If adjuvant chemotherapy is necessary (risk/benefit previous evaluation), its initiation can be delayed up to a maximum of 3 mo after surgery (without reducing efficacy) (Yes: 89%, No: 11%)

(1) Delaying adjuvant chemotherapy in TNBC is associated with an increased risk of relapse and death; and (2) To limit the use of adjuvant chemotherapy, luminal BC should be assessed by clinical and/or genomic risks

BC: Breast cancer; CS: Clinical stage; G-CSF: Granulocyte-colony stimulating factor; PCR: Polymerase chain reaction; TNBC: Triple-negative BC.