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Influence of pandemic COVID 19 on breast cancer treatment: one center experience

Almoosa N

Department of general surgery, Bahrain Defense Force-Royale Medical Service, Riffa -Kingdome of Bahrain

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

DOI: 10.15761/GOS.1000227

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Abstract

Background: Global worldwide COVID19 has become a pandemic disease-causing severe chest infection affecting people of different ages, mostly elderly with immunocompromised disease leading to unexpected death.

Well known that breast cancer is the most common cancer disease. As a result of early breast screening awareness, which enables immediate therapy once diagnosed, but due to the COVID19 outbreak limitations, and restrictions should be considered. So far, international protocols and guidelines and vaccination have been submitted to be followed during management phases, to decrease the risk of infection and mortality per (WHO).

Aim: Strategies of COVID19 risk assessment levels during managing breast cancer: using hospital facility and precautions, giving ways to formulate safe Multidisciplinary team (MDT) discussions; to overcome the spread of COVID19 among breast cancer patients.

Methodology: Case series,descriptive retrospective, study of 9 female patients aged ( 45- 69 ) years old from February 2020 till may 2021.

Results: We found no transmission of the virus disease in any of our patients during the preoperative, intraoperative, and postoperative periods. In a world overshadowed by the COVID19 pandemic, where many lay stranded awaiting their treatments, we highlight the safety of performing elective surgeries in patients during the pandemic.

Conclusion: The best method of reducing the risk of this infection among health care workers and breast cancer patients are to follow infection control prevention teams with setting up precautionary measures in their facilities to advocate higher standard care of treatment

Keywords

COVID 19, Breast Cancer, General Surgery, strategy, priority

Abbreviations

COVID 19-Corona Virus 2, MDT-Multidisplinary Team, PCR-Nasopharyngeal Swap, PPE-Personal Protective Equipment, WLE-Wide Local Excision,SLNB-Sentinel Lymph Node Biopsy, F-Female, AF-Atrial Fibrillation, CAD-Coronary Artery Disease, EF-Ejection Friction, CXR-Chemotherapy, RX-Radiation Therapy, neoCXR-Neoadjuvant Chemotherapy, CDC-Chinese Center For Disease Control And Prevention, FNAC-Fine Needele Aspiration Cytology, CT-Computerized Tomograpgy, LN-Lymph Node, MRI-Magnetic Resonase Imaging, WHO-World Health Organization, ER-Estrogen Receptor, PR-Progesterone Receptor, Her2/neu-Human Epidermal Growth Factor Receptor 2, UOQ-Upper Outer Quadrent, LOQ-Left Outer Quadrent, IUQ-Inner Upper Quadrent, -ve – Negative, Us-Ultrasound Breast

Introduction

At the end of 2019, WHO declared a pandemic; caused by a novel COVID19 virus, identified by the Chinese center for disease control and prevention (CDC), proven by multiple throat swabs in January 2020 respiratory syndrome. The outbreak had originated from China and had an easy predilection for community spread [1,2].

The disease had a severe presentation in patients who were elderly, with co-morbidities like diabetes mellites, and immunosuppressed individuals, mostly; oncology patients [3,4]. With this mindset, it has become imperative to categorize and prioritize patients with breast pathology, needing surgical treatments according to hospital facility and utilization.

During the outbreak of global pandemic disease, categorizing patients with breast cancer disease; was done to identify vulnerable high-risk groups concerning breast-related conditions. Several protocols have been suggested to ease surgical patients' treatment while avoiding unnecessary exposure to the pandemic virus.

Although prioritization urges the challenge of clinicians and medicine to help patients, where American College of Breast Surgeons and the American College of Surgeons have recently published phases that change the long-standing patterns of care [5].

Since breast pathology and surgery does not carry any healthcare worker risk of transmission of the COVID19 virus, there was no need to avoid treating such patients. Instead, a planned approach needed to be put in place to identify plan and execute the necessary treatment for such patients, especially breast carcinoma.

Methods and Materials

A retrospective descriptive case series study was conducted based on breast surgery clinic patients flow at our centre, from February 2020 till May 2021. We would like to present how breast cancer surgeries were categorize with proper COVID19 protocols and standard cancer care.

Ethical consideration:

This study was approved from hospital research center as well as, signed consent from patients were obtained.

Results

The study was conducted on 9 patients; the ages were between 45 and 69 years; all were females, who have been presented to our breast surgical clinic during the period of COVID19 pandemic, with unilateral breast mass as About 66% of them have hypertension, Diabetes mellitus, and dyslipidemia. Only 1(11.1%) has face basal cell carcinoma. Only 2(22.2%) used to take oral contraceptive bills. All of them have early menarche, and no one of them has late pregnancy. All the cases have low COVID 19 risk assessment and negative PCR swab. 6(66%) of the cases had WLE & SLNB surgery,1(11.1%) had simple mastectomy and SLNB. 6 months to one year were the duration of the follow up for 5(55.5%) cases, while 1 (11.1%)of them done last month, 1 (11.1%)still waiting for neo adjuvant chemotherapy,1(11.1%) case refused the surgery due to EF 15%, 1(11.1) case preferred to do the procedure in oncology center ,1(11.1%) preferred to travel aboard. All 6 cases were in the pT1-2 N0 M0 stage. See (Table 1).

Table 1. Demographic data of breast cancer patients.

cases

1

2

3

4

5

6

7

8

9

Age

69

45

62

56

53

69

 

 

 

Gender

F

F

F

F

F

F

F

F

F

Co-morbidity

 (HTN)

 (DM)

Dyslipidemia

face basal cell ca

AF,CAD,EF 15%

 

Yes

Yes

Yes

No

No

 

Yes

Yes

Yes

No

No

 

No

No

No

No

No

 

No

No

No

No

No

 

Yes

Yes

Yes

Yes

No

 

Yes

Yes

Yes

No

Yes

 

No

No

No

No

NO

 

No

No

No

No

No

 

No

No

No

No

No

Risk factors

1.menupasual status

2.FH of cancer

3.OCP

4.late pregnancy

5.early menarche

6.alcohol and smoking

 

Post

Uterine ca

Yes

No

Yes

No

 

Post

-ve

No

No

Yes

No

 

Post

-ve

No

No

Yes

No

 

Post

-ve

No

No

Yes

No

 

Post

-ve

yes

No

Yes

No

 

Post

Breast ca

No

No

Yes

No

 

Post

No

No

No

Yes

No

 

 

Post

No

No

No

Yes

No

 

Post

No

No

No

Yes

No

 

COVID 19 risk

Low

Low

low

low

low

low

low

low

low

PCR swab

-ve

-ve

-ve

-ve

-ve

-ve

-ve

Pending surgery

Travel abroad

Hospital stay days)

1

1

1

1

After chemo

Not done

1

-

Travel abroad

Surgery

WLE &SLNB

WLE &SLNB

WLE &SLNB

WLE &SLNB

Lost followup

refused

WLE&SLNB

NACT

Travel abroad

Follow up (days/weeks /months/year)

2/2/3/1

2/2/1-6

2/2/3/1

2/2/3/1

Lost follow up

3m-1 y

2

-

-

Stage of cancer

pT2 N0 M0

pT2N0M0

pT1N0M0

pT1N0M0

T2N0M0

T2N0M0

T1N0M0

-

-

Adjuvant therapy

CTX +RT

CTX+RT

RT+

hormonl

(femara)

CTX+RT

neoCTX+RT

Hormonl

(Femara)

CTX

RX

hormonal

-

-

recurrence

No

Yes

NO

NO

Lost follow up

NO

NO

-

-

COVID 19 vaccine

Yes

NO

Yes

Yes

Lost follow up

Yes

Yes

Yes

-

COVID 19 symptoms

NO

NO

NO

NO

Lost follow up

NO

NO

NO

-

Risk stratification of COVID19 assessment prior to work up and surgery was shown in (Figure 1).

Figure 1. COVID19 risk assessment.

Case 1:

History: 69 years old female known case of DM and hyperlipidemia referred to the breast clinic with the incidental finding from Health Center after breast screening with mammography revealed; a malignant cluster of microcalcification in the left breast complaining of mild left breast pain and no other associated symptoms.

On examination, found to have supra-areolar left breast mass 2 x 2 cm, irregular, lobulated, not fixed, no pitting edema, no tethering with no axillary lymph node (LN); other breast and axilla were unremarkable.

Imaging: mammogram and ultrasound breast (Us) requested were found with left upper quadrant suspicious mass at 11 o'clock 2 x1.5 cm irregular, tiny calcification; no axillary LN found (Figure 2).

Figure 2. Micro cacalcificattion of left breast indicate invasive ductal carcinoma of breast.

Core biopsy: showed Invasive Ductal Carcinoma Grade III, immunohistochemistry stains with ER: -ve, PR: -ve, Her2/neu: negative, Ki-67:20% proliferation index, FNAC of axillary LN showed negative for malignancy.

Staging workup: patient forwarded to CT chest, abdomen, and pelvis which revealed: Left breast features of malignancy, thyroid nodules, where U/S done and found small nodules for FNAC and came with colloid goiter,

Pulmonary soft tissue nodule12-month interval CT follow up is recommended.

Hepatic cysts for a 2nd look by ultrasound abdomen, which shows the same finding.

Plan: The virtual tumor board discussion was performed and planned for left WLE & SLNB followed by chemotherapy and radiation.

Surgery: Left WLE & SLNB ,5 lymph nodes sent for frozen section and came with negative for metastasis

Final histopathology: Left breast: Grade 3 invasive ductal carcinoma, NOS, measuring 2.6cm in maximum dimension, excision complete,

SLNB: negative (0/5)

Pathological staging TNM: pT2 N0 M0

Follow up: Over 1 year per virtual tumor board discussion she finished her adjuvant chemotherapy and radiation resulted with no recurrence proved by imaging at oncology center, she had mild dizziness after therapy, although she had COVID19 vaccine after approval of oncology center with no symptoms of corona virus.

Case 2:

History: 45 years old female known case of DM, hyperlipidemia, HTN, presented to breast clinic from Health Center with asymptomatic mass, was discovered one week back in the left breast; she comes with ultrasound breast form outside shows mass at left outer quadrant 1 cm most likely fibroadenoma.

On examination, found to have 1 x 1 cm mass at the left axillary tail, no skin changed, normal nipple, no axillary LN felt, right breast and axillary LN normal.

Imaging: mammogram image found small oval dense lesion about 2x1.8cm, is seen at the UOQ left breast, likely benign cyst or fibroadenoma, free axillary LN.

Us breast found irregular heterogeneous soft tissue mass lesion about 2.3 x 1.8 cm is seen in the left axillary tail, with surrounding tissue edema.

Core biopsy: showed left invasive ductal carcinoma grade 3, immunohistochemistry stains were: ER- 3/8 (Allred score), PR - 3/8 (Allred score), her2neu: negative, ki67:40% proliferation index.

FNAC of left axillary LN showed negative for malignancy,

Staging workup patient forwarded to CT chest, abdomen, and pelvis which revealed negative for metastasis. Due to discrepancy between pathology, and imaging we requested MRI breast for confirmation, where it came with heterogeneously enhanced lesion about 2.5 x 2.2 cm is seen in the left axillary tail with surrounding architectural distortion, and tissue edema, with axillary abnormal LN.

Plan: Virtual tumor board discussion was performed, and planned for left WLE & SLNB

followed by chemotherapy and radiation.

Surgery: she underwent left WLE and SLNB, 3 LN sent for frozen section and came with positive for metastasis so converted to formal axillary LN dissection

Final histopathology: Left breast, -Grade 3, invasive atypical medullary carcinoma (Nos) measuring 2.2cm in maximum dimension. Excision complete.

Axillary lymph node: No lymph node metastasis (0/8)

Pathological staging TNM: pT2N0M0

Follow up: After one month of her surgery, she had sign of cellulitis on operated site improved with oral antibiotics, per tumor board plan she had to complete her adjuvant chemotherapy and radiation.

later, after 6 months of operation she presented with enlargement of left breast, edema, peau d ‘orange appearance and retracted nipple. Urgently US and MRI breast done shows retro areolar recurrence mass about 6 cm with suspicious axillary lymph node. Again, core biopsy and staging work up requested, shows recurrence of the disease but no metastasis (Figure 3, 4).

Figure 3: CT scan indicate recurrence of left breast cancer.

Figure 4: recurrence of breast cancer after 6 months.

She had followed with her oncologist and started on new regimen chemotherapy and immunosuppressant for 2 months resulted in good response. She did not receive any COVID 19 vaccine until now but no symptoms corona virus.

Case 3:

History: 62 years old female, referred to breast clinic from Health Center has not been screened for long time came with new outside image of mammogram shows opacity having suspicious features UOQ 1.5 cm by 1.8 cm, and Us showed 1.7cm by 0.9 cm at 2 o'clock suspicious irregular left side mass, axillary lymph node 1.3 cm, bilateral breast cyst.

On examination no lump felt at left side, no axillary LN, no skin changes, right breast and axilla were normal.

Imaging: mammogram image found dense opacity at LOQ lobulated with irregular border 1.1 cm x 1.8 cm. Us breast found 1.7 x 1 x 0.9 cm suspicious irregular nodule at 2 o'clock LOQ, left axillary LN 1.4 cm, bilateral fibrocystic changes.

Core biopsy: showed left grade 2 invasive ductal carcinoma, immunohistochemistry stains were: ER- 8/8 (allred score), PR - 7/8 (allred score), her2neu: negative, ki67 = 10-12% proliferation index, FNAC of left axillary LN shows negative for malignancy

Staging workup: patient forwarded to CT chest, abdomen, and pelvis which revealed negative for metastasis.

plan: Virtual tumor board discussion planned for left WLE & SLNB followed by radiation and hormonal therapy.

Surgery: Left WLE and SLNB, 2 lymph nodes sent for frozen section and came with negative for metastasis

Final histopathology: Invasive ductal carcinoma, Grade 1; All margins are free. no (sentinel) LN metastasis (0/2)

Pathological staging TNM: pT1 N0 M0

Follow up: over 1 year per tumor board she finished her radiation and now on hormonal therapy resulted with no recurrence proved by imaging, in addition she had COVID 19 vaccine after approval of oncology center with no corona virus symptoms .

Case 4:

History: 56years old female, referred to breast clinic with left side painful breast mass for 1-month with no risk factors.

On examination: left mass at 10 o'clock IUQ 1 by 2 cm, no tethering, no nipple changes, no inflammation, LN not identified, right breast, and axilla was unremarkable.

Imaging: mammogram image found a speculated density in the left breast, bilateral axillary LN looks benign, Us breast shows irregular heterogenous vertically oriented suspicious mass about 1.7 x 1.5 cm is seen in the left breast at 10 o'clock position corresponding to the speculated mass seen in mammogram.

Core biopsy: showed left invasive ductal carcinoma grade 3, immunohistochemistry stains were: ER- 0/8 (allred score), PR - 0/8 (allred score), her2neu: negative, ki67 = 80% proliferation index, FNAC of left axillary LN shows negative for malignancy.

Staging workup: patient forwarded to CT chest, abdomen, and pelvis which revealed negative for metastasis.

plan: Virtual tumor board discussion planned for left WLE & SLNB followed with chemotherapy and radiation.

Surgery: Left WLE and SLNB, 2 lymph nodes sent for frozen section and came with negative for metastasis

Final histopathology: Left breast: Invasive ductal carcinoma, NOS, 1.6 cm in maximum dimension. Excision complete. left axillary LN: -No lymph node (sentinel) metastasis (0/2)

Pathological staging TNM: pT1cN0M0

Follow up: over 10 months per tumor board she finished her adjuvant chemotherapy and radiation with no recurrence. In addition, she had COVID19 vaccine after approval of oncology center with no corona virus symptoms.

Case 5:

History: 53 years old female known case of DM, Hyperlipidemia, Basal cell carcinoma of face, presented to breast clinic with a complain of left breast mass in the last 2 weeks, no other complains, no risk factors.

On examination: left breast mass at outer quadrant at 10 ‘o clock 2 by 3 cm, hard, no tethering, no edema, no muscle attachment, no axillary LN, right breast, and axilla were normal.

Imaging: mammogram image found dense mass with surrounding speculations is seen in the left breast UOQ with surrounding architectural distortion. Us breast, a partially defined irregular mass about 3.1 x 2 cm is seen in the left breast UOQ, with increased vascularity and surrounding architectural distortion, with normal Left axillary LN.

Core biopsy: showed left invasive ductal carcinoma grade 3, immunohistochemistry stains were: ER- 0/8 (allred score), PR - 0/8 (allred score), her2neu = negative (0+), ki67 = 75% proliferation index, FNAC of left axillary LN shows negative for malignancy

Staging workup: patient forwarded to CT chest, abdomen, and pelvis which revealed negative for metastasis.

plan: Virtual tumor board discussion planned for neochemotherapy; prior to clipping marker at site of tumor, then waiting for WLE and SLNB followed by radiation.

Follow up: patient preferred to do surgery and complete her treatment in oncology center.

Case 6:

History: 69 years old female know case of DM, Hyperlipidemia, CAD, AF, EF 15% presented to breast clinic complain of Left breast pain for 10 days, no nipple discharge, no other symptoms

On examination found to have left breast lump at 2 o'clock with skin tethering attached to skin, no axillary LN, other breast was unremarkable.

Imaging: mammogram image found ill-defined irregular speculated mass lesion with overlying skin dimpling is seen in the left breast UOQ consistent with malignancy, left nipple retraction is noted, left axillary LN noted, Us breast found irregular ill-defined hypoechoic speculated mass is seen in the left breast 1-2 o’clock position measuring about 3.1 x 2.5 x 1.9 cm with posterior shadowing (Figure 5).

Figure 5: Mammogram finding of invasive lobular carcinoma of breast.

Core biopsy: showed left invasive lobular carcinoma grade 2, immunohistochemistry stains were: ER- 8/8 (allred score), PR - 7/8 (allred score), her2neu: negative, ki67 :10-15% proliferation index, FNAC of left axillary LN shows negative for malignancy.

Staging workup: patient forwarded to CT chest, abdomen, and pelvis which revealed negative for metastasis.

Plan: Virtual tumor board discussion planned for left WLE & SLNB, but patient due to her EF 15% she refused to go for surgery, so she preferred to have hormonal therapy which have been agreed by the tumor board council.

Follow up: Patient was seen at breast clinic once after hormonal therapy (femara 2.5mg) once daily every 3 months for one year to see the effect of therapy where is shows good progress. In addition, she had COVID 19 vaccine after approval of oncology center with no corona virus symptoms felt.

Case 7:

History: 57-year-old female medically free had breast mass for 9 months, no previous screening, had family history of lung cancer and leukemia (first degree line relative), no other risk factors.

On examination: right breast mass less than 1 cm, 4 cm away from the nipple, mobile, not attached to skin, no tethering, no nipple retraction, no axillary lymph node, other breast, and axilla normal.

Imaging: Mammogram shows right sided UOQ asymmetric density is seen, a linear asymmetric density is seen in the left breast at 12 o’clock. Bilateral possibly benign calcifications, more evident on the right UOQ. Skin and both nipples are unremarkable. Bilateral axillary lymph nodes.

Us breast an irregular mass about 5 x 6 x 6 mm is seen in the right breast UOQ with bright halo of compressed tissues. right axillary nodes show altered echogenicity, compressed hilum and relatively thickened cortex.

Core biopsy: Right breast biopsy showing invasive mucinous carcinoma, grade 2.

No DCIS, LVI or micro calcification seen. The tumor shows the following immunoprofile: ER - 8/8 (Allred score), PR - 0/8 (Allred score), Her2/neu - Negative (0+), E-cadherin - Strong positive, Ki67 - 5% proliferation index. FNAC of right axillary lymph node are negative for metastasis.

Staging workup: patient forwarded to CT chest, abdomen, and pelvis shows Right upper lobe posterior segment pulmonary parenchymal soft tissue nodule, 2.7 mm for follow up.

No evidence of gross soft tissue or bony suspicious lesions. Bone scan shows focal increase uptake in relation to the left sided junction of the third rib with transverse process due to underlying degeneration.

plan: Virtual tumor board discussion planned for right WLE & SLNB followed by chemotherapy and radiation and hormonal therapy.

Surgery: right WLE &SLNB, 4 lymph nodes sent for frozen section and 2 lymph nodes came with metastatic cancer, so formal axillary lymph node dissection performed

Pathological staging NM: pT1 N1M0

Follow up: she just finished her surgery and waiting for tumor board council plan, although she had COVID19 vaccine prior to awareness of breast cancer but no corona virus symptoms.

Case 8:

History: 59 old female known case of diabetes mellitus, positive family history of breast cancer (first degree relative), dyslipidemia, asthma, came with screening from health center since 2018 by mammogram with asymmetry of breast mass done but patient not notified until she had mass at RUQ while self-examination.

On examination: right breast mass 3 x 4 cm, 2 cm away from the nipple, mobile, not attached to skin, no tethering, no nipple retraction, no axillary lymph node, other breast and axilla normal.

Imaging: Mammogram an asymmetric density is seen in the right breast UOQ.

No suspicious micro calcifications noted as per visualized through dense breast tissue. Right axillary dense nodes with thickened cortex. Us breast shows an irregular micro lobulated heterogeneous mass about 2.1 x 1.8 x 1.5 cm is seen in the right breast at 9-10 o'clock position with prominent vascularity. Enlarged right axillary lymph node with effaced hilum and thickened cortex is seen.

Core biopsy: Right breast biopsy showing a grade 2 invasive ductal carcinoma (NOS).

No DCIS, LVI or micro calcification seen. The tumor shows the following immunoprofile: ER - 8/8 (Allred score), PR - 8/8 (Allred score), Her2neu - Positive (3+), E-cadherin - Strong positive, Ki67 - 80% proliferation index. FNAC of right axillary LN are positive for metastatic cancer.

Staging workup: patient forwarded to CT chest, abdomen, and pelvis shows right lower lobe posterior pulmonary soft tissue nodule measuring 3.5 mm for follow-up. Bone scan shows no bony metastasis.

plan: Virtual tumor board discussion planned for clipping of tumor prior to neo adjuvant chemotherapy under radiological guidance then to follow again for further treatment, she already had COVID19 vaccine prior to breast cancer awareness with no corona virus symptoms.

Case 9:

History: Presented to gynae clinic for screening and complained of right breast mass for few months so mammogram done at that time.

On examination: Right breast mass at 6 o’clock, skin tethering, 4 x3cm, not attached to muscle, mobile, no nipple retraction. No AXLN felt.

Imaging: Mammogram dense breast, right inner deep part architectural distortion, bilateral scattered micro calcification needs MRI, benign axillary lymph node US breast showed dense breast and bilateral fibrocystic changes, right irregular heterogenous mass 3.3x 1.6 cm at 5 o’clock.

Core biopsy: Right Grade 2 invasive ductal carcinoma, no DCIS, No micro calcification, no lymph vascular invasion, supplementary Report: ER – 7/8 (Allred score), PR - 0/8 (Allred score), Her2neu = score(3+) positive, Ki67 = 30% proliferation index, E -cadherin strong positive.

Staging workup: CT chest, abdomen and pelvis and bone scan shows no metastasis, MRI breast confirmed right solitary breast cancer pathology, bilateral multiple fibrocystic changes as Us findings.

plan: Virtual tumor board discussion planned for surgery and followed by adjuvant therapy, but patient want to travel abroad.

Discussion

These were the first cases of breast cancer disease during pandemic in our hospital, at that time the administration of the infectious control team tried to minimize and limit the workload towards the spread of the pandemic in our country. However, the guidelines and policies that have been established, the breast cancer cases needed active treatment and eventually all patients with low immunity, feasibility, vulnerability, and safety had successful surgeries, and negative symptoms of COVID19 among their treatment.

Under control of our policy and hospital sources, we categorized the priority of the patients that needed urgent treatment as shown in (Figure 6), during that period we have traced breast cancer cases electronically, and through phone consultation to complete their triple assessment 'history - examination, imaging (mammogram and ultrasound breast) & core biopsy'.

Figure 6: Sequale of breast mass assessment in breast clinic.

From thereon, if the patient is a case of "benign disease" they will be followed with phone consultation after 3 months and further treatment if needed, on the other hand if the patient is diagnosed with "malignancy" will be brought to clinic for exact history ,examination and staging workup, (CT chest, abdomen and pelvis and bone scan) with all precautions methods , then a virtual tumor board will be conducted to facilitate the treatment of patient.

Two days prior to the admission, COVID19 risk assessment will be conducted by The Infectious Control Team at the COVID19 clinic (Figure 7), if the score of the risk assessment results as "low”, and the nasopharyngeal swab showed "target not detected", then the patient will be admitted at the ward with full precaution, and personal protective equipment (PPE) was performed from time of admission till discharged.

Figure 7: Algorithm of patient at COVID19 clinic.

At the time of surgical procedure all health workers including surgeons, assistants, anaesthetists, circulating nurses, and scrubbed nurses were wearing (PPE) preoperative from holding bay till recovery stage resulted in a successful free COVID19 infectious surgeries to those immunocompromised patients and predictive high-risk factors.

Later, the postoperative patient starts follow-up stage at breast surgical clinic after few days; for evaluation of wound scar, removal of drain and continue intervals of 2 weeks to monthly and one year by "phone consultation" to trace any complaint or complication or symptoms of COVID19.

Finally, the postoperative histopathology report per hospital policy will be discussed by the tumor board to decide the adjuvant therapy (chemotherapy, radiotherapy, hormonal therapy) to approach the high standard cancer care.

In all 9 study cases they were diagnosed to have early breast cancer as mentioned but according to American association of breast cancer they were categorized as phase I, which is integrated to be challenging stage in time of COVID19, that can wait for 3 months but under all preventive measures they have successful treatment and care [6].

American College of Breast Surgeons and the American College of Surgeons established phases to treat breast cancer which includes Phase 1 includes patients who can wait for 3 months as its not will affect their survival rate. It includes early breast cancer (Stage 1 or 2 ER-positive breast cancer), those who are finishing neoadjuvant chemotherapy course, and some with triple negative breast cancers. also, who are receiving neoadjuvant anti-estrogen medicine to provide treatment for the cancer. Phase II is patients with threaten survival need few days to do the surgery. 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).

Recommendation to perform surgery according to American College of Surgeons includes the following: those who are on chemotherapy therapy, people diagnosed with hormone-receptor-positive, HER2-negative cancer with certain characteristics(luminal classification),anyone diagnosed with triple-negative or HER2-positive disease due to aggressive disease , people who had a breast lump and there is discrepancy between radiology and pathology, although all of these indications applied to our patients.

In comparison with international studies, the lesson learned is that cancer cases need more detailed information, and manners to change in protocols; to adapt in elective, and emergency cases. This needs cooperation and integration between international society.

The SARS-CoV-2 outbreak is the first viral pandemic disease challenges oncology team members during lockdown worldwide. Challenging and modification of guidelines made the clinician think regarding the ways of treatment and protocols to change. Multiple societies had modified their protocols to bring the best outcome for oncological patients as ESMO, ASCO, NCCN [7–11].

The challenge in categorizing the appropriate patients for breast cancer surgery lies between providing the best outcomes and reconstruction (where breast conservation is guided by the extent of involvement). Also risking, young or vulnerable groups to general anesthesia, hospital environment, or similar circumstances where they may be innocent victims of exposure and disease. It becomes imperative to decide if breast cancer surgery needs to be performed with imminent urgency, or can be delayed for additional therapy, or safety of patient alone to avoid the pandemic exposure.

COVID-19 vaccination programme being rolled out across the world, different wide variety types have been introduced to give higher immune response. As breast cancer is the most commonly malignant neoplasm, it is important to encourage vaccination to reduce COVID-19–associated mortality specially among oncologic patients and higher risk of severe illness. [12-14]

Conclusion

COVID-19 pandemic has shaken the healthcare system and affected non-covid individuals in not receiving their deserved treatment in priority. We applied planned protocols in accordance with the hospital's directive and conducted safe breast cancer surgery; in patients awaiting such treatment, although vaccination was encouraged. Thereby resulted in providing an uneventful outcome, vulnerable and safe measures in their path toward standard breast cancer care.

Statements

Acknowledgement: No acknowledgments

Statement of Ethics: This study was supported and granted by National COVID19 Research Team (CRT-COVID2020-078) at Bahrain Defense Force Hospital -Royal Medical Service, all patients have been informed also written consent signed.

Disclosure Statement: Nothing to disclose.

Funding: None

Role of the funding source: This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.

Declarations of interest: The authors declare no conflict of interest related to the publication.

Author Contributions: Dr. Noora Al Moosa contributed to the idea and data collection, and implantation of writing and editing of the manuscript.

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Editorial Information

Editor-in-Chief

Kleanthis Giannoulis
Thessaloniki School of Medicine, Greece

Article Type

Case-series

Publication history

Received: June 14, 2021
Accepted: June 28, 2021
Published: June 30, 2021

Copyright

©2021 Almoosa N. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Almoosa N (2021) Influence of pandemic COVID 19 on breast cancer treatment: one center experience. Glob Surg 7: DOI: 10.15761/GOS.1000227.

Corresponding author

Noora Almoosa

chief resident, Department of general surgery, Bahrain Defense Force-Royale Medical Service, Riffa -Kingdome of Bahrain

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

Figure 1. COVID19 risk assessment.

Figure 2. Micro cacalcificattion of left breast indicate invasive ductal carcinoma of breast.

Figure 3: CT scan indicate recurrence of left breast cancer.

Figure 4: recurrence of breast cancer after 6 months.

Figure 5: Mammogram finding of invasive lobular carcinoma of breast.

Figure 6: Sequale of breast mass assessment in breast clinic.

Figure 7: Algorithm of patient at COVID19 clinic.

Table 1. Demographic data of breast cancer patients.

cases

1

2

3

4

5

6

7

8

9

Age

69

45

62

56

53

69

 

 

 

Gender

F

F

F

F

F

F

F

F

F

Co-morbidity

 (HTN)

 (DM)

Dyslipidemia

face basal cell ca

AF,CAD,EF 15%

 

Yes

Yes

Yes

No

No

 

Yes

Yes

Yes

No

No

 

No

No

No

No

No

 

No

No

No

No

No

 

Yes

Yes

Yes

Yes

No

 

Yes

Yes

Yes

No

Yes

 

No

No

No

No

NO

 

No

No

No

No

No

 

No

No

No

No

No

Risk factors

1.menupasual status

2.FH of cancer

3.OCP

4.late pregnancy

5.early menarche

6.alcohol and smoking

 

Post

Uterine ca

Yes

No

Yes

No

 

Post

-ve

No

No

Yes

No

 

Post

-ve

No

No

Yes

No

 

Post

-ve

No

No

Yes

No

 

Post

-ve

yes

No

Yes

No

 

Post

Breast ca

No

No

Yes

No

 

Post

No

No

No

Yes

No

 

 

Post

No

No

No

Yes

No

 

Post

No

No

No

Yes

No

 

COVID 19 risk

Low

Low

low

low

low

low

low

low

low

PCR swab

-ve

-ve

-ve

-ve

-ve

-ve

-ve

Pending surgery

Travel abroad

Hospital stay days)

1

1

1

1

After chemo

Not done

1

-

Travel abroad

Surgery

WLE &SLNB

WLE &SLNB

WLE &SLNB

WLE &SLNB

Lost followup

refused

WLE&SLNB

NACT

Travel abroad

Follow up (days/weeks /months/year)

2/2/3/1

2/2/1-6

2/2/3/1

2/2/3/1

Lost follow up

3m-1 y

2

-

-

Stage of cancer

pT2 N0 M0

pT2N0M0

pT1N0M0

pT1N0M0

T2N0M0

T2N0M0

T1N0M0

-

-

Adjuvant therapy

CTX +RT

CTX+RT

RT+

hormonl

(femara)

CTX+RT

neoCTX+RT

Hormonl

(Femara)

CTX

RX

hormonal

-

-

recurrence

No

Yes

NO

NO

Lost follow up

NO

NO

-

-

COVID 19 vaccine

Yes

NO

Yes

Yes

Lost follow up

Yes

Yes

Yes

-

COVID 19 symptoms

NO

NO

NO

NO

Lost follow up

NO

NO

NO

-