How should our selection for neoadjuvant chemotherapy for breast cancer change in light of COVID-19?

Topics: Breast Cancer • Radiation Oncology • Medical Oncology • NCI-CCC Tumor Board Question • University of Wisconsin • COVID-19 • NCI-CCC Breast Tumor Board Question

Question Created by Amanda Parkes

Robert Wesolowski, Ohio State University

Added March 20, 2020

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I believe that some patients with low risk hormone receptor positive, HER2 negative (patients with clinical stage T1a-b N0) and those with DCIS could be safely put on endocrine therapy in order to delay surgery to minimize the risk of contracting and spreading COVID-19. It is truly much more difficult to delay neoadjuvant chemotherapy and/or surgery to patients with triple negative, higher risk hormone receptor positive and HER2 positive patients. The risk of dying from COVID-19 has to be carefully weighed against the risk of breast cancer progression to incurable and deadly disease.

Comments

Medical Oncologist, Assistant Professor, Academic Institution (Midwest)

April 3, 2020

Is there any role for genomic profiling for ER/PR positive, Her2 negative patients in the neoadjuvant setting if surgery is being delayed?

Medical Oncologist, Professor, Academic Institution (Midwest)

April 3, 2020

I believe that genomic profiling should be used to identify patients that could benefit from neoadjuvant hormonal therapy, and for whom we can delay chemotherapy and the possibility of immunosuppression and increased risk of fatal outcome if they became infected with COVID-19. This would only be useful in the setting of ER/PR positive, Her2negative disease. For patients with high recurrence scores on oncotype or who have triple negative or Her2neu positive disease, I would not recommend delaying chemotherapy.

Kari Wisinski, University of Wisconsin School of Medicine and Public Health

Added March 24, 2020

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2 people agreed with this answer

To date, the largest analysis of outcomes in cancer patients (Liang et al Lancet Oncology Feb 2020) only include 18 patients (of 1590) with a history of cancer. Of those, only 3 had breast cancer and 2 of these 3 had a distant history of 4 years or more. The cancer cohort in this analysis were noted to have more risk for severe events (a composite endpoint defined as the percentage of patients being admitted to the intensive care unit requiring invasive ventilation, or death) with seven [39%] of 18 patients (vs 8% in the whole cohort), although the cancer patients were also older, another known risk factor for more severe outcomes. More data is needed to better guide our decisions. However, due to the immunosuppression from chemotherapy and general risks of non-COVID-19 complications from chemotherapy, the decision for neoadjuvant chemotherapy needs to be carefully considered in this pandemic. Our approach has been to consider the neoadjuvant approach most strongly for triple negative or HER2+ breast cancers which are node positive or T2 or larger, also considering the age and other medical co-morbid conditions for the individual patient. This may evolve as we adapt to limited operating rooms or better understand the risks of COVID-19 in our populations.

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