Should we delay adjuvant breast radiotherapy for early stage breast cancers as the COVID-19 situation evolves?

This is a very tough question given the unprecedented nature of this pandemic and the fact that its duration is unknown. Recommendations will likely vary based on the density of cases in a specific geographic location and will undoubtedly change frequently given the rapidly evolving nature of this situation.

At the heart of this issue is the question of what are the risks of delaying adjuvant breast radiation and how do we weigh those risks against the risks of COVID-19 transmission to our patients and healthcare workers.

We have some literature to guide us on this question. A study of >6000 pts with T1-2 N0-1 breast CA (not getting chemo, ~85% N0, ~20% ER-,) from Canada showed that only intervals greater than 20 weeks (~5 months) from surger...

Agree with what has been posted here and copying the guidance we have issued to our breast doctors at MSKCC, where we are in the midst of the COVID-19 flare.

To improve capacity in the event of personnel shortages, we have divided patients into priority tiers.

• Inflammatory breast cancer
• Residual node positivity after NAC
• Any patient with 4 or more positive nodes
• Extensive LVI
• Any node positive TNBC
• Any local-regional recurrence patient

• N1a patients
• Path N0 after NAC
• LVI (NOS)
• Node negative TNBC

• DCIS
• Luminal A or B node negative patients

• Please omit radiotherapy in anyone who is a candidate for omission
• Low priority ...

Many centers on the leading edge of the COVID-19 curve are taking this action for luminal node negative patients based on the references posted already. Expect reduced workforce due to efforts to reserve and protect part of the workforce, workforce in quarantine, and the effect of school closings. Deferring patients now who can safely be deferred to maintain capacity for those for whom delay could have a detrimental impact is a practical decision. Consider omission and APBI for eligible patients as well. Consider scheduling the deferred simulation appointments so as not to lose these patients to follow up.

Some data suggest it's OK to start endocrine therapy and radiation can be delayed without detriment up to 20 weeks after surgery.

Olivotto et al JCO 2009

I feel comfortable given the current pandemic in delaying RT with endocrine therapy started now for luminal and DCIS.

Also seriously consider whether radiation is needed at all for low risk patients.

How will you prioritize new starts when the COVID-19 pandemic is over and you have a backlog of delayed patients and newly diagnosed patients to schedule?