A prospective cohort study of the safety of breast cancer surgery during COVID-19 pandemic in the West of Scotland

IntroductionIn order to minimise the risk of breast cancer patients for COVID-19 infection related morbidity and mortality prioritisation of care has utmost importance since the onset of the pandemic. However, COVID-19 related risk in patients undergoing breast cancer surgery has not been studied yet. We evaluated the safety of breast cancer surgery during COVID-19 pandemic in the West of Scotland region.MethodsA prospective cohort study of patients having breast cancer surgery was carried out in a geographical region during the first eight weeks of the hospital lockdown and outcomes were compared to the regional cancer registry data of pre-COVID-19 patients of the same units (n = 1415).Results188 operations were carried out in 179 patients. Tumour size was significantly larger in patients undergoing surgery during hospital lockdown than before (cT3-4: 16.8% vs. 7.4%; p < 0.001; pT2 – pT4: 45.5% vs. 35.6%; p = 0.002). ER negative and HER-2 positive rate was significantly higher during lockdown (ER negative: 41.3% vs. 17%, p < 0.001; HER-2 positive: 23.4% vs. 14.8%; p = 0.004). While breast conservation rate was lower during lockdown (58.6% vs. 65%; p < 0.001), level II oncoplastic conservation was significantly higher in order to reduce mastectomy rate (22.8% vs. 5.6%; p < 0.001). No immediate reconstruction was offered during lockdown. 51.2% had co-morbidity, and 7.8% developed postoperative complications in lockdown. There was no peri-operative COVID-19 infection related morbidity or mortality.Conclusionbreast cancer can be safely provided during COVID-19 pandemic in selected patients.     

Breast cancer survivorship care during the COVID-19 pandemic within an urban New York Hospital System

PurposeTo examine clinicodemographic determinants associated with breast cancer survivorship follow-up during COVID-19.MethodsWe performed a retrospective, population-based cohort study including early stage (Stage I-II) breast cancer patients who underwent resection between 2006 and 2018 in a New York City hospital system. The primary outcome was oncologic follow-up prior to and during the COVID-19 pandemic. Secondary analyses compared differences in follow-up by COVID-19 case rates stratified by ZIP code.ResultsA total of 2942 patients with early-stage breast cancer were available for analysis. 1588 (54%) of patients had attended follow-up in the year prior to the COVID-19 period but failed to continue to follow-up during the pandemic, either in-person or via telemedicine. 1242 (42%) patients attended a follow-up appointment during the COVID-19 pandemic.Compared with patients who did not present for follow-up during COVID-19, patients who continued their oncologic follow-up during the pandemic were younger (p = 0.049) more likely to have received adjuvant radiation therapy (p = 0.025), and have lower household income (p = 0.031) on multivariate modeling. When patients who live in Bronx, New York, were stratified by ZIP code, there was a modest negative association (r = −0.56) between COVID-19 cases and proportion of patients who continued to follow-up during the COVID-19 period.ConclusionWe observed a dramatic disruption in routine breast cancer follow-up during the COVID-19 pandemic. Providers and health systems should emphasize reintegrating patients who missed appointments during COVID-19 back into regular surveillance programs to avoid significant morbidity and mortality from missed breast cancer recurrences.     

Radiotherapy in the treatment of breast cancer: a personal retrospective

Allan Langlands commenced training as a radiation oncologist in 1960 and has continued to treat patients with breast cancer for over 30 years. Moved to Westmead Hospital in Sydney he played a role in the development of radiation oncology in Australia. With an extensive research record (authoring over 200 peer-reviewed papers) this article reflects the changes in breast cancer treatment which have occurred over this period. The incorporation of evidence from the clinical trials in breast cancer management, changes in radiation therapy techniques and incorporation of patient choice in treatment decisions are discussed.     

The impact on clinical outcomes of post-operative radiation therapy delay after neoadjuvant chemotherapy in patients with breast cancer: A multicentric international study

IntroductionRadiation therapy (RT) is frequently used for post-operative treatment in breast cancer (BC) patients who received preoperative systemic therapy (PST) and surgery. Nevertheless, the optimal timing to start RT is unclear.Material and methodsData from BC patients who underwent chemotherapy as PST, breast surgery and RT at 3 Institutions in Brazil and Canada from 2008 to 2014 were evaluated. Patients were classified into three groups regarding to the time to initiation of RT after surgery: <8 weeks, 8–16 weeks and >16 weeks.ResultsA total of 1029 women were included, most of them (59.1%; N = 608) had clinical stage III. One hundred and forty-one patients initiated RT within 8 weeks, 663 between 8 and 16 weeks and 225 beyond 16 weeks from surgery. With a median follow-up of 32 months, no differences in disease-free survival (DFS), overall survival and locoregional recurrence-free survival (LRRFS) were observed of time to indicated RT (<8 weeks versus 8–16 weeks versus >16 weeks). However, in luminal subtype patients (46.5%; N = 478), initiation of RT up to 8 weeks after surgery was associated with better LRRFS (<8 weeks versus >16 weeks: HR 0.22; 95%CI 0.05–0.86; p = 0.03), with a tendency to a better DFS (<8 weeks versus >16 weeks: HR 0.50; 95%CI 0.25–1.00).ConclusionRT initiated up to 8 weeks after surgery was related to better LRRFS in luminal BC patients who underwent PST. Our results suggest that early start of RT is important for these patients.     

Burn center function during the COVID-19 pandemic: An international multi-center report of strategy and experience

The novel coronavirus, SARS-CO V2 responsible for COVID-19 pandemic is rapidly escalating across the globe. Burn centers gearing for the pandemic must strike a balance between contributing to the pandemic response and preserving ongoing burn care in a safe and ethical fashion. The authors of the present communication represent seven burn centers from China, Singapore, Japan, Italy, Spain, the United Kingdom (UK), and the United States (US). Each center is located at a different point along the pandemic curve and serves different patient populations within their healthcare systems. We review our experience with the virus to date, our strategic approach to burn center function under these circumstances, and lessons learned. The purpose of this communication is to share experiences that will assist with continued preparations to help burn centers advocate for optimum burn care and overcome challenges as this pandemic continues.     

The influence of the COVID-19 pandemic on lung cancer surgery in Queensland

Background

The coronavirus disease-19 (COVID-19) pandemic poses unprecedented challenges to global healthcare. The contemporary influence of COVID-19 on the delivery of lung cancer surgery has not been examined in Queensland.

Methods

We performed a retrospective registry analysis of the Queensland Cardiac Outcomes Registry (QCOR), thoracic database examining all adult lung cancer resections across Queensland from 1/1/2016 to 30/4/2022. We compared the data prior to, and after, the introduction of COVID-restrictions.

Results

There were 1207 patients. Mean age at surgery was 66 years and 1115 (92%) lobectomies were performed. We demonstrated a significant delay from time of diagnosis to surgery from 80 to 96 days (P < 0.0005), after introducing COVID-restrictions. The number of surgeries performed per month decreased after the pandemic and has not recovered (P = 0.012). 2022 saw a sharp reduction in cases with 49 surgeries, compared to 71 in 2019 for the same period.

Conclusion

Restrictions were associated with a significant increase in pathological upstaging, greatest immediately after the introduction of COVID-restrictions (IRR 1.71, CI 0.93–2.94, P = 0.05). COVID-19 delayed the access to surgery, reduced surgical capacity and consequently resulted in pathological upstaging throughout Queensland.     

新型冠状病毒肺炎疫情期间老年患者骨折流行病学特点分析

目的分析新冠肺炎疫情期间老年患者骨折的临床特点。 方法回顾性收集河北医科大学第三医院老年骨科2020年1月20日至2月19日收治的老年骨折患者（65岁以上）作为观察组，以2019年1月31日至3月2日（农历与2020年相对应）收治的老年骨折患者作为对照组，比较两组同一时间区域内收治患者的性别、年龄、骨折类型、合并疾病、致伤因素、治疗方式、术前等待时间、住院天数及围术期并发症的差异。 结果本研究共收集患者134例，观察组53例，男性19例，女性34例，男女构成比1∶1.79，平均年龄（81±8）岁；对照组81例，男性23例，女性58例，男女构成比1∶2.52，平均年龄（79±8）岁。观察组合并陈旧脑梗塞患者（30例，56.60%）高于对照组（29例，35.80%，χ²=5.625，P<0.05），跌倒患者（53例，100%）占比高于对照组（71例，87.65%，χ²=5.396，P<0.05）。致伤原因中，站立不稳（18例，33.96%）占比高于对照组（8例，11.27%，χ²=9.432，P<0.05），浴室滑倒（15例，28.30%）占比高于对照组（6例，8.45%，χ²=8.501，P<0.05）。围术期方面，术前等待时间[5（4，7.25）d]长于对照组[4（3，5）d，P<0.05]，住院天数[12（9，15）d]长于对照组[10（6，13）d，P<0.05]；并发肺部感染几率(36例，67.92%）高于对照组（16例，19.75%，χ²=31.306，P<0.05），下肢深静脉血栓几率（31例，58.49%）高于对照组（24例，29.63%，χ²=11.028，P<0.05）。 结论本研究提示疫情期间我院收治的新发骨折患者较去年同期显著减少。合并脑血管病的老年人是预防骨折的重点人群，致伤原因以居家跌倒为主。由于术前等待时间和住院时间延长，住院患者应重点预防围术期肺部感染及下肢深静脉血栓等并发症。     

Portrait,treatment choices and management of breast cancer in nonagenarians: An ongoing challenge

There are only scarce data on the management of nonagenarians with breast cancer, and more particularly on the place of radiation therapy (RT). We report a retrospective study on patients aged 90 years old or older, with breast cancer, receiving RT.Records from RT departments from five institutions were reviewed to identify patients 90 years old of age and older undergoing RT over past decade for breast cancer. Tumors' characteristics were examined, as well treatment specificities and treatment intent.44 patients receiving RT courses were identified, mean age 92 years. Treatment was given with curative and palliative intent in 72.7% and 27.3% respectively. Factors associated with a curative treatment were performance status (PS), place of life, previous surgery, and tumor stage. Median total prescribed dose was 40 Gy (23–66). Hypo fractionation was used in 77%. Most toxicities were mild to moderate. RT could not be completed in 1 patient (2.3%). No long-term toxicity was reported. Among 31 patients analyzable for effectiveness, 24 patients (77.4%) had their diseased controlled until last follow-up, including 17 patients (54.8%) experiencing complete response. At last follow-up, 4 patients (12.9%) were deceased, cancer being cause of death for two of them.The study shows that breast/chest RT is feasible in nonagenarians. Although the definitive benefit of RT could not be addressed here, hypofractionated therapy allowed a good local control with acceptable side effects.     

Metaplastic squamous cell breast cancer: A case report and treatment strategy during covid-19 pandemic

IntroductionSquamous carcinoma is a very rare breast cancer resulting from a differentiated squamous metaplasia. Its diagnosis is late due to the absence of specific clinical and radiological features.Presentation of caseThe authors present the case of a 39-year-old patient with the clinical onset of an inflammatory cyst diagnosed with mammography and cytological examination. After segmentectomy, on histological examination was defined as: “squamous keratinizing aspect”. In light of this report she was subjected to quadrantectomy with lymphadenectomy. She did not undergo radiotherapy treatment, which was delayed due to the ongoing pandemic. After a few months developed a local recurrence and underwent a mastectomy with multidisciplinary treatment.DiscussionSquamously-differentiated metaplastic carcinoma of the breast is one of the rarest forms of breast cancer. Its etiopathogenesis is still unclear but some authors suggest that it originates from a squamous metaplasia deriving from the epithelium of cysts. This is a very aggressive and fast-growing tumour especially in young women, in fact the patient had a recurrence after a few months. She came to our attention 6 months after the initial surgery with a relapse at a local-regional level for which she was subjected to radical treatment and with a metastatic spread for which she was given the first-line chemotherapy treatment.ConclusionThere are no well-defined guidelines for the treatment of this rare form of cancer. The case illustrates how the rapid aggressiveness of the disease requires adequate and immediate multidisciplinary treatment from the very beginning.     

Characteristics and outcomes of COVID-19 infection in 45 patients with breast cancer: A multi-center retrospective study in Hubei,China

BackgroundThe COVID-19 pandemic is a significant worldwide health crisis. Breast cancer patients with COVID-19 are fragile and require particular clinical care. This study aimed to identify the clinical characteristics of breast cancer patients with COVID-19 and the risks associated with anti-cancer treatment.MethodsThe medical records of breast cancer patients with laboratory-confirmed COVID-19 were collected among 9559 COVID-19 patients from seven designated hospitals from 13th January to 18th March 2020 in Hubei, China. Univariate and multivariate analyses were performed to assess risk factors for COVID-19 severity.ResultsOf the 45 breast cancer patients with COVID-19, 33 (73.3%) developed non-severe COVID-19, while 12 (26.7%) developed severe COVID-19, of which 3 (6.7%) patients died. The median age was 62 years, and 3 (6.7%) patients had stage IV breast cancer. Univariate analysis showed that age over 75 and the Eastern Cooperative Oncology Group (ECOG) score were associated with COVID-19 disease severity (P < 0.05). Multivariate analysis showed that patients who received chemotherapy within 7 days had a significantly higher risk for severe COVID-19 (logistic regression model: RR = 13.886, 95% CI 1.014–190.243, P = 0.049; Cox proportional hazards model: HR = 13.909, 95% CI 1.086–178.150, P = 0.043), with more pronounced neutropenia and higher LDH, CRP and procalcitonin levels than other patients (P < 0.05).ConclusionsIn our breast cancer cohort, the severity of COVID-19 could be associated with baseline factors such as age over 75 and ECOG scores. Chemotherapy within 7 days before symptom onset could be a risk factor for severe COVID-19, reflected by neutropenia and elevated LDH, CRP and procalcitonin levels.     

Treating Positive Axillary Disease in Elderly Breast Cancer Patients: The Impact of Age on Radiation Therapy

IntroductionBreast cancer is the second most common cause of cancer death in females, and 30% of these patients are over the age of 70 years. Studies have shown deviation from the standard treatment paradigms in the elderly, especially in regard to radiation treatment.MethodsWe performed a retrospective chart review on 118 patients over the age of 70 years diagnosed with breast cancer and pathologically proven axillary disease over an 8-year period at an urban academic hospital to examine which patient factors influenced radiotherapy.ResultsIncreasing patient age was associated with a decrease in the probability of receiving radiotherapy, while HER2-negative patients were more likely to receive radiation. Neither race, number of coexisting medical conditions, or insurance status showed any influence on radiation treatment.ConclusionPatient age has a significant influence if elderly patients with axillary disease receive radiotherapy. Further investigation and validation are needed to understand why chronological age rather than biological age influences treatment modalities.     

Optimize the management of urological tube-related emergencies during the coronavirus disease 2019 (COVID-19) pandemic

BackgroundTo introduce and determine the value of optimized strategies for the management of urological tube-related emergencies with increased incidence, complexity and operational risk during the global spread of coronavirus disease 2019 (COVID-19).MethodsAll emergent urological patients at Tongji Hospital, Wuhan, during the period of January 23 (the beginning of lockdown in Wuhan) to March 23, 2020, and the corresponding period in 2019 were recruited to form this study’s COVID-19 group and control group, respectively. Tongji Hospital has the most concentrated and strongest Chinese medical teams to treat the largest number of severe COVID-19 patients. Patients in the control group were routinely treated, while patients in the COVID-19 group were managed following the optimized principles and strategies. The case incidence for each type of tube-related emergency was recorded. Baseline characteristics and management outcomes (surgery time, secondary complex operation rate, readmission rate, COVID-19 infection rate) were analyzed and compared across the control and COVID-19 periods.ResultsThe total emergent urological patients during the COVID-19 period was 42, whereas during the control period, it was 124. The incidence of tube-related emergencies increased from 53% to 88% (P<0.001) during the COVID-19 period. In particular, the incidence of nephrostomy tube-related (31% vs. 15%, P=0.027) and single-J stent-related problems (19% vs. 6%, P=0.009) increased significantly. The mean surgery times across the two periods were comparable. The number of secondary complex operations increased from 12 (18%) to 14 (38%) (P=0.028) during the COVID 19-period. The number of 2-week postoperative readmission decreased from 10 (15%) to 1 (3%) (P=0.049). No participants contracted during the COVID-19 period.ConclusionsUrological tube-related emergencies have been found to have a higher incidence and require more complicated and dangerous operations during the COVID-19 pandemic. However, the optimized management strategies introduced in this study are efficient, and safe for both urologists and patients.     

The utilization of telehealth during the COVID-19 pandemic: An American Pediatric Surgical Association survey

BackgroundLimited in-person visits during the COVID-19 pandemic, with liberal reimbursement policies, resulted in increased use of video conferencing (hereby described as telehealth) for patient care. To better understand the impact on pediatric surgeons and their patients, we surveyed members of the American Pediatric Surgical Association (APSA) regarding telehealth use prior to and during the pandemic.Methods:An iteratively developed survey was sent to all active, non-trainee surgeons within APSA during March 2021.ResultsOf 247 responses (23% response rate), 154 (62%) began using telehealth during the pandemic. In addition to the 101 (60.5%) respondents who felt telehealth had a positive impact on their clinical practice, 161 (74.2%) felt that it had a positive impact on their patients’ satisfaction. The most common barriers to telehealth use prior to COVID-19 were availability of technology (39.3%), patient access to technology (36.0%), and lack of reimbursement (32.0%). These barriers became less substantial during the pandemic. Most respondents (95.3%) indicated they would continue using telehealth post-pandemic if it remains appropriately reimbursed.ConclusionsThe majority of pediatric surgeons implemented telehealth during the COVID-19 pandemic and endorsed a positive effect on their clinical practice as well as on patient satisfaction. An overwhelming majority would continue using this technology if reimbursement policies remain favorable.     

Surgical treatment of breast lesions at a Day Centre: Experience of the European Institute of Oncology

Breast cancer is the commonest malignancy in women worldwide. The reduced aggressiveness of breast cancer surgery has made it possible treat patients in the day surgery setting. The European Institute of Oncology, Milan, opened its new Day Center in May 2010. From May 2010 to December 2014, 17,087 patients with breast conditions were treated by the Institute's Division of Senology, 4132 (24.2%) of these in the day surgery setting, including malignant and benign conditions; 204 (4.9%) were not discharged on the day of surgery, being converted to inpatients; five (0.1%) patients returned to hospital for persistent hematoma.Our experience of performing breast cancer surgery in the day surgery setting is in line that of the literature. It is safe, but requires a well-organized unit and multidisciplinary medical team to function smoothly, with much attention paid to patient comfort and education, so as to ensure maximum patient acceptance and satisfaction.     

Effects of the COVID-19 pandemic on breast cancer screening in Taiwan

The breast cancer screening program has continued in Taiwan during the COVID-19 pandemic. Our nationwide data showed that the total number of screenings decreased by 22.2%, which was more pronounced for in-hospital examinations (−37.2%), while outreach showed a 12.9% decrease. This decline in screening participation happened at all levels of hospitals, more significantly at the highest level. Our report revealed that outreach services could maintain relatively stable breast cancer screening under this kind of public health crisis. Building a flexible, outreach system into the community might need to be considered when policymakers are preparing for future possible pandemics.     

The role of Oncoplastic Breast Surgery in the management of breast cancer treated with primary chemotherapy

ObjectiveThe purpose of this study was to evaluate the benefit of Oncoplastic Breast Conserving Surgery (BCS) compared to standard BCS after primary CT, in terms of oncologic safety and cosmetic outcomes.BackgroundThe development of new drugs has led to greater use of primary chemotherapy (CT) for bulky breast cancer (BC) and has allowed wider indications for conservative surgery.Patients and methodsWe identified 259 patients consecutively treated with BCS for primary BC from January 2002 to November 2010. All patients had undergone Oncoplastic Breast Surgery (OBS) or standard BCS after primary CT. Mastectomy rates, and oncological and cosmetic outcomes were compared.ResultsA total of 45 OBS and 214 standard BCS were analyzed. The median tumor size was 40 mm in the two groups (p = 0.66). The median operative specimen volumes were larger in the OBS group than in the standard group (respectively, 180 cm³ and 98 cm³, p < 0.0001). Re-excision (9% vs 2%) and mastectomy (24% vs 18%) rates were similar (p = 0.22 and p = 0.30) in the standard BCS group and in the OBS group respectively. At a median follow-up of 46 months, local relapse (p = 0.23) and distant relapse (p = 0.35) rates were similar.ConclusionOBS allows excision of larger volumes of residual tumor after primary CT. OBS outcomes results were similar to those of standard BCS.Oncoplastic Breast Conserving Surgery (BCS) after primary chemotherapy allows wider breast resection than standard BCS. Survival and relapse probabilities are similar in both groups.     

Omission of chemotherapy for low-grade,luminal A N1 breast cancer: Patterns of care and clinical outcomes

PurposeMultiple ongoing randomized studies are assessing the impact of omission of chemotherapy (CT) in low-risk node-positive Luminal A breast. The goal of this investigation was to evaluate trends and practice patterns of adjuvant CT use in Luminal A pT1-3N1 breast cancer, along with determining the clinical benefit from adjuvant CT in this patient population.MethodsThe National Cancer Data Base was queried (2004–2014) for women with pT1-3N1 luminal A invasive ductal carcinoma receiving adjuvant hormonal therapy (HT). Multivariable logistic regression ascertained factors associated with adjuvant CT administration. Kaplan-Meier analysis evaluated overall survival (OS) between patients treated with CT/HT vs. HT alone, while sub-stratifying patients by age.ResultsOf 8548 total patients, 5182 (61%) received CT/HT, while 3366 (39%) received HT alone. A steady rise in omission of adjuvant CT was observed, from 14% (2004–2005) to 41% (2012–2014). A decision not to use CT was more likely in more recent time periods, in older patients, at academic centers, following lumpectomy, and with lower T classification (p < 0.05 for all). CT was associated with higher OS in all patients (p < 0.001) and women ≤50 years old (p = 0.030), but not for ages 51–60 (p = 0.116), 61–70 (p = 0.222), or >70 (p = 0.239).ConclusionsUsing CT for Luminal A N1 breast cancer is decreasing over time, primarily in older patients and at academic centers. Although CT is still associated with an OS advantage in all patients, subgroup analysis demonstrated no OS benefit in women >50 years of age. These results have implications on the ongoing randomized trials.