key: cord-273875-vpp0l6ij
authors: Johnson, Miguel; Cubison, Tania; Bonomi, Riccardo
title: Creating a ‘safe haven’ for the most vulnerable; Early Reports of Management Strategies for Breast Cancer Patients in the UK during the COVID -19 Pandemic times
date: 2020-09-20
journal: J Plast Reconstr Aesthet Surg
DOI: 10.1016/j.bjps.2020.08.144
sha: 
doc_id: 273875
cord_uid: vpp0l6ij

nan

The National Health Service has identified different categories of individuals to be considered "clinically extremely vulnerable": -any person above the age of 70 -any patient affected by hypertension or diabetes mellitus -cancer patients undergoing chemotherapy or immunotherapy -patients under immunosuppressive treatment [1] . Standard cancer surgical and chemotherapy treatment requiring hospitalization or daily visit had to be suspended to reduce at the minimum the exposure of these vulnerable patients to the possible infection [2] .

The management of breast cancer invariably involves surgical intervention with a curative intent, in early breast cancer as well as for local control in more advance cancer stages, in an effort to improve quality of life. This thus creates a conundrum in the management of this cohort of patient in the COVID-19 era, as one must aim to prevent compromise to the standard of care while sensibly employing strategies to mitigate the acquisition of the COVID-19 virus in this highly vulnerable group. Breast cancer patients may be further subcategorized into high priority (life threatening, clinically unstable), medium priority (non critical but delay > 6-8 weeks could affect outcomes), or low priority (stable condition allowing for delay of care) based on several factors such as type of cancer and comorbidities [3] . The Association of Breast Surgery has provided guidance recommending prioritizing patients based on the aforementioned criteria as well as recommending the use of more oncoplastic techniques where clinically applicable. This in part due to the discouragement of more traditional forms of breast reconstruction using autologous or implant based techniques in an effort to minimize complications and the need for return to hospital in this vulnerable group [4].

In an effort to maintain the standard of care and prevent progression of disease in this cohort while reduce the mortality and morbidity, our institution created a 'safe haven'.

Our institution, a regional centre for Breast reconstruction, Plastic Surgery, Burns and Hands employed emergency protocols to reorganize staff and workforce to facilitate the surgical management of breast cancer for the entire southeast and southwest regions of England. This included an extended invitation to all breast cancer units in south England to utilize our hospital to deliver surgical care to breast cancer patients by Breast & Oncoplastic led Consultants. Our facility's reorganization strategies involved creating a "COVID-19 free" centre by employing rigorous screening protocols of all patients undergoing surgery as well as development of virtual teams [5] . All patients were deemed "fit for surgery" upon satisfying 3 screening areas: 1. The establishment that patient was symptom free for a minimum of 14 days, 2. A negative COVID-19 PCR testing within 48 -72 hours prior to presentation and 3. Self-isolation for minimum of 14 days or the use of a CT chest scan for any patient that did meet all of the above criteria or where the patient warranted surgery on the aerodigestive tract All patients were maintained at social distance throughout the recovery period.

Early results between the periods of March 1, 2020 to May 31, 2020 yielded the surgical treatment of one hundred patients with breast cancer, with age ranging from 30 to 88 years old. There have been no known deaths to date, with 3 patients developing a haematoma, which were successfully managed within 24 hours of their primary surgery.

The establishment of a COVID-19 free environment has allowed for the maintenance of the high standard of care in breast cancer patients, a highly vulnerable group [1] . To date we have treated up to 120 highly vulnerable patients with success and thereby reducing the burden of disease. We believe that standard care of breast cancer can be upheld even in units that were not primarily a cancer led service. This however needs rigid protocols with support of innovative leaders and an adaptable team. This strategy demonstrate early success and may be employed by other NHS Trust or utilized by developing countries to deliver optimal standard treatment to the 'most vulnerable groups' while mitigating the effects of the devastating wave of the COVID-19 pandemic.

Nothing to disclose

Who's at higher risk from coronavirus

How coronavirus is impacting cancer services in the UK. 2020

New ESMO recommendations for breast cancer care during the COVID-19 era

Productively protecting a cohort of vulnerable plastic surgery trainees in the COVID-19 pandemic

None