Breast reconstruction during COVID-19

By Daniel Liu, MD

The world has transformed with the unprecedented spread of SARS-CoV-2,

which is more commonly known as the coronavirus, or COVID-19, pandemic. Millions of infections have resulted in substantial morbidity and mortality, while substantially more people remain asymptomatic or experience mild symptoms.

In the United States, COVID-19 began to spread across most communities in early 2020, and extraordinary lockdown measures were instituted by federal and local governmental entities in March to slow the pandemic for public health. Nevertheless, these restrictions have direct impacts on individuals undergoing breast cancer treatment and those with undiagnosed breast cancer. Breast cancer screening has decreased, and “elective” breast procedures have been postponed around the world.

During the early weeks of the pandemic, most hospitals and healthcare facilities delayed or cancelled elective procedures for cancer patients, including screenings, surgery (particularly breast reconstruction) and other non-urgent treatments. The purpose was to not only protect vulnerable patients, but primarily to preserve scarce personal protective equipment (PPE) and hospital beds for the anticipated surge of COVID-19 admissions. The American College of Surgeons recommended that certain breast cancer surgeries should continue, but breast reconstruction became a lower priority. In fact, ASPS initially recommended that microsurgical autologous breast reconstruction be delayed, due to the need for higher resources and prolonged hospitalization.

Breast cancer surgery may be safely delayed for certain subtypes of earlystage cancer, using neoadjuvant systemic therapy strategies.1 Plastic surgeons and other cancer specialists can maintain communication with their patients through telemedicine for routine monitoring, but in-person visits remain crucial for suspected oncologic emergencies, cancer progression, recurrence and new diagnoses. A multidisciplinary approach must be used to navigate the delicate risk-benefit balance for individual treatment decisions, applying guidance from international protocols.2

Based on currently available epidemiology data, most people have a low risk of becoming seriously ill from COVID-19. Cancer patients are not necessarily at higher risk of becoming infected, but the risk for severe illness (if they do become infected) may be higher among people on active treatments that compromise the immune system (chemotherapy). A recent study from France analyzed a small group of breast cancer patients who developed COVID-19 symptoms and compared their outcomes. Results showed that COVID-19 deaths were more likely due to other medical comorbidities (hypertension, obesity, diabetes and heart disease) rather than current or previous breast cancer treatments.3

Safety first

All cancer patients must take every possible precaution to reduce the risk of contracting and spreading COVID-19 in accordance with CDC guidelines: • Wash hands frequently • Universal mask wear, especially indoors • Avoid close contact with others • Clean and disinfect surfaces • Monitor for symptoms

Once the initial fear of overwhelming the healthcare system was alleviated, facilities reopened for elective surgeries to varying degrees around the country. However, the perioperative experience has changed dramatically and continues to evolve to maximize safety for our patients. Travel restrictions based on regional casepositivity rates continue to make it difficult for some cancer patients to reach the hospital. As COVID-19 testing capability expands, routine screening of asymptomatic patients with cancer will be mandatory before surgery, interventional radiology procedures and chemotherapy. Stringent infection-control safety protocols have been instituted across hospitals and clinics, limiting the number of caregivers and visitors to support patients while admitted to the hospital.

Long-term social distancing has taken a toll on mental health, especially for cancer patients who are already stressed. Loneliness, feelings of uncertainty and emotional distress have been associated with negative clinical outcomes and higher mortality in cancer patients. This cannot be ignored. Outdoor physical exercise may help, combined with social support from close family and virtual support groups. Telemedicine has also been used by psychologists and psychiatrists to benefit certain patients.

COVID-19 changed how we practice reconstructive surgery. We have learned to be more efficient with resources and to reduce the number of in-person visits. Breast reconstruction is certainly possible, but we must be more flexible with timing and unplanned delays. Only time will tell if patient outcomes will be compromised due to altered treatment patterns that have emerged out of necessity. We have not forgotten you. Stay strong, stay healthy and stay hopeful!

ASPS member Daniel Liu, MD, is a boardcertified plastic and reconstructive surgeon at Cancer Treatment Centers of America® in northern Illinois. He specializes in all forms of breast reconstruction and is passionate about promoting public education on breast reconstruction and plastic surgery.

Sources: 1. Minami et al. JACS. (2020) DOI: 10.1016/j. jamcollsurg.2020.06.021 2. Curigliano et al. The Breast. (2020) 52:8-16 3. Vuagnat et al. Breast Cancer Research. (2020) 22:55