Adaptations to Breast Cancer Management

Outpatient visits

High priority

Your outpatient appointment may be a high priority if:

• You have recently undergone surgery for your breast cancer and are experiencing side effects linked to your surgery (e.g. an infection)
• You have been diagnosed with breast cancer during pregnancy

High/medium priority

Your outpatient appointment may be a high/medium priority if:

• You have been newly diagnosed with invasive breast cancer, depending on the size and type of breast cancer that you have. In these cases, a multidisciplinary team will review your full medical history and will advise on the best approach for you
• You are currently receiving treatment for breast cancer and experience new symptoms or side effects

Medium priority

Your outpatient appointment may be a medium priority if:

• You have been newly diagnosed with non-invasive breast cancer
• You have recently undergone surgery for your breast cancer and are not experiencing any side effects linked to your surgery

Low priority

Your outpatient appointment may be a low priority if:

• It is a follow-up visit because you have had breast cancer and are currently in remission
• You have breast cancer but are considered as stable and are not receiving any cancer treatment
• It is a follow-up visit because you are at high risk for developing breast cancer (e.g. family history or mutations in certain genes such as BRCA1 and BRCA2)
• It is an appointment with a counsellor or psychologist for emotional support

Diagnosis and imaging

High priority

Your appointment may be a high priority if:

• You have discovered a lump in your breast or have other symptoms to suggest that you might have breast cancer, e.g. a lump in the armpit, discharge from the nipple or pain in the breast that doesn’t go away
• You have recently been told by your doctor that your breast cancer has returned following initial treatment and that you can undergo surgery to remove the cancer

• 

  You need additional tests following an abnormal mammogram, symptoms of breast cancer or a breast cancer relapse
• You need additional imaging assessments based on results of previous tests that suggest it is highly likely that you have breast cancer

Medium priority

Your appointment may be a medium priority if:

• You need additional tests, e.g. imaging and/or biopsy, to confirm a diagnosis of breast cancer where previous tests suggest that a diagnosis of breast cancer is possible
• You need an appointment for a clinical examination in order to investigate whether your breast cancer has spread to other parts of your body
• You have invasive breast cancer and are due to have an echocardiogram in order to assess your suitability for anti-cancer treatment with either an anthracycline or anti-HER2 therapy

Low priority

Your appointment may be a low priority if:

• You were due to have a mammogram as part of routine screening
• You were due to have a second mammogram due to a slight abnormality seen on a previous mammogram
• You have early-stage breast cancer and are due to have further tests, e.g. imaging, echocardiogram, electrocardiogram or bone density scan
• You have metastatic breast cancer, and were due to have your regular follow-up visit for an imaging assessment, echocardiogram or electrocardiogram, providing you have not developed any new symptoms

Surgery

High priority

Your appointment may be a high priority if:

• You have recently had breast cancer surgery and are experiencing side effects such as bleeding or an abscess
• You are experiencing side effects following breast reconstruction surgery
• You are due to have surgery following neoadjuvant therapy
• You have invasive breast cancer and your doctor has already told you that surgery will proceed as planned
• You are pregnant and are due to have surgery to remove your breast cancer

High/medium priority

Your appointment may be a high/medium priority if:

• Your breast cancer has returned and it can be removed by surgery (dependent on the type and size of the tumour)

Medium priority

Your appointment may be a medium priority if:

• You have low-risk breast cancer and it is possible to receive neoadjuvant endocrine therapy in order to delay surgery. In these cases, a multidisciplinary team will review your full medical history and will advise on the best approach for you
• You have differing results from two separate biopsies and your doctor thinks it is likely that you have breast cancer

Low priority

Your appointment may be a low priority if:

• You were due to have surgery to remove a lump in your breast that is not breast cancer
• You were due to undergo surgery to remove a non-invasive breast cancer, unless it is a high-grade tumour
• You have differing results from two separate biopsies and your doctor thinks it is unlikely that you have breast cancer
• You were due to have breast reconstruction surgery
• You are at high-risk of breast cancer and were due to undergo preventative surgery, but are currently not experiencing any signs or symptoms of breast cancer

Radiotherapy

High priority

Your appointment may be a high priority if:

• 

  You need radiotherapy to relieve pain when this cannot be achieved by medical treatments
• You are already receiving radiotherapy
• You need radiotherapy to treat spinal cord compression, brain metastases or any other situation where radiotherapy is urgently needed to relieve pain
• You are a high-risk patient and need post-operative radiotherapy

Medium priority

Your appointment may be a medium priority if:

• You are a low-/intermediate-risk patient and need post-operative radiotherapy

Low priority

Your appointment may be a low priority if:

• You are an elderly patient with low-risk breast cancer and were due to have radiotherapy. In these cases, you could receive adjuvant endocrine therapy in order to delay radiotherapy. However, a multidisciplinary team will review your full medical history and will advise on the best approach for you
• You were due to have radiotherapy to treat carcinoma in situ (i.e. a pre-malignant lesion)

Medical management of early breast cancer

High priority

Your appointment may be a high priority if:

• 

  You are scheduled to receive neoadjuvant and adjuvant chemotherapy for triple negative breast cancer (TNBC)
• You are scheduled to receive neoadjuvant and adjuvant chemotherapy with targeted therapy for HER2-positive breast cancer
• You are scheduled to receive neoadjuvant and adjuvant endocrine therapy (with or without chemotherapy) for high-risk, ER-positive/HER2-negative breast cancer
• Your neoadjuvant chemotherapy has already started
• You are undergoing treatment given as part of a clinical trial, providing the potential benefit outweighs the risk of COVID-19 infection

Medium priority

Your appointment may be a medium priority if:

• You are postmenopausal and are due to receive endocrine therapy for  stage I, low-/intermediate-risk breast cancer in order to delay surgery
• You have low-risk breast cancer. In these cases, endocrine therapy may be preferred. However, a multidisciplinary team will review your full medical history and will advise on the best approach
• You are receiving ongoing adjuvant trastuzumab therapy. However, your treatment may be postponed by 6–8 weeks

Low priority

Your appointment may be a low priority if:

• You were due to undergo any planned tests to monitor your progress whilst receiving medical treatment for breast cancer. These tests may be delayed providing you do not have any symptoms

Additional considerations for the management of early breast cancer

• If you are receiving adjuvant endocrine therapy, follow-up appointments to review any potential side effects may be conducted via telephone
• If you have stage I/II breast cancer, you may receive neoadjuvant endocrine therapy in order to delay your originally planned surgery by 6–12 months
• If you have HER2-positive breast cancer and are low-risk, elderly or have comorbidities, you might receive 6 months instead of 12 months of adjuvant trastuzumab
• If you have ER-positive/HER2-negative breast cancer and were due to receive surgery followed by adjuvant chemotherapy, you might receive chemotherapy first (i.e. neoadjuvant therapy) in order to delay your surgery
• Chemotherapy schedules may be modified to 2-weekly or 3-weekly dosing instead of weekly in order to reduce your number of hospital visits
• You may receive additional treatments such as prophylactic growth factors to help boost your immune system and antibiotics to fight off any infections in order to make you less vulnerable to serious complications of COVID-19
• Treatment with steroids may be reduced or stopped as they can suppress your immune system
• Some endocrine therapies can be given as a long-acting formula in order to reduce hospital visits. It may also be possible to arrange for a nurse to come to your home to give you these injections
• Any scheduled blood or imaging tests should be relocated to your local healthcare centre or cancer clinic wherever possible
• Any follow-up appointments to discuss side effects of treatments should be conducted via telephone wherever possible

Medical management of metastatic breast cancer

High priority

Your appointment may be a high priority if:

• 

  You have recently been diagnosed with metastatic breast cancer and treatments are likely to prolong your life and maximise your quality of life. In these cases, a multidisciplinary team will review your full medical history and will advise on the best approach
• You need treatment for metastatic breast cancer that is having a significant impact on the functioning of one or more organs in your body
• You are receiving treatment given as part of a clinical trial, providing the potential benefit outweighs the risk of COVID-19 infection

Medium priority

Your appointment may be a medium priority if:

• You are receiving treatment for metastatic breast cancer and have already received one or more lines of treatment for metastatic disease. In these cases, a multidisciplinary team will review your full medical history and will advise on the best approach
• You are receiving treatment with targeted therapies such as mammalian target of rapamycin (mTOR) or PIK3CA inhibitors. These treatments may be stopped or delayed, especially in older patients and in those with comorbidities

• 

  You are due to be enrolled into a clinical trial. This should be discussed via telephone with your doctor

Low priority

Your appointment may be a low priority if:

• You are receiving bone modifying drugs. These may be stopped or delayed if they are not urgently needed (e.g. for pain control) and if they are the only reason for attending a hospital appointment

Additional considerations for the management of metastatic breast cancer

• Oral chemotherapy drugs may be preferred in order to reduce the number of hospital visits
• Chemotherapy schedules may be modified to 2-weekly or 3-weekly dosing instead of weekly in order to reduce your number of hospital visits
• You may receive additional treatments such as prophylactic growth factors to help boost your immune system and make you less vulnerable to serious complications of COVID-19
• Treatment with steroids may be reduced or stopped as they can suppress your immune system
• Some endocrine therapies can be given as a long-acting formula in order to reduce hospital visits. It may also be possible to arrange for a nurse to come to your home to give you these injections
• Endocrine therapies have no effect on your immune system and can be safely continued
• When needed, bone-modifying drugs can be given every three months in order to reduce your number of hospital visits
• If you are receiving treatment with a cyclin-dependent kinases 4/6 (CDK4/6) inhibitor or immunotherapy, you may need to attend more frequent telephone appointments so that your doctor or nurse can closely monitor the effects of treatment. However, if you experience any side effects, you should contact your doctor or nurse immediately
• Treatment with targeted therapies such as mTOR or PIK3CA inhibitors are associated with a risk of side effects that could put you at higher risk of severe illness from COVID-19 and should therefore be avoided wherever possible
• Any follow-up appointments to discuss side effects of treatments should be conducted via telephone wherever possible
• If you require any additional support, this may be arranged via telephone or home-based appointments. Please contact your doctor or nurse to discuss the options available to you
• Depending on the treatment you have received and your response to these treatments, you might be able to take a ‘treatment holiday’ in order to reduce your number of hospital visits and lower your risk of COVID-19 infection. In these cases, a multidisciplinary team will review your full medical history and will advise on the best approach