Breast cancer and COVID-19 pandemic in Brazil.

To the Editor,

The article entitled “Discordance of COVID‐19 guidelines for patients with cancer: A systematic review” evaluated the impact of COVID‐19 on cancer care. The authors did a great job in this review and concluded that “guidelines based on limited evidence show discordance and need to be interpreted with caution”. For breast cancer surgery, there was also discordance in recommendations. We read the article with great interest and agree with these conclusions. Early breast cancer (EBC) is a curable disease at an early stage and with multimodal treatment. Upfront surgery is accompanied by adjuvant therapy in most cases, which improves prognosis. Changes in these protocols may negatively affect outcomes in cases of EBC. We would like to add the perceptions of Brazilian mastologists regarding breast cancer guidelines.

After the pandemic outbreak, for reasons well described in this review, many emergency guidelines , , were developed by experts from around the world. They suggested postponing surgery for invasive EBC, recommending strategies according to molecular subtype. For example, for tumors that express hormone receptors (HR+), the recommendation could be to start treatment with neoadjuvant endocrine therapy (NET) for 3 to 6 months, while in adverse biologic subtypes, such as HER2+ and triple‐negative (TN), the recommendation could be to extend the use of neoadjuvant chemotherapy (NACT). In addition, there was a recommendation to avoid the major procedure, such as the use of myocutaneous flaps in breast reconstruction and prophylactic operations. Although some of these suggestions have not been officially endorsed by the Brazilian Society of Mastology (SBM), it is possible that these international guidelines had an impact in Brazil.

To assess this hypothesis, during the months of April and May 2020, an electronic survey was conducted among SBM members regarding the initial management of EBC. We created questions regarding invasive, T1/2 N0 HR+, and T1N0 HER2+/TN cancers, because these patients, in Brazil, are normally submitted to primary surgery. After approval of the SBM's internal review board, the questionnaire was sent to 1462 Brazilian mastologists. The results were submitted to a scientific journal, but we have an online “pre‐print” publication of the study data. There were 503 responders (34.4% response rate) who returned a completed questionnaire. A comparison was made between respondents and nonrespondents to the survey, using SBM's available database, with no significant differences between the regions initially most affected by the pandemic (Southeast and Northeast). A total of 43% changed their management approach at the beginning of the pandemic, while almost 70% made changes during the course of the pandemic (P < .001). For luminal tumors, the majority of respondents favored initial surgery, but 47.7% would recommend NET for postmenopausal patients and lower proliferation index cancers (Ki‐67 <20%). Menopausal status and higher proliferation index affected treatment decisions (P < .00001). For HER2+ and TN tumors, considerable variations were identified (cut‐off point for NACT), but the majority of the responders would recommend NACT. 36% would not recommend immediate breast reconstruction. The most commonly suggested technique, when recommended, was implanted. A total of 54% would not recommend oncologic mammoplasty, and 85% would not recommend risk‐reducing mastectomy for patients with BRCA deleterious mutations.

These findings highlight important changes in the approach of the mastologists at the beginning and during the pandemic, particularly with respect to HR‐positive tumors, and reflects, in our opinion, the disagreements between the emergency guidelines described by Garg et al. However, since the data were developed from a survey, we cannot confirm that these recommendations translated into treatment recommendations for actual patients. More studies are needed to know the real impact of the pandemic on patients treated with breast cancer in the pandemic period.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.

AUTHOR CONTRIBUTIONS

All authors read the manuscript of Garg et al and agree with this publication.