Impact of the COVID -19 pandemic on the organisation of breast reconstruction in France.

Dear Sir,

Introduction

Since the beginning of the COVID-19 pandemic, the health emergency has justified giving priority to the carcinologic management of breast cancer patients at the expense of breast reconstruction (BR). BR activity was abruptly threatened or even interrupted, generating a waiting list of patients.

National and international guidelines of surgical societies are to postpone delayed BR (DBR) and to give preference to implants in case of immediate BR (IBR).1, 2, 3 Due to the uncertainty about the duration of the COVID-19 pandemic, we worried about a possible decrease in the number of immediate or DBR procedures by giving up care.

We conducted a national survey, the objective of which was to assess the impact of the COVID-19 pandemic on BR practises.

Methods

On 14 May 2020, at the end of national confinement, we posted an anonymous online survey to the French Breast Cancer Intergroup Unicancer (UCBG, 280 surgeons) (supplementary file A).

Regarding the COVID-19 outbreak, French departments were classified as ‘under tension’ (red zones) or ‘less affected’ (green zones) (supplementary file B). The qualitative results of two groups were compared using chi‐square tests. The significance threshold was set at a two-sided alpha level of 0.05.

Results

Most of the 55 breast surgeons who responded (participation rate 20%) declared working in high volume centres performing >100 breast cancer and BR procedures per centre/year (94% and 62% respectively). The low participation rate could be explained by a single response per team and per centre.

At the time of the survey, 37% of the surgeons practised in a red zone area and 63% in a green zone, 38% in a cancer centre, 31% in a private clinic, 31% in a public hospital and/or university hospital.

Variation in breast reconstruction activity

All surveyed surgeons completely stopped DBR activity during confinement. Overall 42% of surgeons reported not changing their indications for IBR during, and 63% after completion of confinement (Figure 1 ). Overall, 32% of surgeons reported resuming DBR activity, with a higher proportion in red zones than in green zones (Figure 2 ). The fear of a second wave of the pandemic in areas initially less affected by COVID-19 may explain this paradoxical result.

Figure 1

Modifications of immediate breast reconstruction indications after confinement according to the epidemic zone of COVID-19.

Red zone: under tension

Green zone: less affected.

Figure 2

Comparison of resuming delayed breast reconstruction after confinement according to the epidemic zone of COVID-19.

DBR: delayed breast reconstruction

Red zone: under tension

Green zone: less affected.

The impact of the pandemic on prophylactic breast surgery activity was variable, with 54% of practitioners reporting that they had discontinued prophylactic breast surgery.

Factors influencing surgical practice

The main reported reason limiting the resumption of BR activity was a reduction in operative theatre access (65%). 85% of surgeons reported that patients asked to postpone the BR procedure until after the end of the pandemic mainly due to fear of COVID-19 infection. Eighty per cent of surgeons referred to the guidelines to organise the resumption of activity. However, 51% and 18% of them declared using pedicled and free flaps, respectively.

Seventy-one percent of the surgeons have set up multidisciplinary meetings with other surgeons and anaesthetists to collegially validate the BR indications on a case-by-case basis.

Discussion

The COVID-19 pandemic poses a severe and long-lasting threat to patients' access to BR. The surgical societies recommended to postpone delayed BR at the end of the pandemic and in case of IBR, to focus on implant-based reconstruction. In our study, as the virus was still circulating, 32% of surgeons reported resuming DBR activity and still performed flap BR if they found those techniques to be more appropriate to the patient.

The recovery of surgical activity after the confinement due to COVID-19 has been a challenge largely discussed in the recent literature in many non-urgent fields, such as orthopaedic or metabolic surgery due to restricted access to the operating theatre. However, because of their life changing implications, these surgeries are not optional. In order to cope with these ethical choices to prioritise and organise BR activity, 71% of surgeons relied on local multidisciplinary collegial discussion taking into account patients’ requests, local intra-hospital constraints and personalised risk–benefits balance.

We also identified that the fear expressed by patients to perform a DBR procedure in this pandemic context was a factor moderating the resumption of activity. Amongst the most penalised are older patients considered more vulnerable to COVID-19 for whom access to BR is already poor, and who will probably not benefit from DBR if their surgical project is deferred.

As a limitation of our study, as the survey was anonymous, we were not able to describe more precisely the participating surgeons and their institutions. However, responders appear representative of expert centres.

Conclusion

In case of a pandemic, all care givers are convinced that non-urgent activity should be stopped during the infection peak. Recent events have helped us to understand that the severity of the sanitary crisis was not homogenously distributed and that it should be considered that multidisciplinary teams discuss and promote non-urgent surgeries to prevent the most vulnerable patients from renouncing care.

Declaration of Competing Interest

None.