|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 332-333
Coronavirus disease-2019 and systemic therapy for breast cancer
Hollis DSouza1, Ajit M Kulkarni2
1 Department of Medical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Oncology, BKL Walawalkar Rural Medical College and Hospital, Ratnagiri, Maharashtra, India
|Date of Submission||06-May-2020|
|Date of Decision||09-May-2020|
|Date of Acceptance||11-May-2020|
|Date of Web Publication||19-Jun-2020|
Department of Medical Oncology, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
DSouza H, Kulkarni AM. Coronavirus disease-2019 and systemic therapy for breast cancer. Cancer Res Stat Treat 2020;3:332-3
India reported its first case of coronavirus disease-2019 (COVID-19) on January 30, 2020, and as of today, there are more than 56,000 cases with 1800 deaths. Oncologists are facing an unprecedented challenge during the COVID-19 pandemic., Breast cancer is the most common malignancy in India. The systemic treatment of breast cancer poses a unique challenge in this pandemic, as it has substantial clinical benefits and deferral of treatment can lead to poor oncologic outcomes. This highlights the need for a framework of guidelines. In normal times, these recommendations would be evidence-based; however, currently, the lack of robust clinical data has prompted the American Society of Breast Surgeons, the National Comprehensive Cancer Network, and the European Society of Medical Oncology  to provide consensus and expert-based recommendations. Chellapuram et al., in the previous issue of the Journal, have put forth their recommendations and institutional practice guidelines for systemic therapy in breast cancer. They can be briefly summarized as below.
- Proper personal and patient protection practices 
- Limiting physical interaction between the healthcare workers and patients by telemedicine, virtual tumor boards, and patient triage in screening areas
- Completion of neoadjuvant, adjuvant, and early-line palliative therapies, especially in triple-negative breast cancer (TNBC) and HER2-positive breast cancer
- Modification of regimens: to convert weekly regimens into 3-weekly ones, use of prophylactic growth factor support, less myelosuppressive regimens, curtailing the duration of maintenance therapies, avoiding corticosteroids, and the use of oral chemotherapy regimens
- Stratifying patients into age groups of ≤50 years, ≤50 years with comorbidity or >50 years without comorbidity, and >50 years with comorbidities and tailoring treatment according to the group
- The specific therapy-related guidelines include avoidance of CDK4/6 inhibitors; use of lapatinib/capecitabine in later lines for metastatic HER2-positive tumors; neoadjuvant hormonal therapy, especially in the luminal A subset; and initiating neoadjuvant therapy in early operable TNBC and HER2-positive breast cancers, if elective surgeries are delayed
These recommendations are a reckoner during this pandemic in the Indian setting and can guide us in the optimal systemic treatment of breast cancers. Specific therapy-based recommendations that need to be considered are the use of four cycles of docetaxel plus cyclophosphamide, rather than eight cycles of anthracycline plus taxane, in low-risk patients such as those with node-negative and hormone receptor-positive breast cancers or those with TNBCs smaller than 10 mm in size with negative nodes; the use of pertuzumab plus trastuzumab in a neoadjuvant, adjuvant, or metastatic setting in HER2-positive cancers; and replacing injectable bisphosphonates with oral alternatives. An important recommendation that needs to be highlighted is the feasibility of home-based infusion chemotherapy regimens. This can only be done with the collaborative efforts of the Indian oncology societies and updated government guidelines.
The authors recommend withholding immune checkpoint inhibitors to mitigate the risk of pneumonitis, but the National Health Service, in its interim guidance, recommends atezolizumab for patients with metastatic TNBC to reduce the risk of neutropenia. Although there are no specific recommendations to interrupt the use of immune checkpoint inhibitors during the pandemic,, our knowledge of COVID-19 and its impact on cancer care is evolving, and in time, we will be better equipped with more robust data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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