Covid-19 HSE Clinical Guidance and Evidence

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NCCP advice for Medical Professionals on the management of patients undergoing Breast Cancer Radiotherapy in response to COVID-19 (CD 19-064 001/17.04.20)

• NPHET, HSE and DoH advice

• Purpose

• Consider radiotherapy omission for patients who meet the following criteria

• Use a 5-fraction schedule if possible

• Consider Accelerated Partial Breast Irradiation (APBI)

• Avoid boost

• Post-mastectomy radiotherapy

• Reduce planning complexity limit deep inspiration breath hold (DIBH) use

• Delay treatment

• General

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This document relates to patients who do not have COVID-19 or are not suspected of having COVID-19.

• Current events surrounding the COVID 19 pandemic are challenging and all public health bodies are placing the safety of patients, staff and communities first in all decisions.
• This is an evolving situation. This advice is based on current information, it is additional to the advice of the NPHET, the HSE and the DoH, and will be updated as necessary.
• The NCCP acknowledges that each hospital is working under individual constraints, including staff and infrastructure, and as a result will implement this advice based on their own unique circumstances.
• The purpose of this advice is to maximise the safety of patients and make the best use of HSE resources, while protecting staff from infection. It will also enable services to match the capacity for cancer care to patient needs if services become limited due to the COVID-19 pandemic.
• Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment.
   

NPHET, HSE and DoH advice

Hospitals will operate under the overarching advice of the National Public Health Emergency Team (NPHET), the HSE and the DoH. Information is available at:

• HSE HPSC - https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/
• HSE Coronavirus (COVID-19) - https://www2.hse.ie/conditions/coronavirus/coronavirus.html
• DoH Coronavirus (COVID-19) - https://www.gov.ie/en/campaigns/c36c85-covid-19-coronavirus/
• Ireland’s National Action Plan in response to COVID-19 (Coronavirus) - https://www.gov.ie/en/campaigns/c36c85-covid-19-coronavirus/

Purpose

• The purpose of this guidance document is to provide guidance to medical professionals on the management of patients undergoing Breast Cancer Radiotherapy during the COVID-19 pandemic.

Consider radiotherapy omission for patients who meet the following criteria

• ≥ 65 years
• Node negative
• Tumour size < 3cm
• Grade 1-2
• ER positive and likely to be compliant on hormonal therapy
• Her2 negative
• Low risk DCIS

For all of these patients clinical follow-up is recommended.

Use a 5-fraction schedule if possible

• Adjuvant radiotherapy 26 Gy in 5 fractions over 1 week (FAST-FORWARD regime)* or 28.5Gy in 5 fractions treating once a week (FAST regime)
• The 5 fraction schedule is not currently recommended in patients 1) requiring full nodal irradiation 2) patients under 40 years of age.
• Criteria may change once FAST-FORWARD data published.

Consider Accelerated Partial Breast Irradiation (APBI)

• In centres where already established

Avoid boost

• Avoid a boost where possible (no survival advantage). Consider giving only in patients under 50 years and or positive margins or patients 50-60 years Grade 3 or extensive intraductal component (25% tumour DCIS). Consider SIB technique if available.
• Limit number of fractions.

Post-mastectomy radiotherapy

• Consider omitting post-mastectomy radiotherapy in low risk patients.
• For patients with tumours >5 cm and/or N2 disease post-mastectomy radiotherapy is still recommended.

Reduce planning complexity limit deep inspiration breath hold (DIBH) use

• DIBH should be limited and may need to be discontinued if capacity does not allow.

Delay treatment

• There may be delays starting adjuvant radiotherapy depending on clinical priorities in the radiation centre. Radiotherapy may be delayed in patients with low risk breast cancer including DCIS.
• For further information on delaying treatment, please refer to ‘SLRON COVID-19 Clinical Response Plan’.

General

• The benefit of attending for radiotherapy must be balanced against the risk of COVID-19 exposure associated with treatment.
• If possible, a discussion should take place with each individual and a decision made taking into account risk/benefit uncertainty and patient choice.
• Patients not suitable for a 5 fraction regime should be treated with 40 Gy in 15 fractions.
• Use clinical judgement if oncotype recurrence score is available and high.