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During this truly unprecedented time, the world swoons from not only the COVID-19 pandemic, but also from the secondary viral impact of the internet and social media. We’re witnessing the metastases of information; some good, some unfounded, some bad that has resulted in the near-paralysis of the world economy, human socialization, and routine institutional operations like schools. Amongst those hit the hardest are the country’s sick from causes other than the COVID-19 virus, although as of April 2020, all illness currently needs to be viewed in light of the Coronavirus pandemic. 

 

 

If you’re like me, you’ve heard every theory ranging from the pandemic being a major medical threat, a secret government plot, to aliens planting the virus on Earth. With all of that information to distill, how can we move forward and continue to take care of patients who have other very real, serious health problems, most of whom have unintentionally been placed on the back burner? How can we, as practitioners, help reduce the fear associated with a breast cancer diagnosis that we don’t necessarily have the resources to treat currently as a result of the pandemic?    

 

Breast cancer and other breast diseases present a unique challenge against the backdrop of the SARS-Cov-2 (the virus associated with the COVID-19 pandemic). With this in mind, a task force, the COVID-19 Breast Cancer Consortium, was assembled to provide clinicians and patients with a set of guidelines, a mammoth undertaking given the uncertainty of the Coronavirus’s course in all-comers and the overwhelming amount of information that has been bombarding the airwaves. 

 

While the COVID-19 Breast Cancer Consortium has initiated an ongoing discussion on how to proceed with breast cancer treatment and management in light of the pandemic, the experts have suggested some preliminary guidelines which place patients into three priority categories:

Priority A Category:

“Priority A patients have a condition that is immediately life threatening, clinically unstable, or completely intolerable and for whom even a short delay would significantly alter the patient’s prognosis. Assuming efficacious treatment, these patients are given top priority even if resources become scarce, requiring urgent treatment for preservation of life or control of progressing disease or symptomatic relief.”

Examples: 

1) patients presenting with an abscess, pain, and fever

2) underlying lung disease with shortness of breath

Priority B Category:

“Patients in the Priority B category are patients who do not have immediately life-threatening conditions but for whom treatment or services should not be indefinitely delayed until the end of the pandemic. Most breast cancer patients will fall under Priority B. If conditions in a geographic location only allow for Priority A patients to receive treatment, then treatment for Priority B patients can be delayed for a defined period of time during the pandemic. A short delay (e.g. 6-12 weeks) would not impact overall outcomes for these patients. Longer delays could impact outcomes in some Priority B patients and triage may become necessary to justify which patients should undergo treatment versus further delay. Patients within the Priority B category will be sub-stratified as B1 (higher priority), B2 (mid-level priority), and B3 (lower priority) as defined by each breast cancer subspecialty.”

Example: patients requiring lumpectomy for breast cancer who are not in the middle of a neoadjuvant treatment 

 

Priority C Category:
“Patients in Priority C category are patients for whom certain treatment or services can be indefinitely deferred until the pandemic is over without adversely impacting outcomes.”

Example: excision of benign disease

While much of our relief efforts are going towards acute treatment of those patients suffering from COVID-19, we want you to know that we are still working hard to make sure those who are COVID-19 negative with chronic medical conditions still receive the treatment they need. We hope you understand that the prioritization is meant to ensure that the entire medical system can continue to run smoothly. Please note that this will be an ongoing discussion as more information becomes available.

Thank you for your understanding during this difficult time. 

 

Rachel B. Wellner, MD MPH FACS 

 

Jonathan Vaynberg, MD 

 

References: 

Medically-Necessary, Time-Sensitive Procedures: A Scoring System to Ethically and Efficiently Manage Resource Scarcity and Provider Risk During the COVID-19 Pandemic. Vivek N. Prachand, MD FACSa,∗,Correspondence information about the author MD FACS Vivek N. Prachand

 

Recommendations for Prioritization, Treatment and Triage of Breast Cancer Patients During the COVID-19 Pandemic. 

 

The COVID-19 Pandemic Breast Cancer Consortium: Representatives from the American Society of Breast Surgeons (ASBrS), the National Accreditation Program for Breast Centers (NAPBC), the National Comprehensive Care Network (NCCN), the Commission on Cancer (CoC), and American College of Radiology (ACR). 

 

Jill R. Dietz, MD; Meena S. Moran, MD; Steven J. Isakoff, MD, PhD; Scott H. Kurtzman, MD; Shawna C. Willey, MD; Harold J. Burstein, MD, PhD; Richard J. Bleicher, MD; Janice A. Lyons, MD; Terry Sarantou, MD; Paul L. Baron, MD; Randy E. Stevens, MD; Susan K. Boolbol, MD; Benjamin O. Anderson, MD; Lawrence N. Shulman, MD; William J. Gradishar, MD; Debra L. Monticciolo, MD; Donna M. Plecha, MD; Heidi Nelson, MD; Katharine A. Yao, MD

What is a Breast Cyst? The breast is a complex gland consisting of ducts, lobules, connective tissue, and fat. On average, a typical breast contains 12-15 major lobules and the same number of major ducts, the function of which is to carry milk out through the nipple during lactation. These ducts and lobules are, in turn, made of hundreds of microscopic ductal cells and lobular cells.

 

Generally, when there is an outpouching of the duct, a cyst forms. The cyst can remain in continuity with the duct or can “pinch off” and form a separate entity. A breast cyst is a fluid filled sac located in the breast usually containing greenish, straw colored, or brownish fluid.  They are generally round with smooth edges containing fluid. 

 

What is the cause of breast cysts? The cause of breast cysts is unclear but their formation is likely related to hormonal changes in the body. They are more common in premenopausal women (women of reproductive age) than women of other age groups and tend to become tender and/or larger around menses and pregnancy. 

 

What are the symptoms of breast cysts? Breast cysts are smooth, palpable lumps with distinct borders. Sometimes they are completely asymptomatic and only discovered when a woman goes for her routine imaging (mammography, sonography). Other cysts present as an asymptomatic mass fitting the description above. Still others can be larger and painful, especially around menses or pregnancy. When they become large and/or painful, aspirating them or removing them may be considered.  

 

Do breast cysts go away on their own? Breast cysts can go away on their own, although if the cyst is large (>2cm), it is unlikely that the cyst will regress spontaneously. If a patient is experiencing discomfort and the cyst is readily palpable, it can be drained using a typical syringe and medium to large bore needle. If the cyst is deeper, nonpalpable or painful, aspiration can be performed by the breast imager using the same technique, but relying upon the ultrasound as a guide to find the cyst requiring aspiration.

 

Can a cyst in the breast turn into cancer? A breast cyst technically can turn into a cancer or represent a cancer at presentation, but this occurs very rarely. The bigger problem occurs when the patient has a cyst that presents as a mass on the exam and can make it more difficult to recognize a concomitant malignancy (malignancy occurring at the same time as a cyst). Both on physical exam and even on imaging, a breast cyst can obscure an underlying cancerous mass. As you will read below, if cysts are aspirated and found to contain bloody fluid and/or the cyst reaccumulates after 2 aspirations, the fluid should be sent for cytologic analysis to rule out carcinoma.

 

How long will a breast cyst last? A breast cyst can last from time of presentation through the reproductive years or even remain throughout the lifetime of a patient, but they’re generally not dangerous. 

 

How to prevent breast cysts? It is unclear how to prevent breast cysts. They are not, in and of themselves, dangerous, so prevention is not the key issue here. The key issue is whether or not to aspirate them, resect them, or just observe them ensuring they don’t change significantly over time or obscure an adjacent tumor.  

 

How to tell the difference between a cyst and a tumor? A cyst on a physical exam presents as a smooth mass with distinct borders, whereas a malignancy generally feels like a firm, non-movable mass with indistinct or “rough” borders. In contrast to a benign breast cyst, a cancerous mass may also present with puckering of the skin, nipple inversion, tumescent skin (‘piel d’orange skin), skin dimpling, asymmetries, redness or inflammatory changes, and/or enlarged axillary lymph nodes (the lymph glands under the armpits). On a mammogram, the cyst will look like a perfectly smooth, balloon-like mass, whereas malignancies can present as calcifications or what’s called a ‘spiculated mass,’ where it appears to almost be “sucking” the tissue around it.  On ultrasound, a cyst is a fluid filled sac, whereas malignancies have their own typical appearance: taller rather than wide, ill-defined borders, the shadowing pattern on ultrasound also characteristic of malignancy.  

 

What is the treatment for breast cysts? Most can just be left alone and safely watched over time. However, they can grow large (>2cm or so), at which point they may be painful, warranting drainage. Note: if the cyst fluid re-accumulates more than twice or is bloody, the fluid should undergo cytologic testing to ensure it’s not a rare presentation of cancer. Clearly, if the aspirate is concerning for malignancy or pre-malignancy, the mass should be excised with appropriate margins. 

 

Can diet affect the breast cysts? This is controversial, but perhaps food high in estrogen content, such as all soy products (phytoestrogens), should be minimized or avoided in the adult patient. 

 

Can you suggest some home remedies and self-care tips for women having a breast cyst? There is no evidence showing the efficacy of a home remedy, although Evening Primrose Oil is a supplement derived from a yellow flower. The therapeutic activity of evening primrose oil is attributed to the direct action of its essential fatty acids on immune cells as well as to an indirect effect on the synthesis of eicosanoids. Evening Primrose Oil contains linoleic acid and gamma linoleic acid (thought to have mild anti-inflammatory properties) may be effective at reducing pain women might feel due to a breast cyst and/or cystic breasts.

 

Can breast cysts repeat even after treatment? The cysts can reaccumulate if drained (see above). If the cysts are removed surgically, they generally don’t recur, but people prone to breast cysts can experience new ones. While they may be inconvenient and uncomfortable, they are rarely if ever dangerous and do not represent a risk factor for breast cancer. 

Do you know what your breast looks like, on the inside?

 

This diagram of the breast from Memorial Sloan Kettering Cancer Center depicts a side view of the breast, showing the gland in relationship to the chest and rib cage. The gland itself is composed of ducts, lobules, fat, and supportive structures. Women tend to have about 12-15 major lobules that empty out the nipple through the ducts. Think of the lobules as flowers and the ducts as the stems. To the right is a picture of the breast depicting the nipple areolar complex, the underlying pectoral muscle, the lymph nodes that are responsible for draining the breast of debris, and some of the major blood flow supplying the breast.

 

The challenge associated with speaking with family, friends, and even colleagues cannot be understated. Receiving a diagnosis of breast cancer can lead to emotional lability-extremes of emotion ranging from optimistic to depressed.

 

It is critical that the patient feel empowered. When, how, and if a loved one is told about the patient’s diagnosis and/or details regarding treatment remains under the patient’s control.

 

Friends and loved ones often want to be a source of support. MY opinion on this includes learning to maintain strong barriers when people are coming on too strong or become controlling, but as women, we tend to take the weight of the world on our shoulders. Allow healthy support in. There WILL be times when you need support and other times when you won’t. Just be cognizant that you’re on an unknown journey and it’s not easy to go it alone.

 

Need more information? Please visit www.breastcancer.org

Although somewhat less rare than having one breast cancer, sometimes more than once breast cancer can occur at the same time, either in the same breast or the opposite breast. For this discussion, we will focus on cancers that occur simultaneously in the same breast. The typical treatment for multiple breast cancers is mastectomy. However, is it possible and/or safe to consider having a patient undergo multiple lumpectomies?

 

While multiple lumpectomies offer shorter OR time and theoretically offer better cosmetic benefits in some patients, larger trials are still needed. Although the data are still limited, the outcomes either mastectomy or multiple lumpectomies may be equivalent.

 

However, some of the problem to look out for:

1) Inferior cosmetic outcomes
2) How to deliver radiation following multiple lumpectomies

 

For more information: See Kari M. Rosenkranz MD, Karla Ballman PhD, Et. Al.

In 2017, the US Department of Health and Human Services declared the opioid epidemic a public health emergency due to opioid misuse and abuse. Patients undergoing surgery for cancer are also at risk for developing use or an addiction. Up to 10% undergoing cancer operations developed opiate addiction.

 

It appears that smoking, preoperative opioid use, bilateral oncoplastic surgery, axillary lymph node dissection, use of surgical drains, high reported postoperative pain score, and receiving a higher opiate discharge prescription are associated with higher postoperative opioid use. Noting that every patient has her own pain threshold and also considering the complexity of the case, judicious use of opioid medication should be used and individualized.

 

Want to learn more? Visit Ko Un Park1, Kristin Kyrish2, Min Yi3, et. al.