Breast Surgery in the Time of Global Pandemic: Benefits of Same-Day Surgery for Breast Cancer Patients Undergoing Mastectomy with Immediate Reconstruction during COVID-19

Abstract

Sir: The coronavirus disease 2019 (COVID-19) pandemic has severely curtailed the American health care system. In response to managing patients with breast cancer during these unprecedented times, a COVID-19 pandemic breast cancer consortium, consisting of leaders from many national organizations, including the American Society of Breast Surgeons, released an executive summary on March 24, 2020, detailing prioritization of breast disease management.1 The official guidelines were recently published on April 24, 2020.2 Cases are currently triaged into three categories: A (immediate life-threatening condition), B (does not need immediate action; can be delayed for 6 to 8 weeks but no more), or C (stable and can be delayed while COVID-19 dissipates). Currently, the trajectory of the pandemic and the impact of delaying treatment on outcomes are unclear. The national guidelines advocate for surgeons to avoid mastectomy in those eligible for breast conservation.2 Although the initial summary advocated for deferring mastectomy until the pandemic resolved, the official guidelines now mention exceptions for mastectomy and immediate, implant-based reconstruction given appropriate hospital resources. Inpatient admission after mastectomy has traditionally been required because of postoperative pain, nausea, and vomiting associated with extensive resections and reconstructions. However, recent improvements in reconstructive and anesthetic techniques have paved the way for same-day surgery for patients undergoing mastectomy with prosthetic-based reconstruction. Our institutional experience with same-day surgery for mastectomy and breast reconstruction began in 2018, followed by enrollment into our prospective clinical trial in 2019. The protocol incorporates both the enhanced recovery after anesthesia pathway and intraoperative liposomal bupivacaine field blocks. The majority of patients undergo prepectoral implant reconstruction, which is associated with significantly less pain than when the pectoralis muscle is manipulated.3 Our preliminary results demonstrate feasibility through no emergency room admissions, readmissions, or additional postoperative opioid prescriptions. Initiating a standard same-day surgery program where patients have the opportunity to safely recover at home with a direct point of contact for issues has the potential for improved outcomes on many aspects. Notably, patients have improved psychological well-being, avoid exposure to nosocomial infections, alleviate health care system burden, and provide cost savings.4 A recent pilot study from Kaiser Permanente Northern California demonstrated the benefits of their same-day surgery program for mastectomy. Similar implementation led to an increase in same-day mastectomy from 23 percent to 61 percent without an associated increase in emergency room visits, reoperations, or readmission rates.5 COVID-19 has tested our ability to deliver innovative surgical solutions. In relation to the pandemic, same-day surgery programs for mastectomy limit strain on hospital resources and staff use. Compared with mastectomy, lumpectomy obviates the need for needle-localization of nonpalpable tumors and in some cases radiation therapy, all of which increase exposure risk. Although some providers are delaying radiation therapy, this leads to undue psychological stress with unclear oncologic outcomes if the pandemic continues to delay care. Understandably, implementation of same-day surgery for mastectomy depends on availability of an anesthesia protocol and provider experience, which may not be available at all hospitals. Overall, we believe outpatient mastectomy with immediate, implant-based breast reconstruction is a feasible and valuable option for breast cancer during the COVID-19 pandemic. DISCLOSURE Dr. Tousimis receives honorarium for speaking faculty as part of Medtronic. The remaining authors have no financial interests to disclose.

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