Re-entry Tool for Breast Surgeons

As health care institutions begin to consider how best to resume surgery once the COVID-19 surge passes, a key challenge is how best to accommodate the backlog of patients waiting for procedures. Patients and their surgeons need an objective and fair way to prioritize operations. Moreover, surgical delays will likely continue for some time—ramping up to full capacity will be a gradual process, as operating rooms and resources may remain in short supply for weeks to months.

At the Massachusetts General Hospital Cancer Center, a team led by Barbara Smith, MD, PhD, director of the Breast Program and professor of surgery at Harvard Medical School, has developed a tool to help breast surgeons and administrators keep track of patients whose surgery has been delayed. Information about each patient’s breast condition, health status and risk of further delay are collected and used to prioritize patients for surgery.

“Keeping track of a large number of delayed patients, with enough individual detail for safe and rational assignment to limited OR slots, is a daunting task,” says Dr. Smith. “Assignment of one patient to surgery while another continues to wait must be done with objective criteria in an equitable and transparent manner.”

The database tool uses specific patient, tumor and risk information to assign a numerical score to each factor that influences risk of delaying breast surgery. Each patient’s total delay score is calculated based on:

• Diagnosis—tumor, atypical or benign
• Patient and tumor factors
• Acuity of the disease process
• Availability of non-surgical treatments that can be used to postpone surgery
• How long surgery has been delayed

Current national guidelines and clinical judgement divide delayed breast surgery patients into three main categories, from highest to lowest urgency for surgery. The Mass General database tool can help sort patients into these groups and help identify the most urgent patients within each group.

1. Neoadjuvant chemotherapy: For patients receiving chemotherapy as their first cancer treatment, surgery should ideally take place approximately three-six weeks after the last dose of chemotherapy. This group of patients receives the highest priority for surgery
2. Early-stage cancers receiving neoadjuvant endocrine therapy: Data suggest that surgery for estrogen receptor positive (ER+) tumors can be safely delayed for as long as six-12 months with neoadjuvant endocrine therapy. However, during this treatment, it is critical that clinicians carefully monitor their patients to be sure that tumors are shrinking, or at least stable in size. Growing tumors receive high priority for surgery
3. Non-malignant and cosmetic surgeries: Per current COVID-19 guidelines, surgery for most non-malignant and cosmetic purposes can safely wait until conditions have improved and resources are less scarce. Within this group, surgery for potentially pre-cancerous conditions is prioritized over other non-malignant conditions

“Our tool aims to characterize individual patients in these groups with enough granularity to accurately assess risk of delay and help prioritize patients for surgery,” says Dr. Smith. Prioritization of breast surgery in this environment will require ongoing multidisciplinary discussion, she affirms.

The tool created is available via two formats: REDCap, a secure data collection tool in compliance with HIPAA compliance standards, and Microsoft Excel, which stores data and performs the same calculations as the REDCap.