Rapid implementation of triaging system for assessment of breast referrals from primary care centres during the COVID-19 pandemic.

OBJECTIVE: The aim of this study was to establish a triaging system for assessment of breast referrals from primary care to ensure safe and effective breast services without compromising breast cancer management. BACKGROUND: COVID-19 was officially declared a global pandemic on 11 March 2020, and with no effective treatment available, preventing spread has been paramount. Previously, all referrals from primary care were seen in the rapid-access breast clinic (RABC). Clinic appointments exposed patients and healthcare professionals to risk. METHOD: Initial triage during the lockdown was in line with national governing body guidance, rejected low risk referrals and streamed remaining patients through a telephone consultation to RABC or discharge. A modified triage pathway streamed all patients through virtual triage to RABC, telephone clinic or discharge with advice and guidance categories. Demographics, reasons for referral and outcomes data were collected and presented as median with range and frequency with percentages. RESULTS: Initial triage (23 March-23 April 2020) found fewer referrals with a higher percentage of breast cancer diagnoses. Modified triage (22 June-17 July 2020) resulted in a 35.1% (99/282) reduction in RABC attendance. Overall cancer detection rate remained similar at 4.2% of all referrals pre-COVID (18/429) and 4.3% (12/282) during modified triage. After six months follow-up of patients not seen in RABC during the modified triage pathway, 18 patients were re-referred to RABC and none were diagnosed with cancer. CONCLUSION: A modified triage pathway has the potential to improve triage efficiency and prevent unnecessary visits during the COVID-19 pandemic. Further refinement of pathway is feasible in collaboration with primary care.

Ambulatory day case oncoplastic and reconstructive breast surgery during the peak of COVID 19 pandemic

Background: The World Health Organization (WHO) declared a novel coronavirus disease 2019 (COVID 19) pandemic on the 11 March 20. In response to this, the United Kingdom (UK) Association of Breast Surgeons (ABS) released guidelines on breast cancer management during the pandemic on the 15 March 20. The UK was in lockdown on the 23 March 20. Whilst the UK breast units adapted to deliver safe cancer services, many limited and some stopped all oncoplastic and reconstructive breast surgery (OPRBS). With careful stratification and prioritisation of cases, coupled with our existing successful integrated ambulatory day case surgery pathway, our unit continued to perform OPRBS safely and we present the outcomes of our OPRBS during the pandemic. Materials and Methods: OPRBS performed between 11 March 20 and 31 July 20 were included in this study. All OPRBS cases were supported by our multidisciplinary team. Surgeons and patients followed hospital’s COVID 19 precautions policy. Primary outcome measured was COVID 19 exposure before or after surgery. Secondary outcomes measured were 30 days surgical complications and delay in adjuvant treatment. Results: A total of 117 patients (120 breasts) had breast cancer related surgeries during the study period. Ten patients (12 breasts), that is 10% underwent immediate OPRBS following breast conserving surgery or mastectomy were included in the study analysis. All OPRBS were planned for ambulatory day case surgery (ADCS). Patients' age ranged was from 35 to 63 years. There were 6 pre-pectoral implant based reconstructions, 4 partial breast reconstruction with chest wall perforator flaps, 1 therapeutic mammoplasty, and 1 central BCS with nipple reconstruction. None contracted COVID 19 before or after surgery, 2 patient developed minor complications with no delay in adjuvant treatment. Six patients were discharged on the day of surgery, and 4 patients were discharged within 23 hours of admission as part of our unit's integrated ADCS (<23 hours stay) pathway. Conclusions: With an established integrated ambulatory day case surgery pathway, and careful stratification and adherence to COVID 19 precautions, oncoplastic and reconstructive breast surgery can be delivered safely and effectively during the peak of the pandemic. Our model can be extrapolated to the reshaping and resuming of oncoplastic and reconstructive breast surgery in the era of COVID 19.