Breast radiotherapy under COVID-19 pandemic resource constraints -- approaches to defer or shorten treatment from a Comprehensive Cancer Center in the United States

Introduction Breast radiotherapy accounts for a significant proportion of patient volume in contemporary radiation oncology practice. In the setting of anticipated resource constraints and widespread community infection with SARS-CoV-2 during the COVID-19 pandemic, measures for balancing both infectious and oncologic risk among patients and providers must be carefully considered. Here, we present evidence-based guidelines for omitting or abbreviating breast cancer radiotherapy, where appropriate, in an effort to mitigate risk to patients and optimize resource utilization. Methods Multidisciplinary breast cancer experts at a high-volume comprehensive cancer center convened contingency planning meetings over the early days of the COVID-19 pandemic to review the relevant literature and establish recommendations for the application of hypofractionated and abbreviated breast radiation regimens. Results Substantial evidence exists to support omitting radiation among certain favorable risk subgroups of breast cancer patients and for abbreviating or accelerating regimens among others. For those who require either whole-breast or post-mastectomy radiation, with or without coverage of the regional lymph nodes, a growing body of literature supports various hypofractionated approaches that appear safe and effective. Conclusion In the setting of a public health emergency with the potential to strain critical healthcare resources and place patients at infection risk, the parsimonious application of breast radiotherapy may alleviate a significant clinical burden without compromising long term oncologic outcomes. The judicious and personalized use of immature study data may be warranted in the setting of a competing mortality risk from this widespread pandemic.