Vital Recommendations for Breast Imaging during Covid-19

Situations arising from the ongoing novel Covid-19 pandemic have thrown a set of unprecedented challenges at healthcare workers involved in the care of breast cancer patients and in the workup of patients with breast symptoms. Definite solutions are hitherto prospectively untested due to the novel nature of the virus.

Current recommendations can only be based on the clinical evidence that has emerged over the last few months. This is a dynamic process and is likely to be ever changing as we learn more about living with the pandemic.

The recommendations in this article are directed at advising the breast radiologist and technical staff on how to triage patients and is not intended to supersede a multidisciplinary clinical decision made at the tumour board, on a case-to-case basis. They are based on various guidelines that have been released by the Government of India, ICMR, WHO, ACR, SBI, EUSOBI and CAR/CSBI.

There is a steady rise in the number of Covid-19 cases across India, with variable geographical distribution resulting in government-imposed containment zones and travel restrictions. The limited availability of health manpower and technical resources as well as the local government and institutional decisions on prioritising these resources, are the determining factor in providing breast care. The recommendations in this article may be modified keeping these local variables in mind.

Identifying susceptible patients

Elderly women with comorbidities, as well as patients undergoing systemic treatment for breast cancer are often immune compromised. Not only are they more susceptible to contracting the novel Covid-19 or SARS-CoV-2 virus, but also have a higher incidence of life-threatening events such as severe pneumonia, acute respiratory distress syndrome & cytokine storm causing multi-organ failure and death. Therefore, triaging patients for imaging and treatment for breast cancer becomes imperative.

Recommendations for patient prioritisation

Determining which patient needs immediate attention in the midst of the pandemic and in which cases imaging investigations can be postponed to a later date, requires an optimal risk benefit assessment. Factors to be considered are the risk of contracting COVID-19 by visiting the healthcare facility versus poor outcome of breast cancer due to delay in the investigations.

Other factors that need consideration are the resources available and the ever-changing prevalence and transmissibility of Covid-19. Therefore, it is important to triage patients requiring immediate attention, while re-scheduling non-urgent radiology care.

A tiered plan, which prioritises patient care, may be considered as follows:

• Priority A: Urgent and immediate care
• Priority B: Non-urgent time sensitive care
• Priority C: Elective care, screening, research and imaging trials

Breast imaging is an important part of the triple assessment in the management of breast diseases, and imaging is mandatory before initiating any definitive treatment. However, during current times like that of Covid-19, it becomes important to reduce the number of visits for patients.

High end state-of-the-art machines like the Amulet Innovality from Fujifilm, which can detect breast cancer at a very early stage with a detection rate of 30-41% higher than the conventional 2D-mammography, is an even more useful technology at such times. The 3D Tomosynthesis in Amulet Innovality helps in the enhanced detection rate of cancer, thus enabling the identification at an early stage of breast cancer. All of this ultimately reduces the need for additional tests and biopsies, thus also patient visits.

Role of imaging in Priority A patient category

Urgent and immediate care needs to be considered only in a few scenarios related to breast care. This may need to be delivered the same day as the patient presents. These include the following:

• Imaging for an acute breast abscess
• Lactating female with acute swelling lump or pain
• Evaluation of a post-operative complication such as an infected seroma/hematoma

Imaging for a non-breast related complication that would come under the purview of a general radiologist, e.g. imaging for deep vein thrombosis (DVT) or pulmonary embolism (PE) is not included in these guidelines.

Role of imaging in Priority B patient category

Non-urgent time sensitive care, applies to the following symptoms and the conditions that are suspicious for breast cancer. These may be scheduled from 7 to 30 calendar days and include:

• New onset palpable lump or breast thickening that is clinically concerning
• New onset unilateral, spontaneous, bloody or watery (not milky, yellow or green) nipple discharge
• New onset axillary lump or arm swelling
• New onset skin dimpling or tethering
• New onset nipple flattening or inversion
• Pregnant woman with any of the above symptoms
• Assessment of response to neo-adjuvant systemic therapy (NAST) and for pre-operative planning scheduled within 4 to 6 weeks following completion of NAST

If suspicious findings are detected following imaging in priority B category patients, image guided breast biopsy should be scheduled on the same day as far as possible. These procedures are not at risk for aerosol generation and can be performed by the attending radiologist with adequate PPE protection.

However, imaging is to be temporarily deferred if a patient is affected by Covid-19, has a family member or a close contact affected with the illness, history of recent travel or within the 14-day quarantine period. In these situations, breast imaging as well as biopsy may be postponed by 2 weeks.

Role of imaging in Priority C patient category

In this low priority category, breast imaging may be postponed until social distancing regulations are lifted or until the threat perception of the pandemic is sufficiently lowered by the local authorities. Imaging in this category may be delayed by 2 months to a year. These include:

• Annual surveillance in breast cancer survivors
• Screening in the average risk women
• Breast pain as the only symptom, typically if cyclical and bilateral
• Low suspicion recalls of BI-RADS 3 lesions, following a review by the radiologist
• Biopsies of low-suspicion BI-RADS 4A lesions, following a review by the radiologist to determine if the procedure can indeed be delayed
• Low-suspicion diagnostic evaluation of elderly patients to avoid infection in this vulnerable population
• Males with tender retro areolar breast masses, likely gynecomastia
• Women at any age to evaluate integrity of breast implants

Recommendations for healthcare workers (HCW)

Personal Protective Equipment (PPE)

The principle method of transmission of the virus SARS-CoV-2 is droplet or direct/indirect contact transmission through fomites. Breast imaging and breast interventional procedures demand close proximity of the HCW to the patient. Typically, the procedures involve a distance of less than 1 meter and last for a duration of about 20 to 30 minutes.

Although, they are non-aerosol generating procedures, the physical proximity raises concern for droplet transmission from the patient. Therefore, PPE is recommended for all staff performing mammography, ultrasound, breast MRI and breast interventional procedures. Surgical mask (triple layer medical mask), disposable gloves, disposable full sleeve coverall/gowns over the clothing, plastic aprons, goggles/face shield/visor, head and shoe cover have been shown to be effective in protecting the HCW.

N95 masks are recommended while performing biopsy/intervention procedures/aerosolising procedures in confirmed or suspected Covid-19 patients.

Psychological Support

Patients and healthcare workers need psychological support during these trying times.

  Cancer patients are emotionally vulnerable due to the nature of the disease and the side effects of the treatment. Resources such as on-line counselling and support groups can help provide emotional and psychological assistance.

One must not forget that the healthcare workers too are going through trying times and should be reassured, educated & appreciated.  

All attempts should be made to minimise the number of personnel present for procedures to preserve the PPE. Hand washing using soap and water for a minimum of 20 seconds before donning and doffing gloves between patients is mandatory. Handsanitisation using sanitizer with at least 60-70% alcohol content by HCW at regular intervals is also necessary.

There are a few PPE items that need to be changed between patients to avoid cross contamination, while a few items of the PPE can be used for a few hours until the HCW takes a break.

Single use for each patient: Disposable gloves (nitrile non-powered gloves are preferred over latex or powdered gloves as they are chemical resistant & hypoallergenic) & plastic aprons

Sessional: Surgical face mask (triple layer), goggles/face shields/visor, cover-all/gown, head covers, shoe covers

For intra-operative ultrasound, surgical scrubs should be donned along with the PPE. Also, PPE should be disposed appropriately in assigned garbage bins after use. Face shields and goggles may be cleaned and reused.

In case an HCW comes in contact with a confirmed case of Covid-19, institutional/government protocols regarding contact tracing and testing should be strictly adhered to.

It is of utmost importance to ensure the following:

• Proper history of travel/Covid-19 contact to be illustrated while registering/at the reception
• All patients coming for imaging/interventions to be given surgical mask to wear, at the reception itself
• Preferably, a recent Covid-19 test should have been done in patients, who have posted electively for interventions

In conclusion

Maintaining the balance between minimising the risk of patient and staff contamination while avoiding unnecessary delay in the diagnosis of breast cancer is vital during the ongoing novel Covid-19 pandemic. This needs a careful assessment of the risk versus benefit for triaging patients. The Covid-19 pandemic is an evolving situation and therefore this living document too will continue to evolve with time.

About the author

Prof. Bhawna Dev (M.D., D.N.B), is the Lead Consultant – Breast Imaging & Interventions at the Center of Excellence in Radio-Diagnosis, Sri Ramachandra Institute of Higher Education & Research (Deemed to be University) in Chennai. She has more than 40 publications in national & international journals & has an experience of 18 years in teaching hospital & university set-up. She has been the Treasurer of the Tamil Nadu & Pondicherry State Chapter of IRIA (2016-2018) & the Joint Secretary of Breast Imaging Society of India (2017-2019).