Aluno Mentor em Tempos de Pandemia by

João Silveira

cxzcwqb4bs — 2021-03-16 19:47:00 UTC

"Algo (legal/interessante) sobre mim, e que poucas pessoas sabem, é que..."

Eu toco gaita em uma banda de sertanejo universitário

isabella cardia

2021-03-16 22:40:13 UTC

eu lutei karatê por anos

Clara Maas

tmclara1599 — 2021-03-16 22:40:16 UTC

Algo (legal/interessante) sobre mim, e que poucas pessoas sabem, é que gosto de desenhar, luto judô desde os 12 e sei tocar piano

Lucas Pedebos

lpedebos — 2021-03-16 22:40:17 UTC

"Algo (legal/interessante) sobre mim, e que poucas pessoas sabem é que..."

Eu faço desenho de anime

Sofia Kieling

vezzanikieling — 2021-03-16 22:40:19 UTC

Algo (legal/interessante) sobre mim, que poucas pessoas sabem, é que eu tenho 20 anos de diferença do meu irmão

Valentina De Nadal

valentinadenadal — 2021-03-16 22:40:41 UTC

Algo legal/interessante sobre mim, e que poucas pessoas sabem, é que eu danço ballet clássico desde os 3 anos de idade.

Samantha S. Ljiljanic

2021-03-16 22:40:42 UTC

Algo (legal/interessante) sobre mim, e que poucas pessoas sabem, é que eu sou filha de um croata.

Lucas Moraes

2021-03-16 22:40:57 UTC

Eu sou vegetariano e sei bordar pedraria

Andressa de Oliveira Felício

2021-03-16 22:41:00 UTC

Algo (legal/interessante) sobre mim, e que poucas pessoas sabem, é que gosto muito de ler, principalmente livros de fantasia

constanza heidrich

2021-03-16 22:41:11 UTC

sou bastante ligada às artes num geral

Luana Azevedo

2021-03-16 22:41:28 UTC

Acho legal/interessante sobre mim, e que poucas pessoas sabem, que pratico meditação como forma de me "desligar" da maior parte dos meus problemas pessoais.

Valentina P. Luz

vpoltronieri1 — 2021-03-16 22:41:36 UTC

Algo legal/interessante sobre mim, e que poucas pessoas sabem, é que eu faço lives jogando Lol e Valorant (twitch.tv/valentilt_)

cavalcantechanaya — 2021-03-16 22:41:48 UTC

Chanaya Gutterres

Algo (legal/interessante) sobre mim, é que poucas pessoas sabem, é que ando gosto de andar de patins nas horas livres.

Luiza Cunha

2021-03-16 22:41:50 UTC

Eu gosto de correr nas horas vagas e também curto jogar futsal

Júlia Pivatto

juliabpivatto — 2021-03-16 22:42:33 UTC

joguei rugby por anos

Sofia Kieling

cavalcantechanaya — 2021-03-16 22:42:35 UTC

Algo (legal/interessante) sobre mim, que poucas pessoas sabem, é que

Gabrieli Alves

gabrielikretz — 2021-03-16 22:42:53 UTC

Eu não desenvolvi os dentes caninos e optei pelo vegetarianismo antes de saber disso KKKKKKK desculpem, foi difícil encontrar algo

"Algo (legal/interessante) sobre mim, e que poucas pessoas sabem, é que... amo experimentar coisas novas mas enjoo de tudo muito rápido

2021-03-16 22:43:03 UTC

2021-03-16 22:43:50 UTC

Sou vegetariana e amo desenhar

Laura Torres

2021-03-16 22:43:51 UTC

“Algo (legal/interessante) sobre mim, e que poucas pessoas sabem é que...”
Eu pratico yoga.

Paloma Stumpf

2021-03-16 22:43:54 UTC

Tenho uma irmã gêmea que ta fazendo Medicina também

vbertagnolli — 2021-03-16 22:43:59 UTC

eu cozinho muito bem

Karolina Fricke

kafricke0 — 2021-03-16 22:44:04 UTC

"Algo (legal/interessante) sobre mim, e que poucas pessoas sabem, é que..."
Luxei meu cóccix tentando fazer uma posição de yoga

Nicolas

2021-03-16 22:44:14 UTC

Algo legal sobre mim: faço bolo e pudim

Nicole Pagliarin

2021-03-16 22:44:15 UTC

adoro tocar violão

Letícia Scortegagna

2021-03-16 22:44:19 UTC

Algo legal sobre mim, e que poucas pessoas sabem, é que eu sou maquiadora profissional

2021-03-16 22:44:23 UTC

Faço aula de dança desde muito pequena

Milena Rizzo

milenarizzo742 — 2021-03-16 22:44:26 UTC

Algo (legal/interessante) sobre mim, e que poucas pessoas sabem, é que eu fiz ginástica olímpica por muitos anos

Sophia

2021-03-16 22:44:38 UTC

toco violão e um pouco de piano

Natália Ferrão

2021-03-16 22:45:31 UTC

Algo interessante/legal sobre mim e que poucas pessoas sabem é que eu adoro fazer miçangas e já fiz três tipos de dança

Amanda Nichele

2021-03-16 22:45:45 UTC

Eu sei maquiar e cozinhar muito bem, amo ver series e tenho um doguíneo chamado Sushi! ❤️

Ana Djulia

anadjuliatesche — 2021-03-16 22:46:07 UTC

algo sobre mim, e que poucas pessoas sabem, é que jogo ff e sou completamente indecisa(libriana)

Pedro Escobar

2021-03-16 22:46:39 UTC

Algo legal sobre mim é que toco violão e instrumentos com cordas em geral desde os 5 anos de idade.

2021-03-16 22:46:43 UTC

Meus amigos me acham engraçada

Laura Cernicchiaro

2021-03-16 22:47:33 UTC

algo legal/interessante sobre mim, é que eu curto mtt esporte e jogo (tento) a maioria

Isabelle antonini

2021-03-16 22:47:41 UTC

“Algo legal/interessante sobre mim, e que poucas pessoas sabem, é que eu...” sou libriana é muito indecisa por isso não sei o que por aqui kkkkkkkk

Giovanna Polo

pologiovanna — 2021-03-16 22:48:15 UTC

Algo legal sobre mim, e que poucas pessoas sabem, é que toquei violão por muitos anos e gosto de jogar vôlei

Isis Reichow

isisreichowcoutinho — 2021-03-16 22:48:35 UTC

Eu aprendi a velejar em 2016 e em 2018 ganhei uma regata de escoteiros no Paraná. kkkk

Raquel Rodrigues

oicubinhos — 2021-03-16 22:52:19 UTC

É que sei costurar e trabalhei muitos anos com artesanato em feltro. E amo cachorros 🐕🐕🐕❤️

Matheus

mcespedes7 — 2021-03-16 22:55:58 UTC

Já quebrei um vaso sanitário "sem querer" numa festa e já lutei kung-fu

Mahara

2021-03-16 23:14:24 UTC

Fiz 5 anos de aula de alemão mas hoje em dia sei falar duas frases. KKKKK

2021-03-19 20:06:26 UTC

1 2 3 4 5 6 7 8 9 10 11 n engl j med nejm.org 1 The new england journal o f medicine Presentation of Case Dr. Aditya Bardia: A 62-year-old woman was evaluated at this hospital after she had identified a mass in her left breast, confirmed by her physician on physical examina - tion, during the pandemic of coronavirus disease 2019 (Covid-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The patient, who was of Ashkenazi Jewish ancestry, had no known family his - tory of breast or ovarian cancer. Medical history included asthma and a fibro - adenoma in the left breast, for which she had undergone excisional biopsy 30 years earlier. Menarche had occurred at 12 years of age and menopause at 54 years of age; she had not received hormone-replacement therapy. Physical examination revealed a mass, measuring 3 cm in greatest dimension, in the left breast. No other masses or axillary lymph nodes were palpable. The patient underwent imaging studies in accordance with the American College of Radiology guidelines. 1 Both breasts were imaged, since the patient’s last mammo - gram had been obtained 7 years earlier. Dr. Gary X. Wang: Mammography revealed an irregular mass with spiculated margins underlying the skin marker in the left breast, with imaging characteris - tics highly suggestive of cancer (Fig. 1A, 1B, and 1C). 2 Subsequent ultrasound examination revealed a solid, irregular mass in the left breast that measured 3.1 cm by 1.5 cm by 1.2 cm (Fig. 1D) and normal left axillary lymph nodes. Tissue sampling with core-needle biopsy under ultrasonographic guidance was performed (Fig. 1E). Pathological Discussion Dr. Amy Ly: Histologic evaluation of the biopsy specimen revealed invasive ductal carcinoma, grade 2, spanning at least 1.6 cm in greatest dimension. No definitive lymphovascular invasion or carcinoma in situ was identified (Fig. 2A). Immuno - From the Departments of Medicine (L.M.S., S.J.I., J.A.S., A.B., B.M.), Surgery (M.C.S.), Radiation Oncology (R.B.J.), Radiology (G.X.W.), and Pathology (A.L.), Massachusetts General Hospital, and the Departments of Medicine (L.M.S., S.J.I., J.A.S., A.B., B.M.), Surgery (M.C.S.), Radiation Oncology (R.B.J.), Radiology (G.X.W.), and Pathology (A.L.), Harvard Medical School — both in Boston. This article was published on July 1, 2020, at NEJM.org. DOI: 10.1056/NEJMcpc2002422 Copyright © 2020 Massachusetts Medical Society. Founded by Richard C. Cabot Eric S. Rosenberg, M.D., Editor Virginia M. Pierce, M.D., David M. Dudzinski, M.D., Meridale V. Baggett, M.D., Dennis C. Sgroi, M.D., Jo‑Anne O. Shepard, M.D., Associate Editors Kathy M. Tran, M.D., Assistant Editor Matthew B. Roberts, M.B., B.S., Case Records Editorial Fellow , Emily K. McDonald, Tara Corpuz, Production Editors Case 22-2020: A 62-Year-Old Woman with Early Breast Cancer during the Covid-19 Pandemic Laura M. Spring, M.D., Michelle C. Specht, M.D., Rachel B. Jimenez, M.D., Steven J. Isakoff, M.D., Ph.D., Gary X. Wang, M.D., Ph.D., Amy Ly, M.D., Jennifer A. Shin, M.D., M.P.H., Aditya Bardia, M.B., B.S., M.P.H., and Beverly Moy, M.D., M.P.H. Case Records of the Massachusetts General Hospital The New England Journal of Medicine Downloaded from nejm.org by Victor Santos on July 1, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. 2 n engl j med nejm.org The new england journal o f medicine histochemical staining showed tumor cells that were strongly and diffusely positive for estrogen receptor (ER) and progesterone receptor (PR) (Fig. 2B). Human epidermal growth factor recep - tor 2 (HER2) overexpression was equivocal on immunohistochemical staining. Subsequent flu - orescence in situ hybridization for HER2 did not reveal amplification. Figure 1. Imaging Studies of the Breast. Bilateral mammograms obtained from the craniocaudal and mediolateral oblique views (Panels A and B, respectively) show a mass in the left breast underlying the skin marker (arrows). At higher magnification (Panel C), the mass ap ‑ pears irregular and spiculated (arrow). An ultrasound image (Panel D) shows a solid, irregular mass, measuring 3.1 cm by 1.5 cm by 1.2 cm. An image obtained during core ‑ needle biopsy under ultrasonographic guidance (Panel E) shows the needle positioned within the mass. A B C D E The New England Journal of Medicine Downloaded from nejm.org by Victor Santos on July 1, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. n engl j med nejm.org 3 Case Records of the Massachusetts General Hospital The patient was referred to a breast surgeon for further evaluation. To carefully consider vari - ous therapeutic options, the breast surgeon saw the patient in a multidisciplinary clinic that in - cluded consultants from the radiation oncology and medical oncology services. Discussion of Management Dr. Bardia: The Covid-19 pandemic poses a major challenge to the health care system, and several organizations have released consensus recom - mendations for management of breast cancer during this unprecedented situation. 3-5 Major dif - ferences in management before and during the pandemic are outlined in Table 1, and key prin - ciples are reviewed here. First, during this pan - demic, although the choice and sequence of method of treatment may be affected, the overall goal of management remains cure. Second, the benefit of treatment needs to be carefully weighed against the known risks associated with treatment and against the potential risk of trans - mission of SARS-CoV-2 to patients and health care providers. Third, the treatment regimen may need to be modified on the basis of the indi - vidual clinical and pathological scenario. Finally, it is important to organize a multidisciplinary plan of alternative options that can be imple - mented in a resource-constrained environment (Fig. 3). M a nagemen t of Br e a s t C a ncer before the Covid-19 Pandemic Dr. Michelle C. Specht: The new diagnosis of breast cancer in this patient gives us an opportunity to reflect on the ways in which patients were typi - cally cared for before the widespread onset of Covid-19. We can then consider appropriate man - agement strategies that can be implemented during the pandemic. Upfront Surgical Options Before the emergence of Covid-19, a patient with clinical stage T2N0 (according to the tumor– node–metastasis classification system), hormone receptor (HR)–positive, HER2-negative breast cancer, such as this patient, would be a candi - date for upfront surgery. Surgical options would include mastectomy or lumpectomy with radia - tion; these approaches are associated with equiv - alent disease-free survival. 6 Given the size of this patient’s breast, the tumor would be resectable; therefore, most surgeons would recommend lumpectomy to preserve body image and sexual sensation. 7,8 Sentinel-node biopsy of the axilla would be performed at the time of lumpectomy. The patient would be informed of the risks as - sociated with the procedure, including a 17 to 59% risk of reoperation if the surgical margin is positive, a 3 to 23% risk of lymphedema, and a less than 10% risk of postoperative infection, seroma, or hematoma. 9,10 Genetic counseling and testing would be recommended, because this patient is of Ashkenazi Jewish ancestry. Although overall survival among patients who have a BRCA1 or BRCA2 mutation is similar after either breast-conserving therapy or mastectomy, the risk of a second, contralateral breast cancer after Figure 2. Core-Needle Biopsy Specimens of the Breast. Hematoxylin and eosin staining of a tissue core (Panel A) shows invasive ductal carcinoma. Immunohistochemi ‑ cal staining (Panel B) shows invasive carcinoma cells that are strongly and diffusely positive for estrogen receptor and progesterone receptor. A B The New England Journal of Medicine Downloaded from nejm.org by Victor Santos on July 1, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. 4 n engl j med nejm.org The new england journal o f medicine breast-conserving therapy is 26 to 40% at 20 years. 11 Therefore, some women choose bilateral mastectomy instead of lumpectomy in order to prevent a second primary cancer. Options for Systemic Treatment Dr. Laura M. Spring: After upfront surgery is per - formed, the final pathological interpretation of the surgical specimen would determine adjuvant systemic treatment. The mainstay of adjuvant treatment for an HR-positive, HER2-negative tumor is endocrine therapy, and some patients also receive chemotherapy. Because this patient is postmenopausal, daily treatment with an aro - matase inhibitor for 5 to 10 years 12,13 or upfront treatment with tamoxifen, followed by an aro - matase inhibitor, would be the most likely treat - ment choice. 14 Standard clinicopathological features are used to determine whether a patient with HR-positive, HER2-negative breast cancer should receive adju - vant chemotherapy before endocrine therapy to further reduce the risk of recurrence. Additional genomic tests such as an RNA-based risk-score assay can be performed to estimate both the risk of recurrence and the potential for risk reduction with chemotherapy. 12,15-18 For example, the 21-gene recurrence-score assay Oncotype DX (Genomic Health) is a gene-expression assay that evaluates 16 cancer-related genes involved in tumor-cell proliferation and hormonal response, along with 5 reference genes; scores range from 0 to 100. 15 A high recurrence score (defined as either ≥31 or ≥26, depending on the specific trial) is associ - ated with a greater risk of distant recurrence and is predictive of chemotherapy benefit, whereas a low score (<11) indicates a low risk of recurrence and limited benefit with chemotherapy. 15 Chemo - therapy can also be safely omitted in patients who have an intermediate score (11 to 25), on the basis of the Trial Assigning Individualized Options for Treatment (TAILORx) study, which showed that efficacy outcomes associated with adjuvant endocrine therapy and with chemothera - Table 1. General Management of Select Early Breast Cancer Scenarios before and during the Covid-19 Pandemic.* Clinical Scenario Typical Management, before Covid-19 Pandemic Modified Management, during Covid-19 Pandemic† Newly diagnosed post ‑ menopausal early HR ‑ positive, HER2 ‑ negative breast cancer Stage I–II: Upfront surgery, followed by adjuvant en ‑ docrine therapy (with or without adjuvant chemo ‑ therapy, radiation therapy, or both). Stage III: Neoadjuvant therapy, followed by surgery, radiation therapy, and adjuvant therapy. Stage I–II: Neoadjuvant therapy (endocrine therapy preferred), followed by surgery (with or without ad ‑ juvant chemotherapy, radiation therapy, or both). Stage III: Neoadjuvant therapy (endocrine therapy pre ‑ ferred), followed by surgery and radiation therapy (with or without adjuvant chemotherapy). Newly diagnosed pre ‑ menopausal early HR ‑ positive, HER2 ‑ negative breast cancer Stage I–II: Upfront surgery, followed by adjuvant en ‑ docrine therapy (with or without adjuvant chemo ‑ therapy, radiation therapy, or both). Stage III: Neoadjuvant chemotherapy, followed by surgery, radiation therapy, and adjuvant endocrine therapy with ovarian suppression. Stage I: Neoadjuvant therapy (endocrine therapy pre ‑ ferred), followed by surgery (with or without adju ‑ vant chemotherapy, radiation therapy, or both). Stage II–III: Neoadjuvant therapy (endocrine therapy preferred), followed by surgery, adjuvant chemo ‑ therapy, and radiation therapy. Newly diagnosed localized HER2 ‑ amplified breast cancer Stage I: Upfront surgery, followed by adjuvant HER2 ‑ targeted therapy (with or without radiation therapy). Stage II–III: Neoadjuvant HER2 ‑ targeted therapy, followed by surgery and adjuvant HER2 ‑ targeted therapy (with or without radiation therapy). Stage I: Modified neoadjuvant HER2 ‑ targeted therapy, followed by surgery and adjuvant HER2 ‑ targeted therapy (with or without radiation therapy). Stage II–III: Neoadjuvant HER2 ‑ targeted therapy, followed by surgery and adjuvant HER2 ‑ targeted therapy (with or without radiation therapy). Newly diagnosed localized triple ‑ negative breast cancer Stage I: Upfront surgery, followed by adjuvant chemo ‑ therapy (with or without radiation therapy). Stage II–III: Neoadjuvant chemotherapy, followed by surgery (with or without radiation therapy). Stage I: Neoadjuvant chemotherapy, followed by sur ‑ gery (with or without radiation therapy). Stage II–III: Neoadjuvant chemotherapy, followed by surgery (with or without radiation therapy). * Of note, these are broad treatment principles, and there could be exceptions. Ultimately, management of breast cancer needs to be individual ‑ ized. HER2 denotes human epidermal growth factor receptor 2, and HR hormone receptor. † If chemotherapy is deemed absolutely necessary during the Covid ‑ 19 pandemic, it is important to consider alterations to chemotherapy regi ‑ mens, including minimizing glucocorticoid use, to decrease the extent of myelosuppression. Once ‑ weekly paclitaxel could be substituted for paclitaxel given every 2 weeks, with the trade ‑ off of the need for a greater number of visits. Alternatively, docetaxel given every 3 weeks can be used, with growth factor support. For HER2 ‑ positive tumors with homogeneous HER2 expression, trastuzumab emtansine (with or with ‑ out pertuzumab) could be considered instead of chemotherapy, particularly for smaller tumors. For stage I triple ‑ negative breast cancer, docetaxel plus cyclophosphamide may be considered, although for patients for whom chemotherapy is not otherwise recommended, su r ‑ gery should remain a high priority. The New England Journal of Medicine Downloaded from nejm.org by Victor Santos on July 1, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. n engl j med nejm.org 5 Case Records of the Massachusetts General Hospital py plus endocrine therapy were similar, although a subgroup analysis suggested some benefit with the addition of chemotherapy among women who were 50 years of age or younger and had lower recurrence scores. 19 If we assume that this patient’s pathological results are consistent with the clinical stage T2N0, grade 2 tumor, performing a genomic as - say is recommended, given that she has certain features that support the use of chemotherapy (e.g., large tumor size) and other features that do not support the use of chemotherapy (e.g., strongly HR-positive tumor). If her recurrence score indicates a chemotherapy benefit, a regi - men such as docetaxel and cyclophosphamide would be a reasonable choice. 20,21 Options for Radiation Therapy Dr. Rachel B. Jimenez: Before the Covid-19 pandemic, radiation therapy would typically be considered after lumpectomy to reduce the risk of a recur - rence in the same breast and to increase sur - vival. 22 Treatment with radiation usually begins 4 to 8 weeks after surgery unless chemotherapy Figure 3. Multidisciplinary Approach for Management of Early Breast Cancer during the Covid-19 Pandemic. Ideally, the multidisciplinary team would include a surgical oncologist, a radiation oncologist, a medical oncologist, a genetics expert (if needed), a social worker (if needed), and a person with expertise in symptom management, palliative medicine, or both (if needed). If a patient does not undergo upfront surgery, the chemotherapy regimen that would have been selected for adjuvant therapy can be administered as neoadjuvant therapy to allow for de ‑ ferred surgery. Multidisciplinary team discussion Diagnosis of early breast cancer Ideal candidate for neoadjuvant therapy Proceed with neoadjuvant therapy Ideal candidate for upfront surgery Upfront surgery feasible Proceed with surgery Determine whether candidate for adjuvant therapy Yes Initiate additional therapy on basis of baseline risk and surgical pathological results No Designate surgery as high priority No No Yes Yes Complete neoadjuvant therapy Monitor patient closely Concern for disease progression (at any time) The New England Journal of Medicine Downloaded from nejm.org by Victor Santos on July 1, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. 6 n engl j med nejm.org The new england journal o f medicine is given, in which case radiation therapy starts once chemotherapy is complete, since delaying chemotherapy may reduce its effectiveness. 23 In the United States, radiation treatment has histori - cally been administered daily to the entire breast over the course of approximately 4.5 to 5 weeks, often followed by a 1-to-1.5-week radiation “boost” focused on the area within a few centi - meters of the lumpectomy cavity. However, ran - domized trials have shown that the efficacy and safety of “hypofractionated” regimens lasting 3 to 4 weeks are similar to those of “conventional” fractionation, and therefore, such regimens are preferred over conventional fractionation for most patients. 24 Accelerated partial breast irradiation, which is used to treat only the area immediately around the lumpectomy cavity over the course of 1 to 2 weeks, is an option for select patients. 25-27 M a nagemen t of Br e a s t C a ncer during the Covid-19 Pandemic Dr. Specht: On March 15, 2020, the Massachusetts Department of Public Health issued an order to suspend nonessential elective invasive procedures to protect patients and health care workers and to conserve hospital resources during the Covid-19 pandemic. With this mandate, the multidisci - plinary treatment of this patient with newly diag - nosed breast cancer changed. The risks associated with surgery during the pandemic — including patient and staff exposure to SARS-CoV-2 and the need for personal protective equipment, ven - tilators, and medical staff who could otherwise be deployed to care for patients with Covid-19 — were weighed against the risk of tumor pro - gression while the patient was receiving sys - temic therapy. Alternative therapeutic options were discussed in the multidisciplinary clinic. Approaches to Radiation Therapy Dr. Jimenez: During the Covid-19 pandemic, a few treatment options can be considered regarding the administration of radiation therapy after sur - gery. First, the initiation of radiation therapy after breast-conserving surgery can be delayed in order to limit a patient’s exposure to health care facilities. Several retrospective studies showed that, among patients who were not receiving chemotherapy, the efficacy of radiation therapy was not affected by delaying the start of radia - tion up to 20 weeks after breast-conserving surgery. 28-30 Second, radiation therapy courses can be shortened with the use of hypofraction - ated regimens or accelerated partial-breast irra - diation for certain patients and by omitting a boost in some patients. 24,27,31 Administering the radiation boost simultaneously with the delivery of whole-breast radiation can also shorten the duration of radiation therapy, although results of randomized trials comparing such an approach with sequential boosts are not yet available. 32 So- called “ultrahypofractionated” regimens, in which the entire breast is treated once weekly for 5 weeks or daily over the course of 5 consecutive days, have shown acceptable short-term tumor control and rates of toxic effects, although the long- term efficacy and safety of these regimens are incompletely established; therefore, such a reg - imen should be used selectively, even during the Covid-19 pandemic. 33-36 Options for Neoadjuvant Endocrine Therapy in Lieu of Surgery Dr. Spring: In lieu of upfront surgery, an alterna - tive treatment option for this patient would be preoperative (neoadjuvant) therapy. 12,37 Neoadju - vant endocrine therapy has been shown to im - prove surgical outcomes by increasing rates of eligibility to undergo breast-conserving therapy and by increasing response rates. 38-40 Such ther - apy would be an option for this patient even in the pre–Covid-19 era, although it is vastly under - used in the United States. 41 It is well established that aromatase inhibi - tors are more effective than tamoxifen when used as neoadjuvant therapy in postmenopausal wom - en. 40,42-46 Initiation of treatment with an aroma - tase inhibitor before lumpectomy could lead to a partial or complete response, thereby increasing the likelihood of negative surgical margins and an improved cosmetic outcome. In one study, 69.8% of the patients had a partial or complete response after receiving an aromatase inhibitor for 3 months. 47 The risk of disease progression while a patient is receiving neoadjuvant endo - crine therapy is low. Furthermore, during the period when neoadjuvant therapy is adminis - tered, results from genetic testing would typi - cally become available, allowing the patient to make a more informed surgical decision regard - ing breast-conserving therapy or mastectomy. This approach also allows identification of endocrine-sensitive disease, thereby enabling some patients to avoid chemotherapy. 37,48 A small number of randomized clinical trials have shown The New England Journal of Medicine Downloaded from nejm.org by Victor Santos on July 1, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. n engl j med nejm.org 7 Case Records of the Massachusetts General Hospital that the response rates and rates of breast-con - serving therapy associated with neoadjuvant en - docrine therapy are similar to those associated with neoadjuvant chemotherapy in the appropri - ate patient population, while neoadjuvant endo - crine therapy confers fewer adverse effects. 38,39,49 The duration of neoadjuvant endocrine therapy is typically 3 to 6 months, although treatment can be extended if the tumor continues to respond; response rates are generally higher when the duration of treatment is longer. 50 One potential concern associated with neo - adjuvant endocrine therapy is the risk of disease progression. Therefore, timely follow-up exami - nation and imaging, if indicated, are important to monitor for progression. Furthermore, it is reasonable to perform a genomic analysis of the diagnostic core-needle biopsy specimen to as - sess whether neoadjuvant chemotherapy should be considered instead of neoadjuvant endocrine therapy when the decision is not clear. Although the validation of genomic assays has occurred mostly for adjuvant treatment, emerging clinical response data from studies evaluating the use of neoadjuvant therapy have become available. In the TransNEOS study, among patients who re - ceived neoadjuvant letrozole, the incidence of disease progression was low if the score on the 21-gene recurrence-score assay was below 31 (<1% among patients with a score of <18 and 4% among those with a score of 18 to 30); in con - trast, the incidence of progression was consider - ably higher among patients with a score of 31 or higher (17%). 51 If this patient’s recurrence score is found to be 31 or higher, a multidisciplinary discussion and consideration of resources would be needed to determine whether the patient should proceed to surgery or begin neoadjuvant chemotherapy. The clinical scenario is more complicated among premenopausal women, given the paucity of data with neoadjuvant endocrine therapy; most phase 3 randomized trials evaluating this treat - ment have focused on postmenopausal women. Although the randomized phase 2 GEICAM/ 2006-03 study showed a significant benefit of neoadjuvant chemotherapy over neoadjuvant en - docrine therapy among premenopausal women, with higher response rates seen among those who had a high Ki-67 proliferation index (a marker of cellular proliferation), the use of neoadjuvant endocrine therapy remains a valid approach in the appropriate clinical situation. 12,37,38 With re - gard to choice of endocrine therapy, the STAGE study showed that neoadjuvant treatment with an aromatase inhibitor plus a luteinizing hor - mone–releasing hormone (LHRH) agonist result - ed in significantly greater response rates than an LHRH agonist plus tamoxifen. 45 However, the length of time it takes the combination of an aromatase inhibitor and an LHRH agonist to suppress estrogen — with maximal suppression typically achieved by week 4 — is a potential concern. 45 During the Covid-19 pandemic, the ad - ministration of an LHRH agonist every 3 months is preferred over a monthly dose to minimize clinic visits. As noted previously, performing a genomic analysis of the core-needle biopsy spec - imen is a reasonable approach to determine whether chemotherapy would be appropriate. Al - though the threshold for recommending chemo - therapy is lower for women 50 years or age or younger, on the basis of the results of the TAILORx study, 19 it is important to balance the potential benefit of chemotherapy with the risk of immu - nosuppression during the Covid-19 pandemic; moreover, the potential role of suppression of ovarian function in lieu of chemotherapy among patients who have a lower clinical risk should also be carefully considered. 52 With regard to this patient, the core-needle biopsy specimen was sent for genomic analysis, which revealed an intermediate recurrence score of 24 on the 21-gene assay. A lter nati v e Scena r ios dur ing the Covid-19 Pandemic Dr. Beverly Moy: Although this patient has clinical stage T2N0, HR-positive, HER2-negative breast cancer, we also want to consider appropriate treatment strategies for women who present with other subtypes of breast cancer during the pandemic. Patients with HER2-Amplified Breast Cancer A widely accepted evidence-based treatment ap - proach used in patients with early HER2-positive breast cancer is surgery, followed by adjuvant therapy, for patients with clinical stage T1N0 disease and neoadjuvant systemic therapy, fol - lowed by surgery, for patients with clinical stage T2–4N0 or node-positive disease. 53,54 On the basis of this approach, the preferred initial treatment for a patient with clinical stage T2N0 HER2- positive breast cancer — even in the absence of The New England Journal of Medicine Downloaded from nejm.org by Victor Santos on July 1, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. 8 n engl j med nejm.org The new england journal o f medicine the Covid-19 pandemic — would be neoadjuvant therapy. This approach is based in part on the KATHERINE trial, which showed improved out - comes with the use of adjuvant trastuzumab emtansine (T-DM1) among women with early HER2-positive breast cancer who had had resid - ual invasive disease after receiving multiagent, HER2-targeted neoadjuvant therapy. 54 However, the Covid-19 pandemic has led oncologists to more carefully weigh the risks and the benefits of standard neoadjuvant HER2-targeted regimens. Commonly used regimens that have been evaluated extensively in clinical trials include doxorubicin and cyclophosphamide, followed by paclitaxel, trastuzumab, and pertuzumab, as well as combination therapy with docetaxel, carbo - platin, trastuzumab, and pertuzumab. 55,56 Although these evidence-based regimens are extremely efficacious, they are also associated with a high degree of immunosuppression, and their use could lead to further consequences if a patient be - comes infected with SARS-CoV-2. The KRISTINE trial evaluated the effects of replacing standard neoadjuvant HER2-targeted regimens with a less immunosuppressive regimen, T-DM1 plus per tuz u - mab. 57 In that trial, despite being associated with fewer toxic effects, neoadjuvant treatment with T-DM1 plus pertuzumab led to a lower pathological complete response rate than combi - nation therapy with docetaxel, carboplatin, trastuzumab, and pertuzumab (44.4% vs. 55.7%), possibly because a strictly HER2-targeted ther - apy approach may be less active among patients whose cancer has heterogeneous HER2 expres - sion. Another alternative neoadjuvant regimen is paclitaxel administered with trastuzumab and pertuzumab, which will be more carefully studied in the upcoming COMPASS trial (ClinicalTrials.gov number, NCT04266249). The downside of treat - ment with paclitaxel, trastuzumab, and pertuzu - mab is that the weekly dose of paclitaxel re - quires frequent trips to a clinic. Adjustment of the chemotherapy regimen, whereby paclitaxel or docetaxel could be administered every 3 weeks, could be performed, but the use of granulocyte colony-stimulating factors to reduce immuno - suppression during the pandemic should be considered. If a patient has a small clinical stage T1N0 HER2-positive tumor, the surgical restrictions resulting from the Covid-19 pandemic could prevent a standard upfront surgical approach. Therefore, neoadjuvant systemic therapy is need - ed, but there is no clear standard regimen. In the absence of clear pathological confirmation of lymph-node status, it may not be advisable to eliminate the use of pertuzumab, since it is as - sociated with modest benefit regarding disease- free survival in early HER2-positive breast cancer. 58 Therefore, reasonable neoadjuvant regimens in this context include paclitaxel, trastuzumab, and pertuzumab or T-DM1 plus pertuzumab. Patients with Triple-Negative Breast Cancer Dr. Steven J. Isakoff: Chemotherapy remains the cornerstone of systemic treatment for early ER- negative, PR-negative, HER2-negative (triple-neg - ative) breast cancer. For this patient with clinical stage T2N0 cancer, the standard approach for triple-negative breast cancer before the Covid-19 pandemic would have involved neoadjuvant che - motherapy with deferred surgery, and this remains the preferred approach during the pandemic. In addition to facilitating successful surgical resec - tion, the neoadjuvant approach allows for the response to neoadjuvant therapy to inform adju - vant therapy decisions; in the Capecitabine for Re - sidual Cancer as Adjuvant Therapy (CREATE-X) trial, treatment with adjuvant capecitabine showed a survival benefit among patients with HER2- negative breast cancer who had had residual disease after receiving anthracycline-based neo - adjuvant therapy. 59 The neoadjuvant regimens used for triple-negative breast cancer tumors that are larger than 2 cm in diameter or that are node-positive typically include an anthracycline and taxane. 12 The addition of neoadjuvant carbo - platin remains controversial; although patho - logical complete response rates are higher with the addition of carboplatin, 60,61 the effect on long- term outcomes remains uncertain, and, espe - cially during the Covid-19 pandemic, the added risks of hematologic toxic effects and immuno - suppression must be carefully considered. Among patients with triple-negative breast cancer tumors that measure 2 cm or less in di - ameter and are node-negative, administration of adjuvant chemotherapy is standard practice for patients with tumors larger than 1 cm in diam - eter (T1c) and is often considered for patients with tumors larger than 0.5 cm in diameter (T1b). 12 However, if access to surgery is limited because of the Covid-19 pandemic, the chemo - therapy regimen that would have been selected for adjuvant therapy can be administered as neo - adjuvant therapy to allow for deferred surgery. The New England Journal of Medicine Downloaded from nejm.org by Victor Santos on July 1, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. n engl j med nejm.org 9 Case Records of the Massachusetts General Hospital For example, docetaxel and cyclophosphamide, a regimen commonly used for adjuvant therapy, 21 may be administered as neoadjuvant therapy. 62 Surgery should remain a high priority for pa - tients whose triple-negative breast cancer tumors are small and for whom chemotherapy is not otherwise recommended 3 ; alternative systemic approaches are not suitable for smaller tumors, and the biologic characteristics of triple-negative breast cancer arouse concern that a sustained delay in surgery could result in tumor growth and upstaging, which in turn may increase the risk of recurrence. Patients Who Have Completed Neoadjuvant Therapy and Need Surgery Dr. Isakoff: Patients completing neoadjuvant che - motherapy regimens during the Covid-19 pan - demic who are unable to proceed to surgery because of limitations in hospital resources re - quire special attention to ensure that long-term outcomes are not compromised. As a general principle, surgery for patients who have progres - sion of disease during neoadjuvant therapy or who have no alternative systemic therapy options is given high priority. 3 Patients with HR-positive breast cancer who are receiving neoadjuvant en - docrine therapy without clinical progression may safely continue endocrine therapy for 6 months or more, with the timing of surgery depending largely on factors relating to hospital resources. For patients with HER2-positive disease, several options are available, depending on the response to neoadjuvant therapy. For patients who have a clinical complete response or a substantial par - tial response, continuation of trastuzumab and pertuzumab as maintenance treatment may be reasonable. In addition, taxane-based HER2- targeted therapy may be safely continued if not limited by the development of adverse effects. 63 For patients with HER2-positive disease who have minimal clinical response or no response, surgery is preferred, but such patients may tran - sition to neoadjuvant treatment with T-DM1 un - til surgery is feasible, with plans to continue adjuvant therapy. 54 It is recommended that sur - gery for patients who have triple-negative breast cancer and are completing neoadjuvant therapy be given high priority. 3 If surgery is not feasible within a reasonable time frame after completion of a standard regimen of neoadjuvant therapy, patients may receive additional cycles of non - anthracycline chemotherapy, such as weekly pa - clitaxel, capecitabine, or other agents, to provide a bridge to surgery; however, surgery should be completed as soon as feasible. Communic ation w i th Patien t s during the Covid-19 Pandemic Dr. Jennifer A. Shin: During the Covid-19 pandemic, providers are faced with the challenge of com - municating with patients about their cancer di - agnosis and treatment plan, while also address - ing concerns about Covid-19 and how it might affect cancer care. An additional challenge is that these conversations may be occurring virtu - ally, rather than in person. Patients may express feeling overwhelmed by a breast cancer diagno - sis and the associated therapies. In the Covid-19 era, patients may have additional anxiety and fear about coming to the hospital or about the possibility that administration of cancer thera - pies may increase their risk of Covid-19 and death. 64,65 Patients may also be concerned about a treatment plan that deviates from routine stan - dard of care and whether this alternative ap - proach could affect their clinical outcome. Communication is at the core of the medical profession, and effective and empathic commu - nication can have a positive effect on a patient’s quality of life, satisfaction with care, and medi - cal outcomes. 66-68 During a clinical visit, identi - fying and addressing concerns and emotions are a key first step before proceeding to the other parts of the visit. 68,69 It is difficult for a patient to absorb medical information if the provider does not acknowledge any worry, anxiety, and distress about the diagnosis and the pandemic. At the start of the visit, checking in with the patient is important. This patient may express worry about the delay in her breast surgery and may ask whether this might affect her cancer outcome. Follow-up Dr. Bardia: After discussing the care of this pa - tient during a virtual multidisciplinary tumor board conference, we determined that upfront surgery was not an option because of Covid-19 restrictions; consequently, neoadjuvant endocrine therapy with an aromatase inhibitor was initi - ated. The patient is currently doing well and has a 2-month follow-up visit scheduled with the multidisciplinary team. The New England Journal of Medicine Downloaded from nejm.org by Victor Santos on July 1, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. 10 n engl j med nejm.org The new england journal o f medicine Final Diagnosis Invasive ductal carcinoma of the left breast, clinical prognostic stage IB (T2N0), estrogen receptor–positive, progesterone receptor–positive, human epidermal growth factor receptor 2–nega - tive, grade 2, with an intermediate recurrence score on the 21-gene assay. 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Rai A, Han X, Zheng Z, Yabroff KR, Jemal A. Determinants and outcomes of satisfaction with healthcare provider communication among cancer survivors. J Natl Compr Canc Netw 2018; 16: 975-84. 68. Back A, Tulsky JA, Arnold RM. Com - munication skills in the age of COVID-19. Ann Intern Med 2020; 172: 759-60. 69. Back AL, Arnold RM, Baile WF, Tul - sky JA, Fryer-Edwards K. Approaching dif - ficult communication tasks in oncology. CA Cancer J Clin 2005; 55: 164-77. Copyright © 2020 Massachusetts Medical Society. The New England Journal of Medicine Downloaded from nejm.org by Victor Santos on July 1, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved.