Version:1.1 Department: Symptomatic Breast Disease Clinics Update date: n/a Code: Br_COVID19_3 Revision date: Guidance development group: NCCP COVID-19 Breast Working Group

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COVID-19 Capacity Response Plan for Symptomatic Breast Disease (SBD) Clinics

This document relates to patients who do not have COVID-19 or are not suspected of having COVID-19. Current events surrounding the COVID-19 pandemic are challenging and all public health bodies are placing the safety of patients, staff and communities first in all decisions. This is an evolving situation. This advice is based on current information, it is additional to the advice of the NPHET, the HSE and the DoH, and will be updated as necessary. The NCCP acknowledges that each hospital is working under individual constraints, including staff and infrastructure, and as a result will implement this advice based on their own unique circumstances. The purpose of this advice is to maximise the safety of patients and make the best use of HSE resources, while protecting staff from infection. It will also enable services to match the capacity for cancer care to patient needs if services become limited due to the COVID-19 pandemic. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment.

1 NPHET, HSE and DoH advice Hospitals will operate under the overarching advice of the National Public Health Emergency Team (NPHET), the HSE and the DoH. Information is available at:

HSE HPSC - https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/

HSE Coronavirus (COVID-19) - https://www2.hse.ie/conditions/coronavirus/coronavirus.html

DoH Coronavirus (COVID-19) - https://www.gov.ie/en/campaigns/c36c85-covid-19-coronavirus/

Ireland’s National Action Plan in response to COVID-19 (Coronavirus) -https://www.gov.ie/en/campaigns/c36c85-covid-19-coronavirus/Purpose

The purose of this capacity response plan is to ensure that patients are appropriately prioritised in

response to the capacity level of the clinic, with those patients most likely to have cancer given the

highest priority.

2 Purpose The purpose of this capacity response plan is to ensure that patients are appropriately prioritised in

response to the capacity level of the Symptomatic Bresat Disease (SBD) Clinic during the COVID-19

pandemic, with those patients most likely to have cancer given the highest priority.

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3 General recommendations To reduce transmission between staff or between staff and patients consult the most up to date

information for health care professionals on the HPSC website and link with your local infection

prevention and control team.

For guidance on managing COVID-19 risk in the Symptomatic Breast Clinics, please refer to the

following documents: “NCCP advice for Medical Professionals on the management of patients

referred to the Symptomatic Breast Clinic in response to the current novel coronavirus (COVID-19)

pandemic” and “NCCP advice for Medical Professionals on minimising COVID19 risk in the

Symptomatic Breast Disease Clinics”.

4 Projected impact levels on the capacity of SBD Clinics For each of the clinical departments, the following are suggested COVID-19 impact levels as

measured against normal capacity to see patients. Factors that impact capacity include staffing

levels, infection prevention and control measures, and diagnostic capacity:

Level 1 80 –100% capacity

Level 2 <80% capacity

Level 3 <60% capacity

Level 4 <40% capacity

Level 5 <20% capacity

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5 Capacity response plan for the SBD Clinics The following tables indicate the capacity levels at which each patient group will be seen and/or the

clinic activity that will take place during the ongoing COVID-19 pandemic.

5.1 Breast clinic capacity response plan for new referrals by patient-presenting

symptoms

Patient presenting symptom: Capacity level:

Level 1 (80–100% capacity)

Level 2 (<80% capacity)

Level 3 (<60% capacity)

Level 4 (<40% capacity)

Level 5 (<20% capacity)

Breast abscess

Breast lump Suspicious for cancer

Suspicious axillary lump (Triage dependent on GP referral)

Peau d’orange

Skin dimpling

Unilateral bloody nipple discharge

Nipple eczema (refractory to treatment)

(Age: ≥ 50)

Asymmetric focal nodularity

Nipple retraction

Nipple eczema (refractory to treatment)

(Age: < 50)

Unilateral, spontaneous, serous nipple discharge

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5.2 Breast clinic capacity response plan for new and returning patients by SBD clinic

activity:

Purpose of patient visit: Capacity level:

Level 1 (80–100% capacity)

Level 2 (<80% capacity)

Level 3 (<60% capacity)

Level 4 (<40% capacity)

Level 5 (<20% capacity)

Results

visits

Benign biopsy (Virtual visit provided clinical examination has occurred)

Virtual Virtual Virtual Virtual Virtual

New cancer diagnosis

Peri-

operative

Dressings follow-up

Post-neoadjuvant chemo review prior to surgery

Post-operative results visits Virtual Virtual

Reconstruction planning/discussion

(Annual) review patients

Cancer review patients Virtual Virtual Virtual Virtual Virtual

Requested clinical reviews (patients with suspicious new symptom)

High risk lesions (Virtual only if not on a recall database. Recall database preferred option)

Virtual Virtual Virtual

Other review patients

Benign breast disease follow-up

Reconstruction/aesthetic

Implant associated issues

Family history patients

(Clinical) review patients: high risk gene-positive

Seen in clinic

Virtual

(Clinical) review patients: high risk gene-negative (or unknown)

Vitual

New patient referrals

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5.3 Breast imaging/radiology capacity response plan by radiology clinic activity:

Purpose of patient visit: Capacity level:

Level 1 (80 –100% capacity)

Level 2 (<80% capacity)

Level 3 (<60% capacity)

Level 4 (<40% capacity)

Level 5 (<20% capacity)

General mammo-graphy

Rapid access clinics or

patients with S4/5

clinical findings

(not necessarily same day as clinic)

S5 only

Radiology recall for additional views, second look, etc.

R4/5 only

Image-detected breast abnormality (If suspicious for cancer – MDT review)

Suspicious for

cancer

Suspicious for

cancer

Annual mammogram: Cancer follow-up

Image first (where offered) (non urgent referrals ≥35)

Mammogram for new patient with S3 clinical exam

Lumps only

High risk lesion annual mammogram

Radiology recall for short interval follow-up

GP direct access (incl. persistent mastalgia for patients ≥35)

One off mammogram booked for a new patient, S1/S2

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Purpose of patient visit: Capacity level:

Level 1 (80 –100% capacity)

Level 2 (<80% capacity)

Level 3 (<60% capacity)

Level 4 (<40% capacity)

Level 5 (<20% capacity)

Family

history

patients

Review patients: high risk gene-positive

Review patients: high risk gene-negative or unknown

New patient referrals

Review patients: moderate risk

Ultra-sound

TAC clinic

Wires for theatre list

Radiology recall for US R4/5 only

Stereotactic biopsies

US for patients ≥35 with an S3 exam

US for patients <35 with an S3 exam

Breast MRI follow-up

MRI

6 Guidance Development Group Dr Eve O’Toole, Guideline Lead, NCCP Mr Martin O’Sullivan, Consultant Surgeon, CUH Ms Juliette Buckley, Consultant Surgeon, UHL Ms Liz Connelly, Consultant Surgeon, SJH Dr Carmel Ann Daly, Consultant Radiologist, UHW Dr Deirdre Duke, Consultant Radiologist, Beaumont Hospital Dr Una Kennedy, GP Adviser, NCCP Dr Sorcha McNally, Consultant Radiologist, SVUH Dr Angela O’Brien, Consultant Radiologist, MMUH Ms Siún Walsh, Consultant Surgeon, MMUH Ms Maeve Cusack, Surgical Oncology Programme Manager, NCCP Dr Helena Gibbons, Senior Researcher, NCCP Dr Ozlem Aslan McDonnell, Data Analyst NCCP Dr Niamh Kilgallen, Senior Researcher, NCCP