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Update: Breast Surgery and Reconstruction During COVID-19
Julie Sprunt, M.D., FACS, and Elisabeth Potter, M.D.
April 29, 2020

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Dr. Julie Sprunt is a board-certified Fellow of the American Academy of Surgeons who specializes in breast surgery, treating all breast conditions. After receiving her medical degree from the University of Texas Health Science Center, she did her residency in general surgery at the University of Texas at Austin and completed a breast surgical oncology fellowship at the University of Southern California.

Dr. Elisabeth Potter is a board-certified plastic surgeon who received her medical degree from Emory University. She completed her plastic surgery residency at the University of Texas Southwestern Medical Center and her reconstructive plastic surgery and microsurgery fellowship at MD Anderson. Dr. Potter specializes in autologous breast reconstruction and has performed more than 750 DIEP flap surgeries.

Drs. Potter and Sprunt work as a team to treat breast cancer and then reconstruct a woman’s breast or breasts.

On April 21, 2020, the American Society of Plastic Surgeons released guidelines on how breast reconstruction surgery can begin again. The American Society of Breast Surgeons also issued updated guidelines on treating people with breast cancer during the pandemic.

Listen to the podcast to hear Drs. Potter and Sprunt explain:

  • why resuming both breast cancer surgery and breast reconstruction surgery will depend on where a woman lives
  • how the surgery process has changed as a result of COVID-19
  • how postoperative procedures have changed as a result of COVID-19

Running time: 27:50

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Show Full Transcript

Jamie DePolo: Hello. As always, thanks for listening. Today, we're extremely fortunate to have two excellent surgeons returning as guests, Dr. Elisabeth Potter and Dr. Julie Sprunt. Dr. Potter is a board-certified plastic surgeon who received her medical degree from Emory University. She completed her plastic surgery residency at the University of Texas Southwestern Medical Center and her reconstructive plastic surgery and microsurgery fellowship at MD Anderson. Dr. Potter specializes in autologous breast reconstruction and has performed more than 750 DIEP flap surgeries.

Dr. Sprunt is a board-certified Fellow at the American Academy of Surgeons who specializes in breast surgery treating all breast conditions. After receiving her medical degree from the University of Texas Health Science Center, she did her residency in general surgery at the University of Texas at Austin and completed a breast surgical oncology fellowship at the University of Southern California. Drs. Potter and Sprunt work as a team to treat breast cancer and then reconstruct a woman's breast or breasts.

Today, they're going to update us on breast surgery and breast reconstruction guidelines in this time of COVID-19, as certain states have started to loosen quarantine restrictions. Dr. Potter, Dr. Sprunt, welcome to the podcast.

Dr. Julie Sprunt: Thanks so much for having us.

Dr. Elisabeth Potter: It's great to be here.

Jamie DePolo: So, Dr. Potter, I want to start with you, because I know the American Society of Plastic Surgeons have released a new statement on what surgeons should consider before resuming reconstruction surgeries. So, could you talk about those a little bit, please?

Dr. Elisabeth Potter: Absolutely. I'm excited to say that the American Society of Plastic Surgeons released a really thoughtful set of considerations for surgeons as we begin operating in this time after COVID has become part of our new reality. Basically, the take-home point from that statement is that decisions really need to be made on a local and regional level.

I think the statement acknowledges that different parts of our country are experiencing this crisis in different times and to varying degrees. I think that that is going to be true going forward, and this statement allows for us, as physicians, to make good medical decisions for our patients if our local/regional situation is safe to proceed with important surgeries such as breast cancer surgery and breast reconstruction.

The statement goes into great detail regarding the decision-making, but basically it boils down to: talk to your doctor, and if your situation is safe, locoregionally, then there are ways to proceed safely.

Jamie DePolo: Okay, and Dr. Potter, I want to stay with you, because I'm assuming this is really going to depend a lot on where a person lives. So, if you're in New York City right now, it's probably unlikely you're going to get surgery, say, this week. But if you live in another place — like, I know you told me before we started the podcast that you had done surgery today. So, if someone is in the Austin area, they may be having surgery this week. Could you talk a little bit about that?

Dr. Elisabeth Potter: Absolutely. Depending on the area of the country that you live in, surgery may not be safe for you yet. And I know that your surgeons and your hospitals are working around the clock to make sure that as soon as it is safe that you can proceed. But it's important to recognize that various characteristics of this pandemic are going to affect who can have surgery at what time.

So, for instance, what is the number of cases in your community? Is that rising or falling? Has the surge — we've all heard that term — has it reached its peak? And does your community have all of the resources, staffing, personal protective equipment [PPE], beds, all of these things available to treat folks who are affected by COVID? You know, our hospitals are really complex systems, and they can work with us to figure out exactly what they need to plan and think ahead for COVID in your community. And once they have set aside those resources and made assurances that that is the case, then there are ways to plan to move forward with other surgeries, even with elective surgeries.

Jamie DePolo: Okay. Dr. Sprunt, I want to turn to you because the American Society of Breast Surgeons also issued updated guidelines on treating people with breast cancer during the pandemic. So, could you talk about those and tell us what that means for patients? And again, I'll ask this now, up front, too — I'm assuming that it will depend on where a person lives, as well?

Dr. Julie Sprunt: That's it, and that really is the crux of the updated guidelines. It's become apparent around the country that certain cities are experiencing COVID very differently and that utilizes resources, locally, in different ways. So, the American Society of Breast Surgeons, in their most updated guidelines, really emphasize that these decisions and guidelines they set forth are based on your local resources. And so certainly, if you are practicing or living in a city that has adequate resources, the goal of us, as breast surgeons, is to continue to treat breast cancer using the standard of care.

If you are in a position where the standard of care may not be possible because you can't get safely to the operating room, fortunately the guidelines set forth by the American Society of Breast Surgeons allow for safe treatment options that don't necessarily involve going to the operating room first. So, a good example of that would be a postmenopausal woman with a strongly hormone-receptor[-positive] breast cancer. Those women could be put on an anti-hormone pill until availability, or the resources, allow for that patient to have surgery. Fortunately, that is a treatment strategy that has been utilized in other countries for some time, and so we have good data showing that that is a safe option.

What has given me comfort with all of the guidelines that are out there is that when I read through those guidelines, I know that those are safe treatment strategies in patients. It may be different than what we did before COVID, but it is a safe treatment strategy based on some really good data. And so really, the updated guidelines are allowing us, as breast surgeons, to assess our local resources and proceed on with standard-of-care treatment if we are able. If we are unable, then we can look to these guidelines to safely manage our patients in alternative ways.

Jamie DePolo: Okay. Thank you. And Dr. Sprunt, I am going to stay with you. Since you both did surgery today, I'm curious if you could talk a little bit about any extra precautions, if those were taken, or how was it? Because I have a feeling that's going to be a question on the minds of a lot of women who may be going in for surgery. You know, what's going to be different? Like, what can I expect to be different, if anything? I don't know. So, I'll start with you, Dr. Sprunt, and then I'll ask Dr. Potter the same question.

Dr. Julie Sprunt: So, there are differences. I am ensuring that almost all of my patients are getting preoperative COVID testing. Right now in Austin, we have, fortunately, adequate amount of PPE, and so far our prediction of that utilization is manageable in a way that we can proceed on with surgeries. Having that issue addressed has allowed me to go back to the operating room, but I still have concerns about the safety of my patients and the safety of my operative team. And so, doing preoperative COVID testing helps me understand and ensure that my patient is not an asymptomatic carrier and also helps me ensure that the operative team, who is in the operating room helping me take care of patients, has as low of a possible risk of exposure to COVID as I can get with a negative preoperative testing.

So, most of my patients are either getting testing the day before by doing drive-through testing, or the hospital is bringing them into a separate area, getting testing, and as long as those results are negative, then they can come into the preoperative area. Certainly, we all understand that COVID is not going away, and so what we are all trying to do is adapt to the new normal so that we can limit exposures in the hospital and to healthcare workers. That is what will best enable us to continue to take care of women with breast cancer.

Jamie DePolo: Okay. Thank you. And Dr. Potter, from the reconstruction standpoint, I know there could be drains. There's sutures. There's risk of infection. So, are you advising people, postoperatively, to do anything differently?

Dr. Elisabeth Potter: Sure. That's a great question. I think that, as Dr. Sprunt alluded to, everything's kind of changed, and that's not necessarily a bad thing. But my entire preoperative, intraoperative, postoperative protocol has adjusted slightly, and that's just to keep all of us safe and to help avoid complications because of COVID.

So, as you brought up, issues like drains — you know, my patients have learned to remove drains at home on video conferences with me and my staff. It's been amazing. We also still do drain removals in person, but for some folks, they really want to minimize that in-person contact, and that's a great way to do it, if they're comfortable doing that.

Additionally, the way that we have office visits has changed. We used to have a busy waiting room with lots of folks chatting and drinking a coffee and reading a magazine, and that is no longer happening. We have phone calls, and we say, “Come on up to our office.” You're met at the door, screened, and taken to your room. There are no magazines being passed around from patient to patient, and there's no waiting room social hour, right?

So, things have been adjusted, and it's a new normal, but it's going to be a good way to move forward, safely. And I think it's so important for our patients, for their families, for our country, to move forward, and we just have to rise to the occasion and do it the right way.

I think, speaking of testing in particular, that's a question that so many patients have posed to me recently, and I think that that's worth just a little bit of discussion.

There are two types of testing. There's PCR testing, and then there are antibody tests. Currently, the test that we do before operating is the PCR test. That is the only test that is approved, currently, for a diagnostic test. That means it's the only test that can show me if you have or don't have COVID.

In the future, the antibody tests are going to be a really important part of living with COVID and developing strategies in our community, but currently, today, on April 27, that is not the case. So, antibody tests are great for helping our public health officials determine the prevalence of a disease in the community and determine how the disease is behaving, but antibody tests are not yet ready for prime time in terms of preoperative management. So, it's the PCR test that we are performing.

Jamie DePolo: Okay. Thank you. And Dr. Potter, I'm curious, too, because somebody has surgery, recovers however long they're in the hospital, and then goes home, and then may come back to you for follow-up. Are you requiring any patients to have testing, post surgery, to keep tabs on that?

Dr. Elisabeth Potter: That's a great question. So, currently, our regimen is that we are doing symptomatic screening of patients before we see them in clinic, and we're educating our patients about just the general signs and symptoms of an infection with COVID, which include cough, shortness of breath, body aches, fever. There are some other ones — loss of smell, etc. — but no. We are not planning on doing repeated COVID tests. And I think I can best explain that by saying the COVID test that we're doing now is really to protect patients in the perioperative timeframe and to protect the team, as Dr. Sprunt alluded to. So, that team of [doctors], especially our anesthesia colleagues, who are right there with the patient and most at risk of contracting COVID if that patient has the virus.

So, my interactions with a patient, postoperatively in clinic — removing a drain or taking care of an incision — those are all things that I can do, safely, with a mask on. So, both my patient and I will be wearing masks, and I will wear gloves and do all of the hand washing and alcohol-based sanitization that we all do, but it is very safe to proceed with those things. So, no. I will not be requiring or performing postoperative tests on my patients unless they develop symptoms.

Jamie DePolo: Okay. Okay. Thank you. And really, the only reason I ask is because as more information comes out, it seems a number of people were asymptomatic. So, we don't really know how many cases there are, in my mind, because there could be a lot of people walking around who never even knew they had it. So, that's why I was just curious about that.

Dr. Elisabeth Potter: That's a great point, and that is why, as Dr. Sprunt said, we're doing this test, because so many patients who would answer no to the questions — they don't have fever or chills or body aches — we would worry, if they were infected and didn't have symptoms, that they might suffer after surgery. So, I think that the test that we're performing is to prevent operating on an asymptomatic patient. But I will tell you that I think the new reality in healthcare is that I assume that any patient that I meet in clinic could have COVID. So, all of the safety mechanisms that we have in place are to keep us all safe.

Jamie DePolo: Okay. And Dr. Sprunt, I want to go back to you. So, it sounds like, from what you've both said, that this is going to kind of be the new normal for breast surgery for a while. If somebody's scheduled for surgery, they could automatically be asked to have a COVID PCR test before surgery is scheduled, and then the follow up would be much the same way that we just talked about. It's a lot of hand washing. Everyone wears a mask. Does that sound right?

Dr. Julie Sprunt: That is certainly what we are doing in Austin, and I think that is what a lot of big cities and hospitals are looking to do and planning to do. And I think that that is the best way that we can try to go back to as normal as we can get, or adjusting to the new normal. But certainly, as far as taking people to the operating room and making sure that our patients are going to be safe after surgery and that the team is going to be safe, then some sort of preoperative testing with a PCR test would be very useful.

Now, if and when antibody testing is ready for prime time — and, unfortunately, I think that that is going to take more time — that, then, will help us understand who is acutely infected with COVID, who may have recovered from COVID and has antibodies, who may have never been exposed to COVID. And then I think that really will help us lift a lot of the restrictions. But until then, the hospitals, our offices, we as doctors have to behave as though every patient we see may have COVID. And that does require more masks, more gloves, limiting patients' families and visitors, both in our office and in the hospital. And that, to me, is a lot to ask anybody with breast cancer, unfortunately, to not have people spend the night with them in the hospital. Or certainly Dr. Potter and I are trying to send people home the same day of surgery instead of having them spend the night so that they can have loved ones around and so that we minimize their exposure.

So, it does look really different right now, and I think it probably will for the next year or so. Fortunately, though, the care we will provide these women for their breast cancer is not going to be compromised by COVID. The experience is, unfortunately, going to be suboptimal, in my opinion, because we do have to limit the number of loved ones who are with you, and we do have to be wearing masks when we're having really difficult conversations. And that, to me, is the biggest change I see in my practice right now, and that's going to continue for the next year, is my best expectation.

Jamie DePolo: Okay. Thank you. And I'm assuming, too, that if a vaccine is developed, perhaps, then, that becomes a requirement for surgery, that you have to show that you've been vaccinated against this? Does that sound right, Dr. Sprunt?

Dr. Julie Sprunt: I think that would be very helpful. I mean, I think the vaccine, we would just need a lot more information as far as the effectiveness of the vaccine, and there would need to be a lot more information to go with that. But certainly, if the vaccine is shown to be effective, then yes. It would be very beneficial to vaccinate people prior to surgery.

Jamie DePolo: Okay. Thank you. And to wrap up, I'm going to ask you both the same question I asked you last time. So, I'll start with you, Dr. Potter. Right now, what are the two or three things you want people to know, people who have been diagnosed with breast cancer and are waiting for surgery? You know, obviously, in places like Austin, surgeries are going forward. So, what do you want them to know? How are things proceeding, and what should they be on the lookout for?

Dr. Elisabeth Potter: You know, I think I want women around the country to know that your treatment team, in your region, is planning, and they'll get there. So don't be nervous. Be patient. Give them a call and say, “I heard that surgeries are moving forward. What's our plan?” And then stick with your team, wait for it to be safe, and do your surgery there.

I think it's really important for women to know that all of the same options that we offered before COVID, for breast reconstruction, are still going to be offered now. Dr. Sprunt and I just did a surgery today that was one of the more advanced techniques in reconstruction where we did a DIEP flap, and that was safe to do today. We thought a lot about it, and we were able to do that safely. I just want women to be encouraged that there is a safe way to move forward, and your team is working on that.

I also think it's really important for women, as they're planning, to be their own best advocates. So I would encourage you to have open discussions with your team about how they're keeping you safe. I know that surgeons just like us around the country are taking lots of extra precautions and making lots of extra plans to keep our patients safe. And I think if you ask your treatment team what they're doing and they're able to share those things with you, that you'll feel even more comfortable and confident moving forward.

Jamie DePolo: Thank you. Dr. Sprunt, I want to ask you the same question, but I wondered if you could add in, what if a woman were scheduled for breast cancer surgery, say, a month ago, and it was recommended that, say, she have a large lumpectomy, as opposed to a bilateral mastectomy? So, how are you talking to your patients? What do you want people to know? Is it possible that that woman could have her bilateral mastectomy now, or does she need to wait a little bit longer and heal from the larger lumpectomy?

Dr. Julie Sprunt: I think that the first question that needs to be addressed, as far as that scenario goes, would be what's changed in 4 weeks? So, are there now enough resources to do bilateral mastectomies or not? And so, certainly, if you're in New York City, you're probably not getting bilateral mastectomies with reconstruction. Now, it may be that, as they are able to get better resources and have adequate PPE, that you are in an environment where you could move forward with bilateral mastectomies. And the timing of that, it really depends on what incisions they made and what your efforts are there. But as far as if you had a big lumpectomy and going back to do a mastectomy, the timing of that — I mean, there's not really a window of time that it needs to be done, sooner than later.

Certainly, we would look at pathology and see what we were dealing with. For example, if you had a lumpectomy and there were multiple involved margins, that's a higher priority to go back for a mastectomy than somebody who had negative margins. That being said, there still is a reasonable time frame that you could safely wait to go back and do a mastectomy in the setting of a large lumpectomy.

So, unfortunately, what I'm doing, what most breast surgeons are doing around the country, is we are keeping lists of all of our patients and essentially triaging those patients based on the American Society of Breast Surgeons' recommendations to say, who are the people that we need to get into the operating room sooner than later, and who are the people that we can safely delay?

And so, the American Society of Breast Surgeons gives a really thoughtful way to essentially score patients and think about adding those people back to your schedule as your local resources allow. And I think there are some times where we will try to actually delay a take-back mastectomy, for example. So, if you made an incision around the nipple and you really wanted to try to spare the nipple, you may give that 4 to 6 weeks for neovascularization to occur to be able to spare the nipple.

But for the most part, I think a lot of the decisions that we're making as far as getting back to the operating room are: assessing our local resources, making sure that we can safely operate on our patients, making sure that we can safely keep our operative team safe, and making sure that we have adequate beds and resources to continue to take care of every person in your community, those with COVID and those who don't have COVID. And I think the most important thing people need to keep in mind during this time is that we, as healthcare workers, are doing the best we can to make sure that we take care of our patients in the best way possible, and we are trying to follow standard of care if we at all possibly can.

If you are in a place where the standard of care isn't possible because of resources, then there are a lot of safe alternative options. And I think, to Dr. Potter's point, you really need to communicate with your treatment team to best understand the resources that are available to them to help take care of you and to best understand why certain things are being done the way they're being done. Because it is on a very case-by-case basis, and that's where, fortunately, all of our societies have helped provide structure for us to safely triage patients. And really, it depends on what your local resources are.

Right now, it's going to feel a lot different having surgery for breast cancer or seeing us in the office, because instead of being able to see my smiling face coming in and saying, “Hey, we actually caught this really early,” you're looking at a sterile mask. And you're not able to bring your loved ones into the office or into the hospital. And we all hope to be able to improve that as vaccines and antibody testing and public health is able to do their thing. But until we can, please know that we are smiling behind our mask, and it's just going to look a little different for this next 6 months to a year.

Jamie DePolo: Yes. Thank you. I will say, I know I was talking to another oncologist, and he said, “I really miss hugging my patients.” It's very hard, especially if you're somebody where that's your natural thing, that you're dealing with somebody, you've just maybe given them some bad news, and you want to give them a hug, and you can't. But it's very encouraging to hear that some surgeries are starting to go forward, depending on the area. So, I thank you both so much for joining us again.

Dr. Elisabeth Potter: Thank you for having us.

Dr. Julie Sprunt: Truly, thank you.

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