Abstract
Background and Objectives:
The majority of patients undergoing mastectomy before the COVID-19 pandemic were admitted for 23-h observation to the hospital. Indications for observation included drain care education, pain control and observation for possible early surgical complications. This study compared the rates of outpatient mastectomy before, during, and after the COVID-19 pandemic and indirectly evaluated the safety of same-day discharge.
Methods:
We retrospectively analyzed patients undergoing mastectomy using Current Procedural Terminology code 19303.
Results:
A total of 357 patients were included: 113 were treated pre-COVID-19, 82 patients during COVID-19 and 162 post-COVID-19. The rate of outpatient mastectomies tripled during the pandemic from 17% to 51% (p < 0.001); after the pandemic remain high at 48%. The rate of bilateral mastectomies decreased during the pandemic to 30% from 48% prepandemic (p = 0.015). Pectoralis muscle block utilization increased during the COVID-19 period from 36% to 59% (p = 0.002). No difference in complication rates, including surgical site infections, hematomas, and readmissions, pre and during COVID.
Conclusions:
The rate of outpatient mastectomy increased during the COVID-19 pandemic. During this timeframe, perioperative complications did not increase, suggesting the safety of this practice.
After the pandemic, the rate of outpatient mastectomy continued to be significantly higher than pre-COVID.
Keywords: breast cancer, COVID-19, outpatient mastectomy, postmastectomy admission rate, same-day mastectomy
1 ∣. INTRODUCTION
Historically, patients undergoing mastectomy remained in the hospital with closed suction drainage until the amount of drainage had decreased sufficiently for them to be removed, even if it took 2 weeks or more.1,2 The cost analysis of prolonged admission, in combination with no significant change in complication rates, led to shortening the in patient stay to under a week3 and, eventually, led to a 23-h observation or 1-day hospitalization that has been the most common practice over the last 20 years.1
Outpatient mastectomy, with or without breast reconstruction, has been evaluated and shown to be safe in the past, although not widely accepted.4-8 There have been a large number of studies that have examined the safety of breast surgery with or without reconstruction during the COVID-19 pandemic, but none have specifically compared outpatient mastectomy rates during the pre-COVID-19 period and the COVID-19 pandemic including the period immediately after, when the operating rooms reopened to accommodate previous capacity.
The aim of our study was to analyze postmastectomy discharge timing, comparing the pre-COVID-19 and the COVID-19 periods, to determine if there was a practice pattern change. We hypothesized that during the COVID-19 pandemic, the same-day discharge rates would be higher than during the pre-COVID-19 period.
2 ∣. METHODS
After the informed consent waiver and HIPAA waiver were obtained, a retrospective chart review of patients of five breast surgeons within the Emory University Healthcare System was performed. All patients underwent mastectomy with or without reconstruction requiring at least one drain between September 1, 2019 and August 31, 2021. At our institution, various services including elective breast surgery were paused due to the COVID-19 pandemic on March 16, 2020. The pre-COVID-19 period was defined as September 1, 2019 to March 16, 2020 and the COVID-19 pandemic period in this was defined as March 17, 2020 to August 30, 2020.
We additionally collected data for the period immediately following the COVID-19 pandemic from August 31, 2020 to August 31, 2021.
All demographic, clinical, and outcomes data, including complications within three months from the original surgery, like hematoma and surgical site infection requiring and additional surgery, were collected via individual chart review, deidentified and evaluated.
2.1 ∣. Statistical analysis
SAS 9.4 (SAS Institute Inc.) and R-Studio 1.3 were utilized to analyze the data and to find associations between variables of interest and the study cohort. SAS macros were developed by Biostatistics and Shared Resource at Winship Cancer Institute.9 Descriptive statistics for each variable were reported. The COVID-19 and pre-COVID-19 groups were compared using χ2 tests or Fisher's exact tests, where appropriate. Observation status (outpatient vs. 23-h observation) was compared using χ2 tests or Fisher's exact tests. In addition, univariate logistic regression models were fit for presence of any complication within 3 months from the original surgery as a function of risk factors. Statistical significance was assessed at the 0.05 level.
3 ∣. RESULTS
A total of 357 patients were included in the study. 113 patients (32%) were treated pre-COVID-19 and 82 (23%) were treated during COVID-19 and 162 patients (45%) were treated in the post-COVID-19 period. Five breast surgeons attending were included in this study. All patients had at least one drain placed after surgery. Before the pandemic, the minority of patients undergoing mastectomy (17%) were discharged home on the same day. During the COVID-19 pandemic, 51% patients had a same-day discharge (p < 0.001) as shown in Figure 1.
FIGURE 1.
Outpatient mastectomy rates pre-COVID-19 and during COVID-19
After the COVID-19 pandemic, a significant number of patients, 77 (48%), continued to be discharge home the same day. Of the 85 patients admitted for 23 h observation, 50 (59%) had bilateral mastectomy. In the patient population treated as outpatient only 22 (29%) had bilateral mastectomy.
Patient characteristics and Univariate Association with COVID status are shown in Table 1. The vast majority of the patients in the cohort were female, 98%.
TABLE 1.
Patient characteristics and Univariate Association with COVID Time Status
| Covariate | Statistics | Level | COVID time status | During Covid N = 82 | p Valuea |
|---|---|---|---|---|---|
| Pre-Covid N = 113 | |||||
| Age (<40, 41–55, ≥55) | N (Raw %) | <40 | 16 (14.16) | 11 (13.41) | 0.290 |
| N (Raw %) | 41–55 | 43 (38.05) | 23 (28.05) | ||
| N (Raw %) | >55 | 54 (47.79) | 48 (58.54) | ||
| Race | N (Raw %) | Caucasian | 48 (42.48) | 32 (39.02) | 0.764 |
| N (Raw %) | African American | 41 (36.28) | 34 (41.46) | ||
| N (Raw %) | Other | 24 (21.24) | 16 (19.51) | ||
| Sex | N (Raw %) | Female | 111 (98.23) | 80 (97.56) | 1.000 |
| N (Raw %) | Male | 2 (1.77) | 2 (2.44) | ||
| Attending | N (Raw %) | 1 | 36 (31.86) | 28 (34.15) | 0.681 |
| N (Raw %) | 2 | 27 (23.89) | 20 (24.39) | ||
| N (Raw %) | 3 | 23 (20.35) | 19 (23.17) | ||
| N (Raw %) | 4 | 11 (9.73) | 9 (10.98) | ||
| N (Raw %) | 5 | 16 (14.16) | 6 (7.32) | ||
| Type of breast surgery | N (Raw %) | Unilateral mastectomy | 59 (52.21) | 57 (69.51) | 0.015 |
| N (Raw %) | Bilateral mastectomy | 54 (47.79) | 25 (30.49) | ||
| Axillary surgery | N (Raw %) | SNB only | 75 (66.37) | 50 (60.98) | 0.630 |
| N (Raw %) | ALND | 9 (7.96) | 7 (8.54) | ||
| N (Raw %) | SNB + ALND | 18 (15.93) | 12 (14.63) | ||
| N (Raw %) | No axillary surgery | 11 (9.73) | 13 (15.85) | ||
| Pre-op Diagnosis | N (Raw %) | IDC/ILC/DCIS | 106 (93.81) | 74 (90.24) | 0.357 |
| N (Raw %) | Genetic mutation | 6 (5.30) | 5 (6.10) | ||
| N (Raw%) | Other | 1(0.99) | 3 (3.66) | ||
| Discharge | N (Raw %) | Outpatient | 19 (16.81) | 42 (51.22) | <0.001 |
| N (Raw %) | 23 h observations | 94 (83.19) | 40 (48.78) | ||
| PEC Block | N (Raw %) | PEC given | 41 (36.28) | 48 (58.54) | 0.002 |
| N (Raw %) | No pec documented | 72 (63.72) | 34 (41.46) | ||
| Type of reconstruction | N (Raw %) | None | 43 (38.05) | 35 (42.68) | 0.110 |
| N (Raw %) | TE or direct implant | 67 (59.29) | 40 (48.78) | ||
| N (Raw %) | Autologous flap | 2 (1.76) | 1 (1.21) | ||
| N (Raw %) | Complex closure by plastic surgery | 1 (0.90) | 6 (7.33) |
Note: Bold values are statistical significance p < 0.05.
Abbreviations: ALND, Axillary Lymph node Dissection; DCIS, Ductal carcinoma in situ; IDC, Invasive Ductal Carcinoma; ILC, Invasive Lobular Carcinoma; PEC, Pectoralis; SNB, Sentinel Node Biopsy; TE, Tissue Expander.
The p Value is calculated by analysis of variance for numerical covariates; and χ2 test or Fisher's exact for categorical covariates, where appropriate.
Before the pandemic, the rate of unilateral mastectomy was lower (52% vs. 70%, p = 0.015). The rate of bilateral mastectomy decreased from 48% pre-COVID to 30% during COVID-19. The use of pectoralis block was lower prepandemic, 36%, in comparison to 59%, during the pandemic (p < 0.002).
The number of patients undergoing reconstruction and the type of breast reconstruction rates did not change with the pandemic.
All male patients were treated as outpatient. Patients with normal Body Mass Index less than 25 were more likely to be treated as outpatient. There were no differences in type of surgery and reconstruction between patients admitted for observation versus outpatient.
No difference in comorbidities and complications in patient treated as outpatient versus 23 h observations as summarized in Table 2.
TABLE 2.
Patient characteristics PRE and during COVID and univariate association with 23 h observation
| Covariate | Statistics | Level | Discharge | 23 h Observations N = 134 |
p Valuea |
|---|---|---|---|---|---|
| Outpatient N = 61 | |||||
| Age (<40, 41–55, ≥55) | N (Row %) | <40 | 11 (40.74) | 16 (59.26) | 0.347 |
| N (Row %) | 41–55 | 17 (25.76) | 49 (74.24) | ||
| N (Row %) | >55 | 33 (32.35) | 69 (67.65) | ||
| RACE | N (Row %) | Caucasian | 21 (26.25) | 59 (73.75) | 0.115 |
| N (Row %) | African American | 30 (40) | 45 (60) | ||
| N (Rw %) | Other | 10 (25) | 30 (75) | ||
| Sex | N (Row %) | Female | 57 (29.84) | 134 (70.16) | 0.009 |
| N (Row %) | Male | 4 (100) | 0 (0) | ||
| Pre-op Body Mass Index (BMI) | N (Row %) | <25 | 16 (22.22) | 56 (77.78) | 0.037 |
| N (Row %) | ≥25 | 45 (36.59) | 78 (63.41) | ||
| Attending | N (Row %) | 1 | 20 (31.25) | 44 (68.75) | <0.001 |
| N (Row %) | 2 | 4 (8.51) | 43 (91.49) | ||
| N (Row %) | 3 | 15 (35.71) | 27 (64.29) | ||
| N (Row %) | 4 | 17 (85) | 3 (15) | ||
| N (Row %) | 5 | 5 (22.73) | 17 (77.27) | ||
| Type of breast surgery | N (Row %) | Unilateral mastectomy | 42 (36.21) | 74 (63.79) | 0.072 |
| N (Row %) | Bilateral Mastectomy | 19 (24.05) | 60 (75.95) | ||
| Axillary surgery | N (Row %) | SNB | 40 (32) | 85 (68) | 0.854 |
| N (Row %) | ALND | 6 (37.5) | 10 (62.5) | ||
| N (Row %) | SNB + ALND | 9 (30) | 21 (70) | ||
| N (Row %) | No axillary surgery | 6 (25) | 18 (75) | ||
| Type of reconstruction | N (Row %) | None | 29 (37.18) | 49 (62.82) | 0.343 |
| N (Row %) | TE or direct implant | 29 (27.1) | 78 (72.9) | ||
| N (Row %) | Autologus flap | 3 (30) | 7 (70) | ||
| Comorbidities | |||||
| Diabetes | N (Row %) | Yes | 9 (31.03) | 20 (68.97) | 0.975 |
| N (Row %) | No | 52 (31.33) | 114 (68.67) | ||
| Hypertension | N (Row %) | Yes | 20 (32.79) | 41 (67.21) | 0.760 |
| N (Row %) | No | 41 (30.6) | 93 (69.4) | ||
| Cardiac history (CHF, A-fib) | N (Row %) | Yes | 4 (17.39) | 19 (82.61) | 0.126 |
| N (Row %) | No | 57 (33.14) | 115 (66.86) | ||
| Renal disease | N (Row %) | Yes | 3 (37.5) | 5 (62.5) | 0.707 |
| N (Row %) | No | 58 (31.02) | 129 (68.98) | ||
| Previous cancer surgery | N (Row %) | Yes | 6 (20.69) | 23 (79.31) | 0.182 |
| N (Row %) | No | 55 (33.13) | 111 (66.87) | ||
| Complications | |||||
| Superficial surgical site infection | N (Row %) | Yes | 4 (44.44) | 5 (55.56) | 0.465 |
| N (Row %) | No | 57 (30.65) | 129 (69.35) | ||
| Need PO antibiotics | N (Row %) | Yes | 3 (50) | 3 (50) | 0.379 |
| N (Row %) | No | 58 (30.69) | 131 (69.31) | ||
| Hematoma/persistent Seroma | N (Row %) | Yes | 3 (25) | 9 (75) | 0.757 |
| N (Row %) | No | 58 (31.69) | 125 (68.31) | ||
| Readmission within 30 days from surgery | N (Row %) | Yes | 1 (16.67) | 5 (83.33) | 0.667 |
| N (Row %) | No | 60 (31.75) | 129 (68.25) | ||
| Need additional breast surgery | N (Row %) | Yes | 2 (22.22) | 7 (77.78) | 0.723 |
| N (Row %) | No | 59 (31.72) | 127 (68.28) | ||
| Plastic surgery complications within 3 months from original surgery | N (Row %) | Yes | 6 (26.09) | 17 (73.91) | 0.250 |
| N (Row %) | No | 25 (26.88) | 68 (73.12) | ||
| Need plastic surgery within 3 months | N (Row %) | Yes | 6 (35.29) | 11 (64.71) | 0.178 |
| N (Row %) | No | 25 (25.25) | 74 (74.75) |
Note: Bold values are statistical significance p < 0.05.
Abbreviations: A fib, atrial fibrillation; ALND, axillary lymph node dissection; CHF, Cardiac Heart Failure; DCIS, Ductal carcinoma in situ; IDC, Invasive Ductal Carcinoma; ILC, Invasive Lobular Carcinoma; PEC, Pectoralis; SNB, Sentinel Node Biopsy; TE, Tissue Expander.
The p Value is calculated by analysis of variance for numerical covariates; and χ2 test or Fisher's exact for categorical covariates, where appropriate.
Overall, the complications rate defined as unplanned return to the operating room within 90 days for hematoma evacuation or severe surgical site infection or abscess, was 7%. No difference in complications were noted between the pre-COVID-19 period and during COVID-19. No difference in complications in patients treated as outpatient vs. 23-h observation.
Complications were higher, 13%, in the 127 patients undergoing reconstructions. Seventeen patients required additional plastic surgery operation within 3 months from the original surgery, mainly for debridement of flap necrosis and tissue expander removal.
Bilateral mastectomy was the only factor associated with increased the risk of complications within 3 months from the original surgery as shown in Figure 2.
FIGURE 2.
Odds ratio plot of complications based on patient characteristics
4 ∣. DISCUSSION
In the spring of 2020, the American Society of Breast Surgeons (ASBrS) and the Society of Surgical Oncology (SSO), laid out recommendations for breast cancer care to face the challenge of the COVID-19 pandemic10 The patients were triaged into high risk, moderate risk and low risk groups. Score risk assignments were developed for factors related to risk of delaying surgery. Mastectomy was recommended to be performed alone and limited to the affected breast. According the national guidelines, in our study we noticed an increase of unilateral mastectomy from 52% pre-COVID to 70% during COVID. If reconstruction were to be performed, immediate unilateral tissue expanders or implants were recommended.
Bilateral mastectomies were discouraged and given considerations only in patients who were at high-risk of developing metachronous contralateral breast cancer. At our institution we followed the national guidelines and, in our study, the rate of bilateral mastectomy decreased from 48% pre-COVID-19 to 30% during COVID-19 and involved mainly patients diagnosed with invasive breast cancer or DCIS. Before COVID, many young women diagnosed with early stage breast cancer were treated with bilateral mastectomy even if no genetic mutation was identified.
During COVID there was a significant reduction of OR time availability. Resources at our Institution were mainly allocated to COVID unit.
The hospitals had no choice but either delay cancer surgeries or transition to the ambulatory surgery with telemedicine follow-up.11 This change was driven by the common goal to preserve resource for COVID-19 positive patients without compromising long-term outcomes for breast cancer patients.10,12,13
One of the practice-changing recommendations that emerged during the pandemic was an increased use of Enhanced Recovery After Surgery (ERAS) pathways.11 Before the COVID-19 pandemic, ERAS pathways have been shown in multiple surgical disciplines to improve outcomes, including reduced opioid consumption, length of stay, and postoperative nausea and vomiting. Only a few studies evaluated application of ERAS to breast surgery and even fewer studies evaluated ERAS in outpatient breast surgery.14 ERAS pathway implies utilization of pre and postoperative multimodal pain management protocols, including nerve blocks.
In our study, the COVID-19 pandemic and the lack of availability of hospital beds15-20 in a way “forced” all the providers to changed clinical practice and implement ERAS protocols. The outpatient mastectomy rate at our institution tripled during COVID-19 from 17% to 51%. To validate our conclusions, after the pandemic as hospital beds became available, we collect the outpatient mastectomy rate from August 31, 2020 to August 31, 2021. After the COVID-19 pandemic, a significant number of patients, 77 (48%), continued to be discharge home the same day.
During the pandemic the pectoralis block utilization increased from 36% to 59%. We did not collect data on pain control mainly due to shortage of clinical research coordinator. At our Institution, we used a combination of pectoralis blocks with nonregional multimodal pain management. We know from the Anesthesia literature that PECS blocks moderately reduce postoperative opioid use, prolong time to analgesic rescue, and decrease postoperative pain scores when compared with systemic analgesics. The society for Ambulator Anesthesia (SAMBA) recommends the use of a PECS-1 or -2 blockade in the absence of systemic analgesia. No evidence currently exists that strongly favors the use of PECS blocks over surgeon-performed local infiltration in this surgical population.
The change in our practice brought a question of the associated changes in complication rates. Similar to other studies,21-26 our analysis showed that the overall complication rates were low and did not differ between the ambulatory and admitted patients. In our cohort, there was an increase in complication rates in one subgroup of patients who had bilateral mastectomy. Patients treated with bilateral mastectomy were admitted to the hospital more frequently than the patients undergoing unilateral surgery, 76% versus 64%, similarly to rates reported in previous studies.27
Another practice change at our institution that emerged during the COVID-19 pandemic was a well-structured and planned patient education. The COVID-19 Pandemic Breast Cancer Consortium recommended preoperative education, focused on postoperative pain management, early mobilization, and drain management. Based on these recommendations, we implemented changes to patient education to ascertain the patient's comfort with the outpatient surgery. At our institution the education was provided preoperatively in clinic, at the time of surgery, and postoperatively. We often use video phone calls to family member to show drain teaching from the postoperative area since no family member was allowed in the hospital during the pandemic. Those efforts played an imperative role in success of outpatient mastectomies.
Despite the pre-COVID-19 studies discussing the safety of outpatient mastectomies and ERAS protocols in combination with the recommendations issued by the major societies,14,28 some providers during the pandemic nationally and at our institution continued to consider a 23-h observation the safest option after mastectomy. In addition, recent studies showed that admission did not increase COVID-19 transmission risk for the breast cancer patients, justifying an overnight stay.29 While the 23-h observation does not appear to be associated with elevated risk of COVID-19 transmission and COVID-19-related deaths in both patients and healthcare workers, it definitely contributes to increased overall cost, and decreased patient satisfaction.29,30
We recognize our study has limitation since it is single institution retrospective review. We did not evaluate or compare ambulatory vs in-house patient satisfaction after mastectomy like other studies.31 We also did not monitor if our outpatient breast surgery patients made more phone calls to our offices with drain-related, wound and dressing-related or pain control questions mainly because of shortage of providers, nurses and research clinical coordinators during the pandemic. Additionally, the fear of COVID-19 and the possibility of infection while admitted to the hospital, may have played a role in convincing some of our patients to be discharge home after mastectomy.
The new changes in practice implemented during the COVID-19 pandemic, including ERAS protocols, regional anesthesia, and early patient education allowed a smooth transition to a higher rate of outpatient mastectomy and echoed previously published studies advocating utilization of outpatient mastectomies.32-34
5 ∣. CONCLUSIONS
The challenges associated with the COVID-19 pandemic changed our clinical practice. After the pandemic, the rate of outpatient mastectomy continued to be significantly higher than pre-COVID.
A higher number of breast cancer surgeries, requiring at least one drain, were treated as outpatient without changes in complication rates.
ACKNOWLEDGMENT
Research reported in this publication was supported in part by the Biostatistics Shared Resource of Winship Cancer Institute of Emory University and NIH/NCI under award number P30CA138292. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
CONFLICT OF INTEREST
The authors declare no conflict of interest.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study have been deindetified and available from the corresponding author, Monica Rizzo, upon request.
REFERENCES
- 1.Clark JA, Kent RB. One-day hospitalization following modified radical mastectomy. Am Surg. 1992;58:239–242. [PubMed] [Google Scholar]
- 2.Edwards MJ, Broadwater JR, Bell JL, AMES FC, BALCH CM. Economic impact of reducing hospitalization for mastectomy patients. Ann Surg. 1988;208:330–336. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Wagman LD, Terz JJ, Hill LR, et al. Evaluation of a short-stay program for patients undergoing mastectomy. J Surg Oncol. 1989;41:98–102. [DOI] [PubMed] [Google Scholar]
- 4.Cordeiro E, Jackson T, Cil T. Same-Day major breast cancer surgery is safe: an analysis of short-term outcomes using NSQIP data. Ann Surg Oncol. 2016;23:2480–2486. [DOI] [PubMed] [Google Scholar]
- 5.Dumestre DO, Redwood J, Webb CE, Temple-Oberle C. Enhanced recovery after surgery (ERAS) protocol enables safe same-day discharge after alloplastic breast reconstruction. Plast Surg. 2017;25:249–254. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Vuong B, Graff-Baker AN, Yanagisawa M, et al. Implementation of a post-mastectomy home recovery program in a large, integrated health care delivery system. Ann Surg Oncol. 2019;26:3178–3184. [DOI] [PubMed] [Google Scholar]
- 7.McManus SA, Topp DA, Hopkins C. Advantages of outpatient breast surgery. Am Surg. 1994;60:967–970. [PubMed] [Google Scholar]
- 8.Margolese RG, Lasry JCM. Ambulatory surgery for breast cancer patients. Ann Surg Oncol. 2000;7:181–187. [DOI] [PubMed] [Google Scholar]
- 9.Nickleach D. SAS® Macros to conduct common biostatistical analyses and generate reports. In: Liu Y, ed. SESUG, 2013. [Google Scholar]
- 10.Dietz JR, Moran MS, Isakoff SJ, et al. Recommendations for prioritization, treatment, and triage of breast cancer patients during the COVID-19 pandemic. the COVID-19 pandemic breast cancer consortium. Breast Cancer Res Treat. 2020;181:487–497. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Knoll K, Reiser E, Leitner K, et al. The impact of COVID-19 pandemic on the rate of newly diagnosed gynecological and breast cancers: a tertiary center perspective. Arch Gynecol Obstet. 2022;305:945–953. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Fregatti P, Gipponi M, Giacchino M, et al. Breast cancer surgery during the COVID-19 pandemic: an observational clinical study of the breast surgery clinic at ospedale policlinico san martino - genoa, Italy. In Vivo. 2020;34:1667–1673. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Garrigós L, Saura C, Martinez-Vila C, et al. COVID-19 in breast cancer patients: a subanalysis of the OnCovid registry. Ther Adv Med Oncol. 2021;13:175883592110534. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Chiu C, Aleshi P, Esserman LJ, et al. Improved analgesia and reduced post-operative nausea and vomiting after implementation of an enhanced recovery after surgery (ERAS) pathway for total mastectomy. BMC Anesthesiol. 2018;18:41. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Ahmed M. Optimizing breast cancer surgery during the COVID-19 pandemic. Breast Cancer. 2020;27:1045–1047. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Are C, Tyler D, Howe J, et al. Global forum of cancer surgeons: cancer surgery during the COVID-19 pandemic: impact and lessons learned. Ann Surg Oncol. 2022;29:2773–2783. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Concepcion J, Yeager M, Alfaro S, et al. Trends of cancer screenings, diagnoses, and mortalities during the COVID-19 pandemic: implications and future recommendations. Am Surg. 2022:31348221091948. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Fedewa SA, Cotter MM, Wehling KA, Wysocki K, Killewald R, Makaroff L. Changes in breast cancer screening rates among 32 community health centers during the COVID-19 pandemic. Cancer. 2021;127:4512–4515. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.ilgün AS, Özmen V. The impact of the COVID-19 pandemic on breast cancer patients. Eur J Breast Health. 2022;18:85–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Kiziltan G, Tumer BKC, Guler OC, Ozaslan C. Effects of COVID-19 pandemic in a breast unit: is it possible to avoid delays in surgical treatment? Int J Clin Pract. 2021;75:e14995. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Hammond JB, Thomas O, Jogerst K, et al. Same-day discharge is safe and effective after implant-based breast reconstruction. Ann Plast Surg. 2021;87:144–149. [DOI] [PubMed] [Google Scholar]
- 22.Faulkner HR, Coopey SB, Liao EC, Specht M, Smith BL, Colwell AS. The safety of performing breast reconstruction during the COVID-19 pandemic. Breast Cancer. 2022;29:242–246. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Hemal K, Boyd CJ, Bekisz JM, Salibian AA, Choi M, Karp NS. Breast reconstruction during the COVID-19 pandemic: a systematic review. Plast Reconstr Surg Glob Open. 2021;9:e3852. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Jallali N, Hunter JE, Henry FP, et al. The feasibility and safety of immediate breast reconstruction in the COVID-19 era. J Plast Reconstr Aesthet Surg. 2020;73:1917–1923. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Tan LR, Guenther JM. Outpatient definitive breast cancer surgery. Am Surg. 1997;63:865–867. [PubMed] [Google Scholar]
- 26.Romics L, Doughty J, Stallard S, et al. A prospective cohort study of the safety of breast cancer surgery during COVID-19 pandemic in the West of Scotland. Breast. 2021;55:1–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Cordeiro E, Zhong T, Jackson T, Cil T. The safety of same-day breast reconstructive surgery: an analysis of short-term outcomes. Am J Surg. 2017;214:495–500. [DOI] [PubMed] [Google Scholar]
- 28.Jogerst K, Thomas O, Kosiorek HE, et al. Same-day discharge after mastectomy: breast cancer surgery in the era of ERAS. Ann Surg Oncol. 2020;27:3436–3445. [DOI] [PubMed] [Google Scholar]
- 29.Ramirez MEF, Dietz JR. Lessons learned: management of breast cancer patients throughout the COVID-19 pandemic. Curr Breast Cancer Rep. 2021;13:227–234. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Schwartz JC. Mastectomy and prepectoral reconstruction in an ambulatory surgery center reduces major infectious complication rates. Plast Reconstr Surg Glob Open. 2020;8:e2960. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Bonnema J, van Wersch AMEA, van Geel AN, et al. Medical and psychosocial effects of early discharge after surgery for breast cancer: randomised trial. BMJ. 1998;316:1267–1271. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Specht M, Sobti N, Rosado N, et al. High-Efficiency Same-Day approach to breast reconstruction during the COVID-19 crisis. Breast Cancer Res Treat. 2020;182:679–688. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Susini T, Carriero C, Tani F, et al. Day surgery management of early breast cancer: feasibility and psychological outcomes. Anticancer Res. 2019;39:3141–3146. [DOI] [PubMed] [Google Scholar]
- 34.Offodile AC, Gu C, Boukovalas S, et al. Enhanced recovery after surgery (ERAS) pathways in breast reconstruction: systematic review and meta-analysis of the literature. Breast Cancer Res Treat. 2019;173:65–77. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study have been deindetified and available from the corresponding author, Monica Rizzo, upon request.