Preoperative imaging of patients with breast cancer is used to determine the extent of disease, assist in surgical planning, and assess the need for neoadjuvant systemic therapy.^1-8 Current guidelines recommend bilateral mammography as the primary imaging modality and, if necessary, preoperative ultrasonography.^1-3 In recent years, there has been growing use of preoperative breast magnetic resonance imaging (pMRI), based on its potential to detect occult disease that might not have been seen with traditional breast imaging.^4-6 However, compared with mammography, breast MRI has a modest specificity that leads to higher false-positive rates, is more expensive, and requires the use of intravenous contrast medium.^4-10 In addition, randomized clinical trials, systematic reviews, and meta-analyses consistently show that pMRI fails to improve surgical outcomes, breast cancer recurrence rates, or survival.^9-17 Moreover, pMRI has been associated with higher mastectomy rates.^11-15

Practice and behaviour change in healthcare is complex, and requires a set of critical steps that would be needed to implement and sustain the change. Neoadjuvant chemotherapy for breast cancer is traditionally used for locally advanced disease and is primarily advantageous for surgical downstaging purposes. However, it does also offer patients with certain biologic subtypes such as the triple negative or Her2 positive breast cancers the opportunity to improve survival, even in early stage disease. During the height of the pandemic, an opportunity and motivation for the increased use of neoadjuvant therapy in breast cancer was identified. This paper describes the conditions that have supported this practice change at the provider and institutional levels. We also include our own institutional algorithm based on tumor biology and extent of disease that have guided our decisions on breast cancer management during the pandemic. Our processes can be adapted by other institutions and breast oncology practices in accordance with local conditions and resources, during and beyond the pandemic.

The probability of detecting radiologically evident metastatic disease in asymptomatic women with newly diagnosed operable breast cancer is low. Despite the recommendations of most practice guidelines imaging is still frequently performed. Relatively little is known about what patients believe is important when it comes to radiologic staging. Patients with early stage breast cancer who had completed their definitive breast surgery were surveyed about their personal experiences, perceptions, and expectations on the issue of perioperative imaging for distant metastatic disease. Over a 3 month period, 245 women with primary operable breast cancer completed the questionnaire (87.0% response rate) and 80.8% indicated having had at least one imaging test for distant metastatic disease. These were either of the thorax (72.2%), abdomen (55.9%) or skeleton (65.3%) with a total of 701 imaging tests (average of 3.5 tests per patient imaged) performed. Overall, 57.1% indicated that they would want imaging done if the chance of detecting metastases was ≤10%. Although 80.0% of patients indicated that, “doing whatever their doctor recommended” was important to them, 70.4% also noted that they would be uncomfortable if their physician did not order imaging, even if this was in keeping with practice guidelines. Most patients with early stage breast cancer recall having imaging tests for distant metastases. Given the choice, most would prefer having imaging performed, even if this is not in line with current guidelines. If patient expectations are, in part, driving excessive imaging, new strategies addressing this are required.