To our patients
Measures for the New Coronavirus Infection (COVID-19)
at Breast Center of Center Hospital of NCGM

Principles of Medical Services for Breast Cancer atNCGM Breast Center during the epidemic of COVID-19(version 1.0 for patients, 2020/4/28)

The current epidemic of COVID-19 is making impact not only on our daily lives but on
regular cancer treatments, and we are deeply concerned that those who are under
treatment for breast cancer or have symptoms such as breast lump feel uncertain about
availability of diagnosis or treatment and are reluctant to visit medical institutions.
Though it may vary for individual patients, cancer is a progressive disease and it must
be avoided that the necessary diagnosis and treatment of breast cancer get delayed forexcessive fear over contracting COVID-19 virus by visiting a clinic or hospital.
While NCGM takes leadership in COVID-19 crisis as a designated medical center ofinfectious diseases, it also takes every measure to provide cancer treatment safely evenin the midst of COVID-19 epidemic as a local designated cancer hospital, so please visit
NCGM with a sense of security.

<Diagnostic Imaging>
1. We may ask to postpone examinations for diagnostic imaging such as medical
inspection with no symptoms or regular checkups which are considered not to beurgent.
2. We conduct image assessment and examinations including biopsy as we normally
would for the cases deemed urgent such as diagnosis of breast cancer or suspectedrecurrence of breast cancer.

<Surgery>
1. Patients who will undergo breast cancer treatment are required to visit us as younormally would to set their schedule for the treatment.
2. For patients who seek medical examination or surgery of breast conditions otherthan cancer such as benign tumor, we may contact them to check their symptoms
by telephone or other ways and ask them to postpone their visit or to make aproposal for a visit to other clinics.
3. Patients who return for postoperative or post-discharge wound care are required tovisit our outpatient clinic as they normally would.
4. Postoperative follow-up outpatient visits may be postponed when we can confirm
that there is no change in their medical condition by consulting over telephone.
When patients experience any symptoms, we consult with them over telephone andevaluate the need for their hospital visits. We may ask them to visit us or may
recommend them to visit a clinic in our network.

<Surgical Indication>
1. According to disease progression (Stage) evaluated by the size of the tumor andlymph node metastasis and based on the types of breast cancer (expression ofhormone receptors and HER2), we consider the following; surgery before
chemotherapy or hormone therapy, preoperative chemotherapy, or preoperative
hormone therapy.
We perform surgery when we determine that the surgery is the best course oftreatment for the patient at that point. It is not that all the breast cancer surgeries
are halted completely.
But in the case when a patient develops symptoms suspected of COVID-19 infection
such as a fever on the day of admission or of surgery, a change in the surgery
schedule may be required.
2. While we request the surgeries for dysplastic lesion or benign lesion to be postponed
as a rule, we will consider surgery in case of change in lesion. Please consult us insuch cases.
3. Risk reducing surgeries for hereditary breast and ovarian cancer syndrome arerequested to be postponed.

<Systemic Therapy>

Some of the systemic therapies such as chemotherapy can weaken the immune system
and require extra caution during COVID-19 epidemic. We try to reduce the infection risk
by making the interval between visits for physical examination longer when patient’scondition is stable. Continuation of scheduled treatment will be provided with extra
caution for infection risks.
In the case when a patient has symptoms suspected of COVID-19 infection such as afever on the day for a visit, a change in the treatment schedule may be required.

・ Treatment for early-stage breast cancer
1. We may request patients who are currently under observation without treatment
such as intravenous or oral medication to postpone their appointments. Pleasecontact your attending physician by telephone without hesitation in case ofdevelopment of any symptoms. We will consult and evaluate the need for yourhospital visits.
2. Long-term prescription is available for postoperative hormonal therapy. You canreceive prescription by having a telephone consultation without a visit to the hospitalwhen in stable condition.
3. 3-month formulations and 6-month formulations of LEUPLIN® and Zoladex® areused for hormone injection.
4. Postoperative chemotherapy may be postponed depending on the condition of
COVID-19 epidemic. Attending physician will make such decision according to thecondition of patients.
5. Patients currently undergoing preoperative/postoperative chemotherapy continue toreceive their treatment as scheduled.

・Treatment for metastatic breast cancer

1. We may request patients who are currently under observation without treatment
such as intravenous or oral medication to postpone their appointments. Pleasecontact your attending physician by telephone without hesitation in case ofdevelopment of any symptoms. We will consult and evaluate the need for yourhospital visits.
2. We will consider long-term prescription for the patient in stable condition who isunder oral hormonal therapy alone.
3. We will not make up long-term prescription of oral cytotoxic drugs such as

CAPECITABINE, TS-1® and oral molecularly targeted drugs such as IBRANCE®,
Verzenio®, AFINITOR® because it is required to check adverse reaction of thosemedications.
4. FASLODEX® injection is administered as scheduled.
5. Intravenous or oral chemotherapy is administered as scheduled.
6. RANMARK® or ZOMETA® for bone metastasis treatment are administered as we
normally would for the patients who visit for other treatment. Administration ofRANMARK® or ZOMETA® alone may be postponed.
7. Postponement of one or two therapy sessions for any reason does not have much
impact on therapeutic effect.

*Maximum period for long-term prescription is 99 days.

<Breast Reconstructing Surgery>
Even though breast reconstructing surgery itself is not relevant to COVID-19 infection
risk, postponement of such surgeries is considered wherever possible because hospital
visits and medical examinations increase chances to contact other people.

1. For the patients who desire to have reconstructing surgery following breast cancer
surgery, we perform cancer surgery first, and such reconstructing surgery will be
performed sometime later.
2. Please contact us if you experience any problem with breast implant and such.

<Radiation Therapy>
Radiation therapy itself is not relevant to COVID-19 infection risk in principle.
Postoperative radiation therapy has little or no radiation exposure to lung(s) and isconsidered to have no relevance to the risks of exacerbation of Coronavirus infection.
We will consider postponement of radiation therapy when possible because hospital
visits and medical examinations increase chances to contact other people.

1. Patients who need radiation therapy are referred to a radiation oncologist as we
normally would.
2. Radiation therapy after breast-conserving surgery may be postponed becausepostponement of the radio therapy considered not to have serious impact on
therapeutic effect.
3. We consider a therapy which can be completed in short period of time if possible.

<Genomic Medicine>
Genomic Medicine itself is not relevant to COVID-19 infection risk. Postponement ofconsultation is considered whenever possible because hospital visits and medical
examinations increase chances to contact other people.

1. Patients who need preoperative genetic counseling and genetic testing deemedurgent are referred to our Genomic Medicine department as we normally would.
2. Patients with metastatic breast cancer are referred to our geneticist or genetic
counselor for their genetic counseling and genetic testing for Lynparza® use as wenormally would.
3. We are not accepting appointments for Cancer Gene Panel Testing now. It may takea longer period of time even if the testing is resumed.
4. Counseling such as postoperative genetic counseling or genetic counseling of family
members is considered less urgent and referral to our geneticist or genetic counselor
may be postponed.

<Clinical Trial>
Clinical trials may be relevant to COVID-19 infection risk depending on treatments. We
conduct clinical trials with thorough measures to prevent COVID-19 infection.

<Consultation on Palliative Care and Daily Life>For those who require day-to-day control of symptoms, we recommend coordinatingwith local medical institutions and using home-visit medical care and medical services
to minimize hospital visits by public transportation. Our counseling staff of Cancer
Support Desk will help you with regard to coordination with medical institutions andconsultation for daily life.

<Measures Taken by our Staff>
As COVID-19 spreads in the community, NCGM has enhanced in-hospital infection
control and every staff of NCGM exercise extreme caution to prevent bringing COVID19 into the hospital from outside. We place emphasis on monitoring health condition of
our staff and prevent in-hospital infection by fully enforcing following rules. In the casewhen any of our staff member is suspected to have COVID-19 infection, we takeappropriate responses such as performing PCR (polymerase chain reaction) tests onsuch staff member.
The zone areas for treating patient with confirmed Coronavirus infection or suspectedcases and the zone areas for treating those without the virus are completely separated
so that no increased risks of Coronavirus infection will be imposed on those who receive
treatment in NCGM. Currently none of our staff of Breast Center has chances to contact
patient with confirmed COVID-19 infection and risks for infection is never higher thanordinary situation.

1.

All the staff member of NCGM measure their body temperature before leaving home
for work and report their temperature at work. Any member who has a fever does
not come to work and stands by at home.

2.

Equipment such as personal computers and desks are disinfected with alcohol
before our outpatient care starts.

3.

When seeing a patient, we always wear a surgical mask and carry out hand hygiene
by washing hands or by alcohol disinfection for each patient.

4.

All the patients are required to measure their body temperature before entering thehospital.

5.

We request patients to enter examination room alone as a rule. In the case when apatient needs escort, we ask for one person to accompany in principle.

<Suspected COVID-19 Infection of Patients or their family members >We take our action expecting that every patient has infection risk because Coronavirus
infection spreads in the community. Even though the zone areas for treating patientwith confirmed COVID-19 infection or suspected cases and the zone areas for treating
those without the virus are completely separated so that no risks of COVID-19 infection
will be imposed on those who receive treatment in NCGM, everyone is required to keep
in mind that there are infection risks in hospital visits by public transportation. When apatient or his/her family member who cannot be denied of the possible COVID-19
infection enters the hospital without giving it much thought, infection risks are posedon other patients and healthcare workers. Please make sure to consult us beforehand if
you have any symptoms that you feel uneasy about.
If a patient should be suspected of Coronavirus infection, we will respond appropriately
with our fully equipped testing and treating system for Coronavirus infection.

1.

Patients currently undergoing anticancer drug treatment with no symptoms except
for a fever and having preliminarily prescribed antimicrobial drug are needed tostart taking the antimicrobial drug. If your temperature does not go down below
37.5℃ (99.5℉) in 48 hours after taking it, please contact us immediately. We willrefer you to our Department of Infectious Diseases.

2.

Patients currently undergoing anticancer drug treatment with symptoms (especiallyupper respiratory symptoms) except for a fever and not having prescribed
antimicrobial drug preliminarily are required to contact us immediately. We will refer
you to our Department of Infectious Diseases.

3.

In the case when patients who are currently undergoing preoperative examination,
who are undergoing hormone therapy alone, or who are under observation develop
fever, we will refer such patients to our Department of Infectious Diseases.

4.

If your residence is far from NCGM, we may refer you to a medical institution inyour area. Please consult your attending physician by telephone.

5.

Currently family members of inpatients are not allowed to visit them in principal asa preventive measure for COVID-19 infection. In the case when their visitation isrequired, the attending physician will get in touch with them. In addition, pleasecontact any of hospital staff if family members wish to have a consultation.