Many LMICs have published their challenges, experiences, and general recommendations with regards to general oncological care. Apart from a limited number of cancer care facilities, most cancer care was available in urban settings. Countrywide lock-downs, travel bans, and restricted hours of operation resulted in limited access to oncologic care. Under usual circumstances, cancer patients in Gaza require Israeli travel permits to leave Gaza and access treatment. Following travel restrictions, the mobility of these patients was greatly reduced and thus they avoided leaving Gaza for fear of not being able to return home, while some were forced to stay away from home to continue treatment. Patients were concerned about catching COVID-19 in the hospital setting, as overcrowding of waiting areas did not allow access to clean toilets and social distancing requirements could not be met . Already burdened cancer care facilities were used as makeshift COVID-19 testing facilities and some were shut down due to resource allocation, greatly impacting the continuity of care. COVID-19 was also stigmatized and patients had started to fear COVID-19 more than cancer itself. The stigmatization prevented the patients from revealing their travel and exposure history which compromised the safety of the healthcare staff .
Though infection rates appeared to be lower in severely resource-constrained environments such as Africa , the speed with which the infected were identified and isolated was also low, thus putting the healthcare providers at risk. Though patients and providers were aware of the need for PPE, the lack of availability of PPE, medical consumables, and life support equipment, as well as the absence of health insurance to cover expenses, all led to great difficulty for both patients and the healthcare staff. Due to these limitations, a good number of healthcare workers got infected, were restricted to quarantine or isolation, or even died, further complicating the delivery of care .
Furthermore, limited external funding for an indefinite period inhibited research and resulted in a paucity of outcomes data in cancer patients during the pandemic, especially in LMICs . This means that research on COVID-19 and its effect on cancer or vice versa will be limited from LMICs and greatly compromise our capacities to guide care in the future.
Breast cancer management in most countries was dictated by government mandates, institutional guidelines, or adaptation of guidelines from international organizations. No unified standard management plan could serve the global needs. Recommendations were made to guide care in all three fields of management including surgical, medical, and radiation oncology. It is recommended that in the case of COVID-19 and cancer, the infection should be prioritized and all treatment be halted unless the patient attains an asymptomatic state. It was unanimously suggested to delay or cancel elective procedures with the approval of the patient and the multi-disciplinary teams [17, 22, 23, 26,27,28,29,30,31].
For medical oncology, IV regimens were shifted to oral. In certain places, oncology teams were split into two: one to deal with infected patients with cancer and the other to deal with uninfected cancer patients. This plan helped with the distribution of workload, judicious use of PPE, and offered greater safety to the non-infected cancer patients . Adjuvant radiotherapy regimens were also altered based on the cancer type and stage. Radiation therapy was sometimes shortened, made less intense, and/or shifted to alternate protocols that did not require in-patient admission. Low-risk patients and those where benefit from radiation was limited were encouraged to omit the modality. Data from the Egyptian literature recommended delaying all adjuvant radiotherapy except in high-risk breast cancer patients, including those with T3–4 tumors, clinically N2–3 patients, those who had triple negative disease, or those who were diagnosed young age. In general, the recommended radiation dose for adjuvant treatment was 40 Gy/15 fractions, with a possible concomitant boost of 200 cGy/5–8 fractions to the primary tumor site in patients who had breast conserving surgery . Routine clinic follow-ups and postoperative clinic patients were shifted to telehealth wherever possible.
To the best of our knowledge, Morocco was the only LMIC that published a standardized protocol for the treatment of breast cancer patients during the COVID-19 pandemic. For patients currently under treatment, their guidelines were similar to those of major leading organizations. They specifically recommended spacing out treatment protocols, replacing cisplatin-based therapies with carboplatin or oxaliplatin-based regimens wherever possible, advocated for the use of q3weekly chemotherapy regimens and the use of granulocyte-colony-stimulating factors (GCSF) to avoid neutropenia. They suggested postponing regular screening for breast cancer and deferment of surgery for carcinoma in situ and low-grade tumors. It was suggested that adjuvant radiation therapy be delayed for low-risk disease and hypofractionated RT be preferred for patients in whom radiation cannot be postponed. They further proposed the use of oral therapies for metastatic breast cancer patients  and replacing physical consultations with teleconsultations. For patients receiving palliative care, they recommended planning therapeutic spacing/de-escalation whenever possible. Breast cancer patients who were being seen for surveillance alone were advised to present to the clinic in person only in case of development of symptoms of recurrence.
For all new cases, a risk-benefit assessment was advised based on urgency and need. For hospitalized patients, steps to prevent exposure and minimize expense were suggested including advising patients to bring their own alcohol-based hand sanitizers and blankets, decreasing family visits, limiting the number of doctors visiting the bedside, and provision of isolation facilities for patients who develop symptoms of COVID-19 infection [17, 22, 23, 26,27,28,29,30,31].