‘Sequelae of COVID-19 pandemic’: Delays in breast cancer diagnoses, treatment
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Concerns about the downstream effects of the COVID-19 pandemic are common across all breast cancer types.
One concern is that the risk for becoming seriously ill due to COVID-19 may be higher for patients with breast cancer and cancer in general.
“We think this risk is most pronounced among individuals currently diagnosed with breast cancer, including those undergoing active treatment for the disease,” Erica T. Warner, ScD, MPH, assistant professor in the department of medicine at Harvard Medical School, said during an interview with Healio. “Because the disease itself, and treatments like chemotherapy may temporarily weaken the immune system, this makes patients less likely to control an infection, should they become infected with COVID-19.”
Warner spoke with Healio about the delays in diagnosis and treatment of breast cancer caused by COVID-19, whether the health care system is now better equipped to deal with the changes in screening, diagnosis and treatment resulting from COVID-19 and if introduction of the vaccine will affect care for patients with breast cancer.
Healio: Has COVID-19 caused significant delays in diagnosis and treatment of breast cancer?
Warner: The pandemic has certainly caused widespread disruptions in preventive care across the health care system. In many places, breast cancer screening stopped completely in the spring of 2020. Routine care resumed at reduced capacity in the summer of 2020 for most, but there remains a large backlog of missed visits. In terms of missed diagnoses, declines in diagnostic imaging were less steep than what we saw with screening. This suggests that patients with symptoms or with prior abnormal results continued to receive care at a greater rate than others during the pandemic, which is promising, and suggests that there has been effort to prioritize who receives care during a time when care is limited due to significant COVID-19 related stress on the health care system.
For otherwise asymptomatic patients, we must remember that most routine mammograms are negative with no evidence of cancer found. However, there is a subset of patients for whom an abnormal screening mammogram would be their first sign of breast cancer. These are the patients for whom a missed mammogram may mean a delayed diagnosis. It is too early to see the impact on the stage at diagnosis in cancer statistics, but others and I have proposed studies to look at the long-term impact of these missed screening visits on the stage at diagnosis. The modeling study that was released by the NCI estimates that there will be 10,000 excess deaths due to colorectal and breast cancer throughout the next 10 years.
The story is somewhat different for treatment. The CDC and CMS recommended cessation of routine preventive care and nonessential invasive elective procedures back in the spring of 2020 because, for average-risk people, this type of care could be delayed without reasonable expectation of harm. However, the balance of harms and benefits are different for a patient with known breast cancer for whom untreated cancer can lead to disease progression. The recommendation was to continue to provide care for patients with cancer and other people who were in treatment for chronic and potentially deadly diseases. The approach has been to maybe modify the schedule and/or sequence of treatment for cancer patients in treatment instead of completely forgoing care.
Healio: Now that it has been a year, are we better equipped to deal with the changes in screening, diagnosis and treatment resulting from COVID-19?
Warner: We certainly learned some new things during the pandemic regarding the way care can be successfully delivered. We are all aware of the massive transition to telemedicine. There had been a lot of institutional and regulatory barriers that have prevented widespread use of telemedicine prior to the advent of the pandemic. There are a few different examples of how the pandemic forced us to do things that had been talked about and thought about for a long time but had not been able to be successfully implemented. Otherwise, we are still learning about what the long-term impacts are. One major area of interest is identification and implementation of the key strategies necessary to mitigate the harm caused by the pandemic, specifically regarding disruptions in care. For example, how do we bring back patients most likely to experience harm because of missed visits to try and mitigate those harms?
Healio: Are there new concerns about breast cancer care as we navigate the next wave of the pandemic?
Warner: The main concern is how long any potential delays in care will go on. Now that we are approaching the 1-year mark in which a patient may not have been screened, any future COVID-19 waves that continue to complicate reengagement in health care can expand these windows in which people are not receiving preventive care. The longer that the pandemic goes on and the longer we experience the sequalae of the pandemic, the more we worry about people not receiving timely diagnoses and treatment. For the average-risk person normally screened annually, a delay of 6 months or even 1 year probably is not associated with harm. However, looking at the horizon, we are not certain that this pandemic will be fully resolved by 2022 and then, the level of concern, even for average-risk people, starts to increase.
Healio: Has the COVID-19 pandemic highlighted disparities in care among certain populations with breast cancer?
Warner: The disparities that we have observed with COVID-19 in terms of the morbidity and mortality of the disease has shone a light on the broader problem of health disparities across the health care system. We have seen racial and ethnic minority populations as well as individuals of lower socioeconomic status bear the brunt of the pandemic, not just in terms of the health effects but also because of the social and economic hardships that have accompanied the pandemic. We worry about this regarding breast cancer with early diagnosis and treatment.
When looking at the data prior to COVID-19, breast cancer screening is one of the cancer screening tests that has the highest and the greatest levels of participation across different populations. This is a success story that we do not want to be undermined by the pandemic-related disruptions in care. However, despite what looked like very good screening rates across populations defined by race and ethnicity or socioeconomic status, there were still challenges before the pandemic, such as ensuring that all individuals with an abnormal mammogram obtain timely follow-up, diagnostic resolution and treatment initiation. I worry about how the new chasm of the pandemic may add to these challenges. Regarding treatment, there were already differences between treatment groups with insurance status and socioeconomic status regarding timely diagnosis and completion of treatment as well as access to breast-conserving surgery. This pandemic is a time in which differences that already exist can potentially grow and new gaps can appear.
Healio: Will introduction of the vaccine affect care for patients? Is it safe or recommended for patients with breast cancer?
Warner: Dr. Fauci said that cancer patients should be encouraged to get the vaccine. Although most of the phase 3 trials of the available vaccines did not enroll people with cancer — only Johnson & Johnson did not exclude people with cancer — we do not have specific safety data about this population. There does not appear to be a strong hypothesis that the safety profile would be markedly different in patients with cancer than in other individuals. What we do think about is whether due to treatments or the disease process itself, cancer patients may not have as rigorous of an immune response to immunization and therefore might not receive as great a degree of protection as other individuals. This is more so for those undergoing active treatment for cancer vs. cancer survivors.
However, a less robust response related to immune suppression caused by cancer treatment is not a rationale not to get vaccinated. The efficacy that we have seen with the COVID-19 vaccines is extraordinary. There are many other vaccines that we routinely use that are not nearly as efficacious but are widely accepted. Even somewhat less protection in cancer patients would still be highly beneficial.
In terms of affecting care, the COVID-19 vaccine will provide peace of mind for both patients and providers. Everyone is balancing risks and benefits, and both patients and providers will most likely feel more comfortable doing more things such as in-person visits and other in-person care once more people are vaccinated.
Healio: Are the reactions to the COVID-19 vaccine that mimic breast lumps common? How should patient concerns be addressed?
Warner: I personally do not see or treat patients, but I do know that that Society of Breast Imaging recommends that women schedule their annual screening mammogram either prior to their first vaccine dose or 4 weeks to 6 weeks after the second dose because of the concern that there may be inflammation due to the vaccine that could appear as a breast lump or lymph node inflammation that may be misleading on imaging.
Healio: How has the COVID-19 pandemic affected breast cancer research or ongoing clinical trials in the space?
Warner: From the experience with my own research, there was a period during spring where there was a full stop of clinical research. Non-therapeutic research was basically told to stop and could potentially reconvene once a plan was figured out for how to protect the safety of participants as well as the study staff and investigators.
There was a period of several months from mid-March 2020 to the early summer in which we were not actively enrolling or engaging any patients in a study. There was a period in which we had to pivot — the word of 2020 — and figure out how to conduct research remotely on Zoom, for example. Even for the clinical trials of therapeutic treatments that were not stopped were difficult to conduct. In April and May 2020, very little clinical trial activity was going on. In the late summer, more clinical trials restarted and have rebounded completely by now.
I hope that this experience with how trials were modified can be a model going forward because many of the changes reduced the burden of participation on patients in a meaningful way. This is one of the positive lessons learned from the COVID-19 pandemic.
For more information:
Erica T. Warner, ScD, MPH, can be reached at ewarner@mgh.harvard.edu.
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