Safety-net hospital sees increase in late-stage breast cancer diagnoses during pandemic
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COVID-19 restrictions led to a 1.2-fold increase in presentation of late-stage breast cancer at an urban safety-net hospital, according to a study presented at an American Society of Breast Surgeons Annual Meeting press briefing.
Researchers also reported a longer time to first treatment, including time to surgery, during the pandemic.
Patients accessing the hospital already demonstrated a threefold higher likelihood of presenting with late-stage breast cancer prior to COVID-19 when compared with women at other Commission on Cancer-accredited sites in the U.S.
“Historically, safety-net populations are disproportionately affected by educational inequities, language barriers, transportation difficulties, job loss and lack of insurance, dependent children at home, and medical and mental health comorbidities. The pandemic restrictions may have exacerbated many of these problems and acted as another comorbidity for this population,” Kelly Alexandra Kapp, MD, general surgery resident at University of Missouri-Kansas City School of Medicine, told Healio.
Background and methodology
Kapp said CDC concerns last year that the pandemic may lead to increased disparities among women already experiencing health inequities motivated her to study the impact of COVID-19 on the hospital’s safety-net patients.
“[The CDC] noted an 87% decline in screening at the National Breast and Cervical Cancer Early Detection Program in April 2020 compared with the five previous Aprils,” Kapp told Healio. “I was concerned that the stay-at-home orders might further disenfranchise our safety-net patients from presenting for breast cancer care.”
The cohort study included 172 patients with new breast cancer diagnoses identified through the institution’s cancer registry. They included 82 patients treated between March 2020, when the local “stay-at-home” order was issued, and February 2021, when restrictions were lifted, and 90 patients in a pre-COVID control cohort who received treatment from March 2018 to February 2019.
Researchers collected stage at presentation, time to first treatment and time to surgery — as well as demographic information, including race and payor — and then compared the two cohorts. They defined late-stage breast cancer as American Joint Committee on Cancer stage III or stage IV disease. The cohorts had similar characteristics at baseline, including age (55 years in both) percentage of non-white patients (59% pre-COVID vs. 61% COVID) and payor (Medicaid, 35% vs. 46%; Medicare, 24% vs. 22%).
Key findings
Results showed patients in the COVID-19 cohort demonstrated a higher likelihood of presenting with late-stage disease than the pre-COVID patients (32% vs. 19%).
Additionally, after controlling for race and insurance, Kapp and colleagues reported a 1.2-times higher likelihood that their safety-net patients presented with late-stage disease during COVID-19 restrictions compared with pre-COVID-19 patients.
Moreover, women treated during COVID-19 experienced a longer time to first treatment and to surgery (when surgery served as the first treatment) compared with the pre-COVID-19 cohort (median 48 days vs. 29 days to first treatment; median 65 days vs. 36 days to surgery).
“The benefits achieved by the restrictions may be paradoxically causing increased cancer care morbidity and mortality for certain vulnerable patients who we will not see for many years,” Kapp said.
Implications
The perception that care was not accessible during the COVID-19 pandemic, as well as other stressors and competing priorities, may have contributed to delays in care, Kapp and colleagues concluded. They emphasized that efforts are necessary to minimize disruption to safety-net hospitals during such public health crises, as these patients are already vulnerable.
“We can't make sweeping generalizations based on our study, but it is reasonable to assume that similar circumstances and findings may occur in other safety-net populations. Here we identified a problem and now we must address it,” Kapp said. “We have considered public service addresses, public information associated with vaccine services and phone call reminders to eligible patients. Currently, our hospital is investigating the use of text reminders and scheduling for vulnerable patients.
“Ultimately, I would like to conduct further research to evaluate the specific barriers that may have led to these delays and this segment of the population not getting appropriate care in the COVID-19 period,” she added.
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Kapp KA, et al. Impact of COVID-19 restrictions on stage of breast cancer at presentation and time to treatment and surgery at an urban safety-net hospital. Presented at: American Society of Breast Surgeons Annual Meeting (hybrid meeting); April 6-10, 2022; Las Vegas.
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