Lessons from COVID-19 pandemic, impact on breast cancer care
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Healio spoke with Daphna Yael Spiegel, MD, MS, about screening, delays in diagnosis, and other ways the COVID-19 pandemic has impacted the breast cancer care continuum.
Moreover, Spiegel, assistant professor of radiation oncology at Harvard Medical School and Beth Israel Deaconess Medical Center, highlighted ongoing concerns specifically related to HER-positive disease.
Healio: After 2 years and multiple waves of COVID-19, what more has been learned about the delays in diagnosis and treatment of breast cancer?
Spiegel: During the height of the COVID-19 pandemic in 2020, elective tests and procedures were halted in order to reduce patient exposure and redeploy medical personnel. These elective tests included screening for many cancers — breast cancers with mammography, colon cancers with colonoscopies and skin cancers with routine dermatologic exams.
Multiple studies have reported substantial reductions in the rate of screening mammography during the pandemic shutdown period in 2020, with screening mammograms falling between 40% to 90% of their usual volume during that period. We presented our data previously at ASCO Annual Meeting and San Antonio Breast Conference, which specifically showed between 70% and 80% fewer screening mammograms during the pandemic shutdown period compared with the same time period in 2019. Another recently published study by Chen et al., which used administrative claims data for 60 million people in the United States, showed an absolute deficit in breast cancer screening of 3.9 million people in 2020 compared with 2019.
Additionally, multiple studies have raised concerns about an increase in late-stage breast cancer diagnoses following the pandemic shutdown. For example, a study from Koca et al. published in Journal of Surgical Oncology in 2021 showed that patients presented with larger breast tumors and increased axillary node involvement during 2020 compared with the prior year.
Modeling studies have also predicted that the reduction in routine screening mammography during the COVID-19 pandemic surge would lead to more locally advanced breast cancers and increased rates of breast cancer mortality. A study by Alagoz et al. published in Journal of the National Cancer Institute in 2021 estimated a 0.52% cumulative increase in breast cancer deaths is expected by 2030 due to the pandemic disruptions in breast cancer screening.
In our study, we observed institutional and regional variation in late-stage disease presentation. Interestingly, we found that at our institution in the Northeast, where the COVID-induced shutdown period was prolonged, there was a twofold increase in late-stage diagnoses in 2020 compared with 2016 to 2019. At a partnering institution in the Southeast, where the shutdown period was brief, this effect was not seen, and rates of late-stage disease were similar compared to prior years (2016 to2019).
Healio: Now that it has been 2 years, how has the adaptation been to changes in screening, diagnosis and treatment resulting from COVID-19?
Spiegel: There have been efforts across the board to increase awareness about the importance of screening mammography. As someone who sees patients with breast cancer in follow-up, I am acutely aware of the need for annual mammography and ensure that my patients are up to date with follow-up mammograms. However, the bulk of the outreach work has really been done by our primary care physicians and radiologists. They are the ones who have put in countless hours calling patients, sending patients letters and reaching out via our electronic medical record software, urging patients to come in for their scheduled mammography or reminding them that they are overdue for a mammogram.
Healio: What new concerns about breast cancer care have arisen during the last year of the pandemic? Are there any specific concerns for those with HER2-positive breast cancer?
Spiegel: There have been ongoing concerns about patients presenting with later stage disease due to the shutdowns that we experienced during the height of the COVID-19 pandemic. This is potentially particularly relevant for patients with HER2-positive cancer, as these tend to be faster-growing malignancies and delaying a screening mammogram even for only a few months could potentially lead to more locally advanced disease compared with if the mammogram had been performed on time. More studies will need to explore this, though, as much of the data has not been broken down by receptor status.
Once patients have been diagnosed with breast cancer, the other issue that we have had to contend with is actually getting patients through chemotherapy or radiation. As a breast radiation oncologist, patients are typically treated with radiation therapy daily for 4 to 6 weeks. However, in an effort to minimize patient exposure, some practices moved toward moderate or ultra-hypofractionated treatments — meaning delivering larger radiation doses per day over fewer treatments — during the height of the pandemic. This allowed patients to complete their treatments much faster than usual and reduce the potential for exposure while traveling to/from appointments and at their daily treatment visits.
Healio: As has been widely documented now, the COVID-19 pandemic highlighted disparities, not only in breast cancer care, but across the health care system. In this last year, have you seen any practical changes or interventions to improve health disparities among patients with breast cancer?
Spiegel: Yes, there is concern that the pandemic has served to further exacerbate disparities in care for breast cancer patients. A study from UCSF showed that there was a reduction in screening mammograms across all racial groups, but that the proportion of completed mammograms was lowest among Black women at all time points during the pandemic. We know that non-Latina Black women have the highest breast cancer mortality rates of all racial groups in the United States at baseline. Our research showed that Black patients were more likely to be diagnosed with late-stage disease during the pandemic compared to prior years. While we cannot determine the exact reason for this from our study, we know that traditionally underserved groups have been disproportionality affected by COVID-19, potentially due to exacerbated issues with access to care, and breast cancer seems to make no exception.
Healio: How have vaccination rates been among patients with breast cancer? What misinformation have you had to combat, especially among those with HER2-positive breast cancer?
Spiegel: I have not yet seen data to quantify vaccination rates among patients with breast cancer in the United States specifically. Anecdotally, I can say that the vaccination rate here in the Greater Boston area and specifically within my patient population is very high. I can only recall a handful of patients who chose not to be vaccinated for various reasons. Some patients have brought up concerns related to getting vaccinated while undergoing active treatment. After a discussion regarding the optimal timing of vaccination, patients generally feel reassured and get vaccinated, or at this point get their booster, if they haven’t already. There have also been concerns about the development of axillary lymphadenopathy following the COVID-19 vaccine. Vaccine-associated lymphadenopathy is more commonly seen with the COVID-19 vaccine compared with other vaccines. This lymphadenopathy is a benign, reactive enlargement of the lymph nodes that is due to the immune response from the vaccine. We have found this to be a stressor for patients who have been diagnosed with breast cancer, as axillary metastasis in the form of lymphadenopathy can be seen with breast cancer. If not counseled appropriately, patients may be concerned about disease progression following the vaccine. Thankfully, appropriate discussion and counseling prior to the vaccine or shortly thereafter can mitigate the stress related to this overall relatively uncommon side effect of the vaccine.
Healio: How has the COVID-19 pandemic affected breast cancer research or ongoing clinical trials in the space?
Spiegel: Another particularly unfortunate consequence of the pandemic is that research suffered. In particular, women in academia fell behind their male counterparts in terms of publications and obtaining grant funding. This was particularly true for women with young dependents at home. Additionally, during the pandemic, accrual to some clinical trials was halted for various reasons, including lack of funding, redeployments of medical personnel usually involved in clinical research, or space limitations in clinical offices due to social distancing guidelines.
References:
- Alagoz O, et al. J Natl Cancer Inst. 2021;doi:10.1093/jnci/djab097.
- Chen RC, et al. JAMA Oncol. 2021;doi:10.1001/jamaoncol.2021.0884.
- Koca B, et al. J Surg Oncol. 2021;doi:10.1002/jso.26581.
- Stephens SJ, et al. Multi-institutional perspective on screening mammography and breast cancer stage at diagnosis during the COVID-19 pandemic. Presented at: San Antonio Breast Cancer Symposium Annual Meeting. Dec. 7-10, 2021; San Antonio.
- Velazquez AI, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.19929.
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