Q&A: Navigating COVID-19’s disruptions to breast cancer care

ByJanel Miller

Research suggests that the COVID-19 pandemic has disrupted breast cancer screening, diagnosis and treatment.

For example, a study conducted in Massachusetts revealed that the screening mammogram rate in April 2020 was down 98% from the rate in April 2019. Another study of women across the United States that made the same comparison showed a 90.8% drop.

The quote is: "As they say, necessity is the mother of invention, and now we are more broad-minded in how we look at breast cancer." The source of the quote is: Deborah Toppmeyer, MD.

In addition, 42.6% of patients with breast cancer who were scheduled for IV or injectable therapy at one New York City medical center had a delay or change in cancer-related systemic therapy, surgery, radiation and radiology care in the early days of the pandemic, while a large academic center in Philadelphia reported that 55.6% of patients who had a new histologic diagnosis of invasive breast cancer, ductal carcinoma in situ or lobular carcinoma in situ reported delays in either radiation therapy or surgery.

The long-term impact that COVID-19 will have on breast cancer care remains unclear. National Cancer Institute director and former acting FDA commissioner Norman “Ned” E. Sharpless, MD, wrote in Science that “disruptions in breast cancer care during the COVID-19 pandemic may have a small long-term cumulative impact on breast cancer mortality in the U.S.,” while the authors of the New York City-based study wrote in JCO Oncology Practice that “the long-term impacts of these COVID-19-related care delays and/or changes on [breast cancer] outcomes are currently unknown.”

Mammogram screenings appear to be returning to pre-pandemic rates, according to Deborah Toppmeyer, MD, the director of the Stacy Goldstein Breast Cancer Center at Rutgers Cancer Institute of New Jersey.

“In the U.S., the majority of people are vaccinated against COVID-19 and are comfortable coming in for their routine mammogram screening,” Toppmeyer told Healio Primary Care.

In commemoration of Breast Cancer Awareness Month, we asked Toppmeyer to discuss other ways the COVID-19 pandemic has affected breast cancer care, time intervals between COVID-19 vaccine administration and mammograms, and more.

Healio Primary Care: Previous research has suggested that the COVID-19 pandemic led to fewer mammograms. How can we get back to pre-pandemic mammogram screening rates?

Toppmeyer: Italy essentially shut down mammography screening during the initial months of the COVID-19 pandemic. A recent study showed how this led to an increased risk in node-positive disease in that country as well as diagnoses of breast cancer in later stages. This finding was most pronounced in women with more aggressive histologies.

Although at this point screening has returned to baseline in the general population, there are important underserved groups that have been disproportionately affected. The consequence of the pandemic on screening has had the greatest impact on lower-income populations. Fedewa and colleagues examined educational initiatives that were very successful in increasing the uptake of mammographic screening among the underserved in the U.S., increasing screening by 18% between July 2018 and July 2019. Amid the pandemic, not only was this improvement lost, but the rate dropped by 8% from baseline. This is a population that has paid the greatest price during the pandemic on multiple fronts and continued educational initiatives and interventions tailored to the underserved are critical to address this.

Healio Primary Care: How else has the pandemic affected breast cancer care?

Toppmeyer: The health care community has adopted greater use of neoadjuvant hormonal therapy using oncotype analysis to guide decision making as it was not feasible to take those patients with operable breast cancer immediately to surgery.

Before the COVID-19 pandemic, this approach was not typically taken given the lack of barriers to surgical scheduling. But as they say, necessity is the mother of invention, and now we are more broad-minded in how we look at breast cancer treatment in this particular patient population.

In addition, initially some patients were more reluctant to come in for treatment, but the majority seemed very grateful that our doors remained open. We delivered their care in a very safe, socially distanced environment.

Healio Primary Care: A common short-term effect of COVID-19 vaccination is swollen lymph nodes. How long should a woman wait to receive a mammogram after getting vaccinated? What, if any, are the exceptions to this?

Toppmeyer: The usual recommendation is to wait approximately 4 to 6 weeks to receive the vaccine. That should be adequate for most women. If women want to put their booster off for a couple of weeks and get their mammogram first, that should be OK.

Healio Primary Care: Another previous study suggested that that there is a “longstanding expert disagreement about the age at and frequency with which women should be screened for breast cancer.” What are some of the things primary care physicians should consider when choosing between the USPSTF and American Cancer Society screening recommendations?

Toppmeyer: The recommendations are a challenging concept to get around and are also discordant among medical societies. In that previous study, the researchers noted that the focus on the conflict and controversy, as you know, is what then leads to confusion for the woman considering screening.

This is a very challenging conversation for a primary care physician or a gynecologist to have with their patients, such as those in their early 40s without significant risk factors. In this population, the risk is low and, thus, the false-positive rate is also higher.

On the other hand, mammography does lead to early detection, and that saves lives. At the end of the day, it should be a discussion between the patient and their provider about the risks and benefits of screening.

Healio Primary Care: What lifestyle behaviors should PCPs recommend to patients to lower their risk for breast cancer? What evidence is there to support these behaviors?

Toppmeyer: The Women’s Health Initiative addressed many of these questions, as did multiple other studies.

To lower their risk, patients should maintain healthy lifestyle, exercise regularly and maintain a healthy body weight. I recommend that my patients follow a Mediterranean-type diet — more grains, more plant-based foods, less red meat, less fat, less processed foods, those sorts of things. I’m a huge proponent of exercise, but that does not mean that you need to be running marathons. Rather, patients should move their bodies and set reasonable goals to achieve. It’s very reasonable to say to patients “if you maintain a healthy body weight, adopt a helathier diet, you’re going to have better outcomes.”

When a woman is first diagnosed with breast cancer, there is significant anxiety surrounding the diagnosis and you do not want to overwhelm them. But I still very much encourage them to embrace exercise, because it mitigates the deconditioning typically associated with breast cancer and most importantly, can have a significant positive impact on mood.

Healio Primary Care: What role does a PCP play in a breast cancer survivor’s care?

Toppmeyer: Advances in early detection and treatment of breast cancer have resulted in dramatic increases in the number of women living long after their original diagnosis. Because of an anticipated shortfall of oncologists in the future, transition of cancer survivors back to their primary care physicians will be imperative.

Today, some primary care physicians may be uncomfortable with a patient who has received treatment for breast cancer. However, engaging the primary care physician and making sure we adequately disseminate cancer survivorship guidelines to them and their patients is critical. Ultimately, it is the primary care physician who will be monitoring the patients’ bone health and addressing other side effects of cancer treatment, including those related to early menopause, for example. There is ongoing research to identify ways to optimize the transition of the cancer survivor’s care back to the PCP, with early engagement of the patient and the providers.

Healio Primary Care: What is your message to PCPs during Breast Cancer Awareness Month?

Toppmeyer: Primary care physicians and OB/GYNs through shared decision-making need to ensure that their younger patients in their 40s understand the risks and benefits of screening. However, for patients aged 50 years and older, it is important that they undergo screening at least biannually or annually. I would encourage PCPs to make sure that their patient walks out of the office with a mammogram script in hand.