Healio spoke Daphna Yael SpiegelMD, MS, on screening, delays in diagnosis and other ways in which the COVID-19 pandemic has affected the treatment continuum for breast cancer.
Daphna Yael Spiegel
In addition, 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 more waves of COVID-19, what more has been learned about the delays in diagnosing and treating breast cancer?
Mirror: During the peak of the COVID-19 pandemic in 2020, optional tests and procedures were halted to reduce patient exposure and relocate medical staff. These optional tests included screening for many cancers – breast cancer with mammography, colon cancer with colonoscopy, and skin cancer with routine dermatological examinations.
Several studies have reported significant reductions in the rate of screening mammography during the pandemic shutdown period in 2020, with screening mammography falling between 40% and 90% of their usual volume during this period. We presented our data earlier at ASCO annual meeting and San Antonio Chest Conferencewhich specifically showed between 70% and 80% fewer screening mammograms during the pandemic shutdown period compared to the same time period in 2019. Another recently published study by Chen et al., which used administrative claim 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 to 2019.
In addition, several studies have raised concerns about an increase in breast cancer diagnoses in the late stages after the closure of the pandemic. For example, a study by Koca et al. published in Journal of Surgical Oncology in 2021 showed that patients had larger breast tumors and increased axillary nodule impact during 2020 compared to the year before.
Modeling studies have also predicted that the reduction in routine mammography screening during the COVID-19 pandemic will lead to more locally advanced forms of breast cancer and increased breast cancer mortality. A study by Alagoz et al. published in Journal af National Cancestors Iinstitute in 2021, a cumulative increase of 0.52% in breast cancer deaths is expected in 2030 due to pandemic disturbances in breast cancer screening.
In our study, we observed institutional and regional variation in late disease presentations. Interestingly, we found that at our institution in the Northeast, where the COVID-induced shutdown period was extended, there was a doubling of transmission diagnoses in 2020 compared to 2016 to 2019. At a partner institution in the southeast, where the shutdown period was short, this effect was not seen and the frequency of disease in the late stage was similar compared to previous years (2016 to 2019).
Healio: Now that it has been 2 years, how has the adaptation been to changes in screening, diagnosis and treatment as a result of COVID-19?
Mirror: There has been an effort across the board to raise awareness of the importance of mammography screening. As someone who sees patients with breast cancer in follow-up, I am very aware of the need for annual mammograms and ensure that my patients are up to date with follow-up mammograms. But the bulk of the outreach work has really been done by our primary care physicians and radiologists. They are the ones who have spent countless hours calling patients, sending letters to patients and contacting them through our electronic journal software, encouraging patients to get in for their scheduled mammogram or reminding them that they are late for a mammogram.
Healio: What new concerns about breast cancer treatment have arisen in the last year of the pandemic? Are there any specific concerns for those with HER2-positive breast cancer?
Mirror: There have been persistent concerns about patients presenting with later disease due to the shutdowns 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 a few months could potentially lead to more locally advanced disease compared to if the mammogram had been performed on time. However, several studies need to examine this, as much of the data has not been broken down by receptor status.
Once patients have been diagnosed with breast cancer, the second problem we have had to contend with is actually getting the patients through chemotherapy or radiation. As a chest radiologist, 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 ultrahypo-fractionated treatments – meaning delivering larger radiation doses a day over fewer treatments – during the peak of the pandemic. This enabled patients to complete their treatments much faster than usual and reduce the risk of exposure during travel to / from appointments and during their daily treatment visits.
Healio: As has now been widely documented, the COVID-19 pandemic highlighted inequalities, not only in breast cancer treatment, but across the health care system. In the last year, have you seen any practical changes or interventions to improve health inequalities among patients with breast cancer?
Mirror: Yes, there is concern that the pandemic has served to further exacerbate inequalities in the treatment of breast cancer patients. A study by UCSF showed that there was a reduction in mammography screening across all racial groups, but that the proportion of completed mammograms was lowest among black women at all times during the pandemic. We know that non-Latina black women have the highest breast cancer mortality rate of any racial group 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 previous years. Although we can not determine the exact cause of this from our study, we know that traditionally underserved groups have been disproportionately affected by COVID-19, potentially due to exacerbated problems with access to care, and breast cancer does not appear to do any exception.
Healio: How have vaccination rates been among patients with breast cancer? What misinformation have you had to fight, especially among those with HER2-positive breast cancer?
Mirror: I have not yet seen data to quantify vaccination rates among patients with breast cancer specifically in the United States. 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 remember a handful of patients who, for various reasons, chose not to be vaccinated. Some patients have raised concerns about being vaccinated while on active treatment. After a discussion about the optimal time for vaccination, patients generally feel reassured and get vaccinated, or get their booster at this time if they have not already done so. 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 to other vaccines. This lymphadenopathy is a benign, reactive enlargement of the lymph nodes caused by the immune response of the vaccine. We have found this as a stress factor for patients who have been diagnosed with breast cancer, as axillary metastases in the form of lymphadenopathy can be seen in breast cancer. If not properly advised, patients may be concerned about disease progression following the vaccine. Fortunately, appropriate discussion and advice prior to the vaccine or shortly thereafter can alleviate stress related to this generally relatively uncommon side effect of the vaccine.
Healio: How has the COVID-19 pandemic affected breast cancer research or ongoing clinical trials in space?
Mirror: Another particularly unfortunate consequence of the pandemic is that research has suffered. Women in particular in the academic world lagged behind their male counterparts in terms of publications and obtaining grants. This was especially true for women with young relatives in the home. In addition, access to some clinical trials was halted during the pandemic for various reasons, including lack of funding, relocation of medical staff normally involved in clinical research, or space constraints in clinical offices due to social distancing guidelines.
- 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. 7.-10. December 2021; San Antonio.
- Velazquez AI, et al. JAMA Netw Open. 2021; doi: 10.1001 / jamanetworkopen.2021.19929.