Spiegel experiences no related monetary disclosures.
Healio spoke with Daphna Yael Spiegel, MD, MS, about screening, delays in prognosis, and different methods the COVID-19 pandemic has impacted the breast most cancers care continuum.
Daphna Yael Spiegel
Moreover, Spiegel, assistant professor of radiation oncology at Harvard Medical School and Beth Israel Deaconess Medical Center, highlighted ongoing issues particularly associated to HER-positive illness.
Healio: After 2 years and a number of waves of COVID-19, what extra has been discovered concerning the delays in prognosis and remedy of breast most cancers?
Spiegel: During the peak of the COVID-19 pandemic in 2020, elective exams and procedures had been halted so as to scale back affected person publicity and redeploy medical personnel. These elective exams included screening for a lot of cancers — breast cancers with mammography, colon cancers with colonoscopies and pores and skin cancers with routine dermatologic exams.
Multiple research have reported substantial reductions within the charge of screening mammography through the pandemic shutdown interval in 2020, with screening mammograms falling between 40% to 90% of their normal quantity throughout that interval. We introduced our information beforehand at ASCO Annual Meeting and San Antonio Breast Conference, which particularly confirmed between 70% and 80% fewer screening mammograms through the pandemic shutdown interval in contrast with the identical time interval in 2019. Another not too long ago revealed examine by Chen et al., which used administrative claims information for 60 million individuals within the United States, confirmed an absolute deficit in breast most cancers screening of three.9 million individuals in 2020 in contrast with 2019.
Additionally, a number of research have raised issues about a rise in late-stage breast most cancers diagnoses following the pandemic shutdown. For instance, a examine from Koca et al. revealed in Journal of Surgical Oncology in 2021 confirmed that sufferers introduced with bigger breast tumors and elevated axillary node involvement throughout 2020 in contrast with the prior 12 months.
Modeling research have additionally predicted that the discount in routine screening mammography through the COVID-19 pandemic surge would result in extra domestically superior breast cancers and elevated charges of breast most cancers mortality. A examine by Alagoz et al. revealed in Journal of the National Cancer Institute in 2021 estimated a 0.52% cumulative improve in breast most cancers deaths is predicted by 2030 as a result of pandemic disruptions in breast most cancers screening.
In our examine, we noticed institutional and regional variation in late-stage illness presentation. Interestingly, we discovered that at our establishment within the Northeast, the place the COVID-induced shutdown interval was extended, there was a twofold improve in late-stage diagnoses in 2020 in contrast with 2016 to 2019. At a partnering establishment within the Southeast, the place the shutdown interval was transient, this impact was not seen, and charges of late-stage illness had been related in comparison with prior years (2016 to2019).
Healio: Now that it has been 2 years, how has the variation been to adjustments in screening, prognosis and remedy ensuing from COVID-19?
Spiegel: There have been efforts throughout the board to extend consciousness concerning the significance of screening mammography. As somebody who sees sufferers with breast most cancers in follow-up, I’m conscious about the necessity for annual mammography and be sure that my sufferers are updated with follow-up mammograms. However, the majority of the outreach work has actually been accomplished by our main care physicians and radiologists. They are those who’ve put in numerous hours calling sufferers, sending sufferers letters and reaching out by way of our digital medical file software program, urging sufferers to come back in for his or her scheduled mammography or reminding them that they’re overdue for a mammogram.
Healio: What new issues about breast most cancers care have arisen over the past 12 months of the pandemic? Are there any particular issues for these with HER2-positive breast most cancers?
Spiegel: There have been ongoing issues about sufferers presenting with later stage illness as a result of shutdowns that we skilled through the top of the COVID-19 pandemic. This is probably notably related for sufferers with HER2-positive most cancers, as these are usually faster-growing malignancies and delaying a screening mammogram even for only some months might probably result in extra domestically superior illness in contrast with if the mammogram had been carried out on time. More research might want to discover this, although, as a lot of the information has not been damaged down by receptor standing.
Once sufferers have been identified with breast most cancers, the opposite subject that we’ve got needed to deal with is definitely getting sufferers by chemotherapy or radiation. As a breast radiation oncologist, sufferers are usually handled with radiation remedy every day for 4 to six weeks. However, in an effort to reduce affected person publicity, some practices moved towards reasonable or ultra-hypofractionated remedies — that means delivering bigger radiation doses per day over fewer remedies — through the top of the pandemic. This allowed sufferers to finish their remedies a lot sooner than normal and scale back the potential for publicity whereas touring to/from appointments and at their every day remedy visits.
Healio: As has been extensively documented now, the COVID-19 pandemic highlighted disparities, not solely in breast most cancers care, however throughout the well being care system. In this final 12 months, have you ever seen any sensible adjustments or interventions to enhance well being disparities amongst sufferers with breast most cancers?
Spiegel: Yes, there’s concern that the pandemic has served to additional exacerbate disparities in take care of breast most cancers sufferers. A examine from UCSF confirmed that there was a discount in screening mammograms throughout all racial teams, however that the proportion of accomplished mammograms was lowest amongst Black ladies in any respect time factors through the pandemic. We know that non-Latina Black ladies have the best breast most cancers mortality charges of all racial teams within the United States at baseline. Our analysis confirmed that Black sufferers had been extra more likely to be identified with late-stage illness through the pandemic in comparison with prior years. While we can not decide the precise motive for this from our examine, we all know that historically underserved teams have been disproportionality affected by COVID-19, probably resulting from exacerbated points with entry to care, and breast most cancers appears to make no exception.
Healio: How have vaccination charges been amongst sufferers with breast most cancers? What misinformation have you ever needed to fight, particularly amongst these with HER2-positive breast most cancers?
Spiegel: I’ve not but seen information to quantify vaccination charges amongst sufferers with breast most cancers within the United States particularly. Anecdotally, I can say that the vaccination charge right here within the Greater Boston space and particularly inside my affected person inhabitants could be very excessive. I can solely recall a handful of sufferers who selected to not be vaccinated for numerous causes. Some sufferers have introduced up issues associated to getting vaccinated whereas present process lively remedy. After a dialogue relating to the optimum timing of vaccination, sufferers typically really feel reassured and get vaccinated, or at this level get their booster, in the event that they haven’t already. There have additionally been issues concerning the growth of axillary lymphadenopathy following the COVID-19 vaccine. Vaccine-associated lymphadenopathy is extra generally seen with the COVID-19 vaccine in contrast with different vaccines. This lymphadenopathy is a benign, reactive enlargement of the lymph nodes that’s as a result of immune response from the vaccine. We have discovered this to be a stressor for sufferers who’ve been identified with breast most cancers, as axillary metastasis within the type of lymphadenopathy might be seen with breast most cancers. If not recommended appropriately, sufferers could also be involved about illness development following the vaccine. Thankfully, applicable dialogue and counseling previous to the vaccine or shortly thereafter can mitigate the stress associated to this total comparatively unusual facet impact of the vaccine.
Healio: How has the COVID-19 pandemic affected breast most cancers analysis or ongoing scientific trials within the house?
Spiegel: Another notably unlucky consequence of the pandemic is that analysis suffered. In specific, ladies in academia fell behind their male counterparts by way of publications and acquiring grant funding. This was notably true for ladies with younger dependents at house. Additionally, through the pandemic, accrual to some scientific trials was halted for numerous causes, together with lack of funding, redeployments of medical personnel normally concerned in scientific analysis, or house limitations in scientific places of work resulting from social distancing tips.
- 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 most cancers stage at prognosis through 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.