Special Report: COVID-19’s Impact on Breast Cancer Care

On March 11, 2020, the World Health Organization (WHO) said that COVID-19 had become a pandemic — a disease that has spread across multiple countries. The U.S. declared a national emergency shortly after. As the first shutdowns began and many of us started to learn the term “social distancing,” thousands of Americans received even more troubling news: they had a breast cancer diagnosis.

Nancy Richards, 67, of Barnstable, Mass., was one of those people. She found out in March that she had invasive ductal carcinoma. Because it was her second breast cancer diagnosis, she quickly made up her mind about what to do without having to do much research.

“Since it was right at the beginning of the pandemic, everything was sped up very quickly,” she said. “I went from diagnosis to surgery in 2 weeks.”

On the day of her surgery — a double mastectomy with no reconstruction — Nancy had to go to the hospital alone. No visitors were allowed.

“My husband had to drop me off and pick me up at the curb. Like a parcel. That was a little bit hard,” she said.

To protect her from being exposed to COVID-19, the hospital discharged Nancy right after the surgery, and almost all of her follow-up care took place over the phone.

Like Nancy, Maria D’Alleva, 43, of Eagleville, Pa., also learned she had invasive ductal carcinoma just as the COVID-19 crisis was beginning. Her surgery was delayed from March until early June, and she wasn’t able to have the surgery she originally wanted — a double mastectomy with immediate autologous reconstruction (which uses tissue from another part of the body to create the reconstructed breasts).

During the first couple of months of the pandemic, many hospitals stopped performing breast reconstruction procedures. This was because public health authorities recommended that elective (non-urgent) surgeries be postponed, and breast reconstruction was considered to be elective surgery at the time.

If Maria wanted to have surgery in March, her surgeon told her that she could have only the breast with cancer removed (a single mastectomy) and no reconstruction.

“I didn’t want to be completely flat, wait to recover, then do some kind of reconstruction,” she said. “To avoid putting myself through more procedures and recovery, I opted to wait.”

Because she was diagnosed with hormone-receptor-positive breast cancer, Maria was able to take tamoxifen, a hormonal therapy medicine, to keep the cancer from growing while she waited for surgery. But eventually, she decided to change her original plan and was able to schedule a double mastectomy with immediate reconstruction using tissue expanders in early June. She plans to get breast implants after the tissue expansion process.

“It seemed more prudent to remove the breast cancer rather than continue to wait for the autologous reconstruction,” she said. “These are crazy times.”

As we’ve come to learn, Nancy’s and Maria’s experiences are not uncommon. Across the country, the COVID-19 pandemic has caused delays and disruptions in care for people with breast cancer — whether they are newly diagnosed, in active treatment, in long-term survivorship, or living with metastatic breast cancer — adding extra anxiety and uncertainty to an already challenging journey.

Why did COVID-19 delay breast cancer care?

In March, the Centers for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services (CMS), and local and state governments recommended that healthcare systems delay elective care, meaning surgeries, screenings, and other treatments that are not considered urgent or emergencies. Hospitals began canceling some surgeries and limiting other services to protect people from being exposed to COVID-19 and to save resources such as hospital beds, personal protective equipment (PPE), blood supply, and staff time so they could be used to care for seriously ill patients with COVID-19.

Medical organizations such as the:

• American College of Surgeons
• American Society of Breast Surgeons
• American Society of Clinical Oncology
• American Society of Plastic Surgeons
• American Society for Radiation Oncology
• American College of Radiology
• National Comprehensive Cancer Network
• Society of Breast Imaging

and a newly formed group called the COVID-19 Pandemic Breast Cancer Consortium have all released recommendations to help healthcare providers make decisions about managing and prioritizing the care of people with breast cancer during the pandemic.

“Time will tell whether we made the right decisions in order to try to protect our patients from the virus and take care of the breast cancer,” said Jill Dietz, M.D., FACS, co-founder of the COVID-19 Pandemic Breast Cancer Consortium, president of the American Society of Breast Surgeons, and associate professor of surgery at Case Western Reserve University School of Medicine in Cleveland, Ohio. “Having a diagnosis of breast cancer at any time is very scary, and now it’s especially difficult. I feel so bad for the patients going through breast cancer treatment during the pandemic, and I feel bad for the physicians who were told they can’t practice like they normally practice.”

Doctors are looking at each person’s unique situation and diagnosis when deciding how to best move forward with breast cancer treatment during the pandemic. For example, they are looking at whether a person has a higher risk of becoming seriously ill from a COVID-19 infection due to a weakened immune system from treatments such as chemotherapy or targeted therapy, or because of their age or other health problems.

Healthcare facilities have adopted stricter safety practices to reduce the risk of exposing people to COVID-19. At the same time, many cancer treatment plans have been changed so people don’t have to spend as much time at these facilities. Medical appointments are being spread out to avoid close contact between people, more appointments are being done over the phone or online, and hospital stays after surgery have been shortened. In some cases, fewer in-person visits are required to complete chemotherapy or radiation therapy.

Still, all of the usual treatment options may not always be available to people with breast cancer during the pandemic. In the spring, for example, people may have had to wait weeks or months for certain breast cancer surgeries unless they were diagnosed with an aggressive type of breast cancer. Also, breast imaging was only available for urgent cases, access to new treatments through clinical trials was limited, and fertility-preserving procedures were not available in some places.

Donna-Marie Manasseh, M.D., chief of the division of breast surgery and director of the breast cancer program at Maimonides Medical Center in Brooklyn, NY, said the changes to treatment plans have been stressful for both patients and healthcare providers. But she wants people with breast cancer to know that healthcare providers are carefully considering their decisions, with the goal of providing the best care possible in these circumstances.

“It’s not that the COVID-19 patients became more important than the breast cancer patients,” she said. “We’re making a true, conscious effort to figure out the right things to do for our breast cancer patients — which includes protecting them from COVID-19 and treating their cancer.”

In May, when some areas of the country were seeing a drop in COVID-19 cases, the CDC and other health authorities said that healthcare systems should consider providing elective care again. Surgeries, screenings, and other care that had been put on hold started up again in many parts of the United States during May and June. But by late June and early July, restrictions on elective care started again in new hot spots such as Arizona, Texas, and Florida. As the situation evolves, changes in breast cancer care continue to happen in some places.

From www.breastcancer.org