How has COVID-19 changed breast cancer care?

The pandemic has affected many aspects of breast cancer care in the United States and across the globe. From April 28 through June 7, 2020 more than 600 people shared how COVID-19 affected their breast cancer care in an online survey conducted by Breastcancer.org.

From these respondents (83% of whom live in the United States, and 42% of whom were in active treatment), we learned:

• There were delays in many aspects of breast cancer care, including routine clinical visits (32%), surveillance imaging (14%), routine mammograms (11%), reconstruction (10%), radiation therapy (5%), hormonal therapy (5%), mastectomy (5%), and chemotherapy (4%). About 30% reported no delays.
• About 30% reported they chose or considered delaying or changing their own treatment plans due to concerns about contracting COVID-19.
• About 11% reported that COVID-19 affected their desire or ability to get a second opinion.
• Other health conditions linked to a higher risk of complications from COVID-19 were common: 30% reported obesity, 28% had asthma, 15% had a heart condition, and 14% had diabetes.
• About 80% reported feeling some level of anxiety about their care being affected by the pandemic.
• More than half (58%) have used telemedicine, and about 45% found virtual appointments to be helpful and effective.
• About 67% reported being satisfied or very satisfied with the quality of care they were receiving.
• About 26% reported they or a family member had lost their job, and about 42% reported they or a family member had their hours cut.
• Our findings are similar to those reported by the American Cancer Society (ACS) from its survey of more than 1,200 people diagnosed with a variety of cancer types. In the ACS survey, 87% reported their healthcare was affected in some manner by early May, up from 51% in April. The most common changes for people in active treatment were for in-person cancer provider appointments (57%), imaging services (25%) and surgery (15%).
• Almost 1 in 4 people who took the ACS survey reported it was harder to contact healthcare providers. And 1 in 5 people said they were worried about their cancer growing or coming back due to interruptions in their care. Financial problems affecting their ability to pay for care was reported by 46%, and 23% were worried about losing their health insurance.

The following is a more detailed snapshot of some of the ways care changed for people with breast cancer during the first few months of the pandemic.

Breast surgery and reconstructive surgery

Since the pandemic began, many people with breast cancer have experienced changes to their surgical treatment and reconstruction plans at medical centers around the United States.

Certain procedures have been postponed. Mastectomies and lumpectomies have been taking place without much delay for people who urgently need them. For example, some people with more aggressive types of breast cancer, such as triple-negative or HER2-positive breast cancer, have been able schedule a lumpectomy or mastectomy if their doctors determined it was the best treatment plan for them. Some people with other types of breast cancer have been offered the option of having a lumpectomy or mastectomy without much delay. But immediate reconstruction (meaning reconstruction that happens during the same surgery as the mastectomy) may not be available when elective surgeries are being postponed. Still, some hospitals do allow people who meet certain criteria to have immediate reconstruction with a tissue expander or breast implant without delay in these situations.

“Reconstructions were postponed not only to preserve hospital resources, but also to protect patients,” said Robin M. Ciocca, D.O., a breast surgical oncologist at Main Line Health in Wynnewood, Pa. “Having immediate reconstruction can increase the length of the hospital stay, increase the recovery time, and increase the risk of complications from the surgery, all of which we wanted to avoid when there was also a risk of being exposed to COVID-19.”

Treatment before surgery (neoadjuvant treatment) was used when surgeries were delayed. Many people who had to wait weeks or months for a lumpectomy or mastectomy were given either hormonal therapy, chemotherapy, or targeted therapies (depending on their diagnosis) while they waited. Treatment given before surgery — which doctors call neoadjuvant therapy — can slow or stop the growth of the cancer and may shrink some tumors. Neoadjuvant therapies are being used more often than usual in the United States during the pandemic.

In addition to some mastectomies, lumpectomies, and immediate reconstruction surgeries, the following procedures have in many cases been postponed:

• delayed reconstruction with a tissue expander, breast implant, or autologous tissue flap (that takes place sometime after a mastectomy or lumpectomy surgery and after other breast cancer treatments are completed)
• follow-up or corrective breast reconstruction surgeries, such as procedures to swap out tissue expanders for breast implants and procedures to correct asymmetry
• appointments to fill tissue expanders
• preventive (prophylactic) mastectomies to reduce the risk of developing breast cancer in women who have a genetic mutation or other risk factors that put them at high risk for breast cancer

The changes to surgical treatment plans resulted in some people needing more surgeries overall. Dhivya Srinivasa, M.D., a plastic surgeon and academic faculty member at Cedars-Sinai in Los Angeles, said some of her patients needed a second procedure because they weren’t able to get the surgery they wanted at the beginning of the pandemic.

“I have a patient who was getting a single mastectomy and wanted an immediate DIEP flap [autologous] reconstruction. She was a perfect candidate for it. But because her surgery was at the end of March, when we weren’t able to do flap reconstruction, she got an implant then and is getting the DIEP flap as a separate surgery in June,” she said.

Two of her other patients had planned to get a lumpectomy and a breast reduction in one operation, but had to get them as separate operations. “It was unfortunate for the patients who had to have multiple surgeries, but state mandates allowed for no other options,” said Dr. Srinivasa.

Many hospitals started doing elective surgeries without delays in May and June, but this continues to change as the situation evolves.

“Initial restrictions on elective surgeries were appropriately broad in the face of the healthcare crisis presented by the pandemic, but as the months pass and conditions stabilize, I think we must return to the standard of care for our patients,” said Elisabeth Potter, M.D., a plastic surgeon in Austin, Texas, and affiliate faculty member in the department of surgery and perioperative care at the University of Texas at Austin Dell Medical School.

Dr. Potter said that even in areas with spikes in COVID-19 cases, surgeons can work with hospital administrators to advocate for surgeries to take place without delays when that is what’s in the best medical interest of the patient.

Systemic therapy (chemotherapy, hormonal therapy, targeted therapy, immunotherapy)

People who were scheduled to start or to continue receiving chemotherapy, hormonal therapy, immunotherapy, or targeted therapy mostly did so without delays, although there were adjustments to treatment plans.

Appointments with oncologists often took place through telemedicine rather than in person. And oncologists postponed some appointments if they felt it was safer to do so.

Brian Wojciechowski, M.D., a medical oncologist at Riddle, Taylor, and Crozer hospitals in Delaware County, Pa., and Breastcancer.org medical adviser, said that during March and April he was mainly seeing patients in person who had an urgent issue, such as someone who had discovered a new breast lump. “But we delayed in-person visits if we didn’t think delaying would cause harm or risk for the patient,” he said. “For instance, if a patient is a long-term breast cancer survivor whom I usually see for routine follow up every 6 months or so, we could delay that appointment for 3 months.”

Here are other examples of how treatment changed:

• As mentioned above, certain people who had a mastectomy or lumpectomy delayed by weeks or months were given either hormonal therapy, chemotherapy, or targeted therapy before surgery. This approach can prevent the cancer from progressing and can potentially shrink tumors.
• Some cancer centers have been requiring that patients get a COVID-19 test before a chemotherapy treatment. If the person tests positive for COVID-19, in most cases they won’t receive chemotherapy until they are re-tested at a later point and found to be negative. This is to protect them from developing serious complications from a COVID-19 infection because they are immunocompromised due to chemotherapy.
• In some cases, chemotherapy regimens that required a weekly visit to an infusion center were switched to a visit every 3 weeks if it would not change the effectiveness of the treatment.
• People receiving chemotherapy were more often prescribed growth factor medications such as Neulasta (chemical name: pegfilgrastim) to increase their white blood cell count and make them less vulnerable to developing serious complications if they were infected with COVID-19.
• Infusion centers made changes to help keep people safer, such as staggering appointment times, seating people in private infusion rooms or in seats spaced further apart than usual, not allowing visitors, and screening everyone for COVID-19 symptoms before they enter the building. Also, some people started getting routine lab tests (such as blood tests) done at another facility so that visits to the infusion center could be shorter.
• Some cancer centers have set up curbside clinics so people can receive services like blood draws and injections in their car.
• People who were receiving GnRH agonists given by injection such as Zoladex (chemical name: goserelin) or Lupron (chemical name: leuprolide) in some cases switched from receiving them at a clinic to administering them at home, or started receiving a different dose less frequently. Some people reported having trouble getting their injections on time or at the healthcare facilities where they usually received them.

From www.breastcancer.org