Millions of elective surgeries and medical procedures were canceled or postponed by the COVID-19 pandemic. Now, research shows that COVID-19 restrictions were also associated with significant delays in breast cancer care.1
Findings of a cohort study, which compared breast cancer care before and after COVID-19 restrictions at an urban safety-net hospital, showed that local restrictions negatively affected breast cancer stage at presentation, time to treatment, and time to surgery, increasing the vulnerability of an already high-risk population.
During a press briefing at the American Society of Breast Surgeons 2022 Annual Meeting, authors of the study emphasized the need to minimize disruption to safety-net hospitals during future shutdowns or public health crises.
Kelly Kapp, MD
“We hypothesized that the COVID-19 pandemic would cause delays across all parameters studied, and our research corroborates this,” said lead study author Kelly Kapp, MD, PGY4 general surgery resident at the University of Missouri–Kansas City School of Medicine. “Given that our population already had a history of presenting with threefold higher rates of late-stage cancer before the pandemic, the increased risk and implications for care and outcomes are enormous.”
Following the first confirmed case of COVID-19 in the United States in January 2020, the Centers for Disease Control and Prevention (CDC) recommended postponing all elective procedures in March 2020. Although cancer surgeries continued, ASCO recommended suspending cancer screenings, including mammography, to decrease viral spread and to provide for the needs of the most critical.
As Dr. Kapp reported, even before the COVID-19 pandemic, women accessing this safety-net hospital had breast cancer screening rates well below the national average: 42% of patients older than 50 received screenings, whereas the national rate is 75% in this age group. In addition, patients at this safety-net hospital had a threefold higher rate of late-stage breast cancer at presentation compared with women accessing other Commission on Cancer–accredited centers across the country.
“The CDC voiced concern that the pandemic may lead to increased disparities among women already experiencing health inequities after observing an 87% decline in screening at the National Breast and Cervical Cancer Early Detection Program in April 2020 compared to the prior year,” said Dr. Kapp. “We were concerned that the public restrictions of the pandemic might further discourage our already vulnerable safety-net population.”
At their urban safety-net hospital, Dr. Kapp and colleagues conducted an institutional review board–approved cohort study of newly diagnosed patients with breast cancer. The COVID cohort spanned from March 2020, when the local “stay-at-home” order was issued, through February 2021, when restrictions were lifted. This was compared with a pre-COVID control cohort from March 2018 to February 2019.
Patients with new breast cancer diagnoses (n = 90 before the COVID pandemic and n = 82 during the COVID pandemic) were identified through an institutional cancer registry. Information on the stage at presentation, time to first treatment, time to surgery, and demographic information (including race and insurance payer) was collected and compared between cohorts using multivariate logistic regression.
Increase in Late-Stage Cancer Presentation
Findings of the study showed that the pandemic further exacerbated health disparities in this vulnerable population. Women accessing the urban safety-net hospital were 1.2 times more likely to present with late-stage breast cancer during COVID-19 restrictions than before (P < .05). Both cohorts had similar baseline characteristics with respect to race, age, and insurance, added Dr. Kapp.
Additionally, the median time to first treatment more than doubled under COVID-19 restrictions. According to Dr. Kapp, this increase may be explained by the significantly longer time from symptom to diagnosis during the pandemic. Of note, the time from diagnosis to first treatment was no different during COVID-19 restrictions than before, she said.
“Our clinics and essential breast cancer surgeries never stopped during the pandemic, but we are concerned that the ‘stay-at-home’ orders, public service announcements, and notices of limitations on health-care services may have disenfranchised these women from accessing breast cancer care at our safety-net hospital,” Dr. Kapp commented. “These delays in care could have long-term implications on morbidity and mortality.”
According to Dr. Kapp, these delays were likely caused by a range of factors. Safety-net hospital populations generally have less access to child care and transportation, she continued, and often lack remote work options, making their schedules less flexible.
With the possibility of new variants and future public health crises looming on the horizon, Dr. Kapp underscored the need to address how public protections may be exacerbating inequities, disproportionately disenfranchising already-vulnerable populations. As Dr. Kapp
explained, proactive outreach is important to help safeguard the health of safety-net populations. Public service announcements, communications through primary care physicians, and telephone reminders might “help re-engage women in their health care,” she said.
“As we make advances in breast cancer care, we do not want to leave a segment of the population behind,” Dr. Kapp concluded. “Patients at safety-net hospitals are already significantly disadvantaged, and COVID-19 set them back even more. We must make sure this does not happen again.”
Expert Point of View
Mediget Teshome, MD, MPH
Mediget Teshome, MD, MPH, Associate Professor of Breast Surgical Oncology at The University of Texas MD Anderson Cancer Center, Houston, said that recent data have illuminated widening disparities in health care caused by the COVID-19 pandemic, especially those related to income inequality.
“Clearly, more needs to be done to safeguard vulnerable populations and ensure that public health crises do not exacerbate preexisting inequities,” Dr. Teshome told The ASCO Post. “The biggest challenge is to build an adaptable infrastructure that can support these patients now while being mindful of potential earth-shattering events like the one we all experienced.”
Although COVID-19 restrictions may have “made sense from a public health standpoint at the time,” said Dr. Teshome, one of the unintended consequences of ‘stay-at-home’ orders has been an impact on cancer care. According to Dr. Teshome, patient outreach and community partnerships are important to ensure the continuity of cancer care during public health crises, but structural, systemwide solutions are needed, too. “There may be some strategies adopted and lessons learned during this time of crisis that can inform better ways to deliver care in the future to reach and support more patients,” she said.
DISCLOSURE: Dr. Kapp reported no conflicts of interest. Dr. Teshome reported no conflicts of interest.
1. Kapp K, Cheng, AL, Ahmadiyeh N, et al: Impact of COVID-19 restrictions on stage of breast cancer at presentation and time to treatment and surgery at an urban safety-net hospital. Press Briefing for the 2022 American Society of Breast Surgeons Annual Meeting. Presented April 6, 2022.