COVID-19 Pandemic Drove Strategic New Breast Cancer Approaches to Avoid Hospitalization

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The COVID-19 pandemic rapidly altered breast cancer treatment approaches, with a significant rise in neoadjuvant endocrine therapy for estrogen receptor–positive tumors, enabling immediate evidence-based treatment of women with an extremely common form of breast cancer, while delaying surgery and hospitalization. These were the preliminary findings of a new study presented by Lee Wilke, MD, and colleagues during the American Society of Breast Surgeons (ASBrS) Annual Meeting (Abstract 242).

The study also found that fewer immediate breast reconstructions were performed due to a growth in outpatient surgeries to avoid patient hospitalizations.

According to Dr. Wilke, Professor of Surgery at the University of Wisconsin School of Medicine and Public Health, the study presents an accurate snapshot of treatment changes wrought by the pandemic and was based on a representative geographic and ethnic cross section of patients entered into an ASBrS database.

Interestingly, COVID-related breast cancer treatment changes may have provided the context for testing new protocols, with some likely to persist beyond the pandemic.
— Lee Wilke, MD

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“Interestingly, COVID-related breast cancer treatment changes may have provided the context for testing new protocols, with some likely to persist beyond the pandemic,” she said.

Preliminary Analysis

The preliminary analysis focused on data collected from 2,476 patients entered in an embedded COVID segment in the ASBrS Mastery Program registry, which tracks the patient outcomes of ASBrS member surgeons, as well as 2,303 within the Mastery registry itself from March 1, 2020, to October 28, 2021. Data through March 15, 2021, showed similar trends and is now available.

Patient information was entered by 172 ASBrS breast surgeons nationwide and indicated whether treatment was consistent with usual protocols or modified due to COVID.

Treatment Changes

Researchers found that neoadjuvant endocrine therapy was used to treat an additional 36% of patients with estrogen receptor–positive/HER2-negative cancers than would have otherwise received the therapy. Patients who would have received neoadjuvant endocrine therapy in spite of the pandemic ranged from 6.5% to 7.8% in the two segments of the registry. Although the initial analysis reflects only data through the fall of 2020, according to Dr. Wilke, trends are likely to remain consistent throughout the study period.

She notes that many women with estrogen receptor–positive cancers, which generally have a good prognosis, receive antiestrogen endocrine therapy at some point during their treatment. However, most patients in the study would have received endocrine therapy following surgery if deemed appropriate—not in advance.

“During COVID, however, these drugs provided a way to start cancer treatments when hospitalization for breast cancer therapy was difficult or impossible due to operating room restrictions, with surgery then scheduled for a later date,” she said. “The rise in neoadjuvant endocrine therapy showed significant regional variation, appearing earlier in the northeastern and southeastern United States, correlating with earlier COVID infection spikes in these areas.”

Dr. Wilke also noted that treating estrogen receptor–positive cancers with neoadjuvant endocrine therapy was part of an initiative of the ASBrS and other well-recognized cancer societies to develop algorithm-based, tiered guidelines for alternative treatments to help hospitals avoid surgeries when possible.

“Especially early during the pandemic these revised treatments were necessary because access to hospital operating rooms was limited or unavailable. These algorithmic-based treatment guidelines allowed us to offer high-quality evidence-based care fine-tuned for a patient’s specific cancer profile.”

“Physicians also developed a series of options for further evaluating patients with the goal of delivering the most appropriate care possible,” she said. “For example, genomic testing on a core biopsy assessed the ability to forgo chemotherapy and thereby use neoadjuvant endocrine therapy or proceed to surgery. Patients that needed standard approaches still got them. Women with aggressive triple-negative and HER2-positive tumors were treated standardly with neoadjuvant chemotherapy.”

Researchers will continue to some follow patients post-pandemic to assess the effectiveness of COVID treatment strategies and the impact on their outcomes.

Dr. Wilke believes certain changes in treatment protocols may continue into the future.

“Internationally, neoadjuvant endocrine therapy is used far more frequently than in the United States, with good results,” she says. “Perhaps in the United States, we will see a shift in protocols with an increasing comfort level of endocrine therapy as an initial treatment for appropriate cancers.”

Disclosure: For full disclosures of the study authors, visit

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.