Management of Breast Cancer During the COVID-19 Pandemic: A Stage- and Subtype-Specific Approach

Did the COVID-19 consortium recommendations impact the treatment of breast cancer during the COVID-19 pandemic?

PURPOSE

We examined the impact of the COVID-19 consortium recommendations on the surgical management of breast cancer during the first year of the pandemic.

METHODS

Patients with newly diagnosed ER + DCIS, ER- DCIS, AJCC Stage cT1-2N0-1 ER + , HER2-, HER2 + , and triple negative breast cancer were identified from the National Cancer Database from 2018 to 2021. An interrupted time series design evaluated differences in surgical delay and use of neoadjuvant chemotherapy/immunotherapy (NAC) and endocrine therapy (NET) before and after the pandemic.

RESULTS

A total of 895116 female patients were included in the study with a mean age of 61.7 years. Time to surgery decreased by an average 5.5 days from January 2020 to May 2020 for all breast cancer types, corresponding with a 62.2% decrease in breast cancer diagnoses per month from January 2020 to April 2020. The use of NET increased from 5.6 to 23.6% from January to March 2020 for patients with ER + DCIS and 8.0 to 31.1% for ER + cT1-2N0 cancer (both p < 0.01). The use of NAC for HER2 + tumors and triple negative breast cancers has been increasing since 2018 and a larger than expected increase was seen from 57.2 to 63.6% for HER2 + tumors and 55.6 to 68.7% for triple negative breast cancers (both p < 0.01). Treatment practices returned to pre-pandemic levels in June 2020.

CONCLUSION

Prior to the publication of the Consortium recommendations, time to surgery decreased while the use of NET and NAC increased, with the resumption of pre-pandemic practices by June 2020.

Impact of the COVID-19 Pandemic on Breast Cancer Patient Care: Results From a Tertiary Care Center in Lebanon

PURPOSE

We aimed to evaluate the impact of COVID-19 on breast cancer care in terms of the stage at presentation, treatment delays, and follow-up in a tertiary care center in Lebanon.

MATERIALS AND METHODS

This retrospective study compared patients with breast cancer who presented to a tertiary care center in Lebanon before (September 2019-December 2019) and during (September 2020-December 2020) the COVID-19 pandemic. We extracted data from the electronic medical records of patients with breast cancer who had their initial presentation, were under treatment, or were on follow-up during our period of interest.

RESULTS

Of the 333 patients, 186 visited the hospital in the pre-COVID-19 period and 147 during the pandemic, showing almost a 12% reduction in the number of patients during the COVID-19 pandemic. In the pre-COVID period, more patients were presented for screening (52%); however, more symptomatic patients were presented during the pandemic (51.4%). Almost 54% had an advanced stage at presentation during the pandemic compared with 48% before the pandemic but with no statistical significance (P = .50). Significantly fewer patients came for chemotherapy in the COVID-19 period (38.1%) compared with the pre-COVID-19 period (52.2%). Fewer patients underwent surgery during the pandemic, although the difference was not statistically significant. Multivariate analysis showed that the COVID-19 pandemic was not associated with having an advanced stage at presentation (P = .24).

CONCLUSION

The management of breast cancer was not substantially affected by the COVID-19 pandemic in a sample of Lebanese patients. However, 4 months might not be sufficient to draw a solid conclusion.

Time From Screening to Treatment at Accredited Breast Centers in the United States

PURPOSE

The National Accreditation Program for Breast Centers (NAPBC) launched the Patient-Reported Observations for Medical Procedure Timeliness quality collaborative to assess time intervals between screening and treatment for patients with breast cancer.

METHODS

Sites submitted monthly timeliness data in calendar days from 2019 to 2021 along with their perceptions of timeliness at their centers and facility characteristics. All patients were included in the interval from screening to diagnosis, whereas only patients with cancer were included in the biopsy to treatment intervals. Institutions were compared and assessed for differences and associations with center characteristics via the Kruskal-Wallis test.

RESULTS

Three hundred seventy-three (64.5%) NAPBC-accredited breast centers enrolled, and 311 (83.3%) provided complete timeliness metrics. Two hundred nine (56%) sites did not have trainees, 154 (41.3%) sites were within 10 miles of a major city, and the median number of annual breast cancer cases was 280 (IQR, 189-366). From 2019 to 2021, the time between diagnosis and treatment was as follows: 11-12 days between screening mammogram (MGM) and diagnostic MGM, 8-9 days between diagnostic MGM and biopsy, 32-34 days between biopsy and neoadjuvant therapy, and 39-42 days between biopsy and surgery. The enrolled centers believe that these intervals should be 7, 7, 21, and 28 days, respectively. Higher annual case volume and a larger number of surgeons exclusively devoted to breast disease were significantly associated with longer time intervals.

CONCLUSION

Time from biopsy to first treatment is longer than that centers expected compared with time from screening to diagnosis. There is significant variability across NAPBC in time from screening mammogram to treatment, and some institutions will face more challenges with timely quality measures than others. Further investigation into whether these differences confer outcome differences should be pursued.

Impact of the Coronavirus disease pandemic on early breast cancer

Objective

To assess the impact of the COVID-19 pandemic on the presentation, treatment, and survival of patients with early breast cancer (Stage I-III).

Methods

This study utilized data from the Surveillance, Epidemiology, and End Results database from January 1, 2018, to December 31, 2020. Patients diagnosed with primary breast cancer in 2020 were compared to those diagnosed in 2018 or 2019. The primary outcomes were stage distribution and changes in the treatment modalities for early breast cancer. The secondary outcomes were overall survival (OS) and breast cancer-specific survival (BCSS).

Results

We analyzed 142,038 patients. There has been a decrease in breast cancer diagnoses in 2020, as well as the smaller number of surgeries. The distribution of breast cancer stages among patients exhibited a notable shift in 2020, with a decrease in the proportion of Stage 0-I and an increase in advanced-stage. Additionally, there was a significant decrease in the proportion of breast-conserving surgery (BCS) performed in 2020. The proportion of patients undergoing radiation decreased, while that of chemotherapy cases increased significantly in 2020. Patients showed a shorter treatment delay in 2020 than in 2018 or 2019 (2018: hazard ratio [HR] = 0.969, 95% confidence interval [CI] = 0.956-0.982, p < 0.001; 2019: HR=0.959, 95% CI = 0.946-0.972, p < 0.001). Diagnosis in 2020 showed a significant correlation with worse OS than diagnosis in 2018 (HR = 0.861, 95% CI = 0.743-0.996, p = 0.045).

Conclusion

We observed a shift to advanced-stage and a change of treatment modalities of early breast cancer in 2020. The OS of patients with breast cancer was worse during the pandemic than before the pandemic. The findings could provide empirical basis for optimizing cancer prevention and control strategies in future public health emergencies.

Shifting the Paradigm: The Transformative Role of Neoadjuvant Therapy in Early Breast Cancer

The use of neoadjuvant systemic therapy (NST) has become increasingly important in the treatment of breast cancer because of its various advantages. These include the ability to downstage tumors without compromising locoregional control and the potential to obtain valuable information about clinical and biological response to therapy with implications for individual prognoses. Surgical response assessment paves the way for response-adapted therapy, and pathological complete response (pCR; defined as ypT0/is ypN0) serves as an additional endpoint for drug development trials. Recommended NST regimens commonly consist of anthracyclines and taxane, with dose-dense anthracyclines and weekly paclitaxel often preferred, whenever feasible. For patients with human epidermal growth factor receptor-2 (HER2)-positive tumors, dual anti-HER2 therapy (trastuzumab and pertuzumab) is indicated together with NST in case of elevated risk of recurrence. For patients with triple-negative breast cancer (TNBC), adding carboplatin to NST correlates with improved pCR and survival rates, as does the addition of immune checkpoint inhibitors. For hormone receptor (HR)-positive/HER2-negative cancers, emerging data on NST including immune checkpoint inhibitors may elevate the significance of NST in high-risk luminal breast cancer. Here, we present a synthesis of the results from neoadjuvant clinical trials that aim at optimizing treatment options for patients with high-risk breast cancer.

Impact of in vitro SARS-CoV-2 infection on breast cancer cells

The pandemic of coronavirus disease 19 (COVID-19), caused by severe respiratory syndrome coronavirus 2 (SARS-CoV-2), had severe repercussions for breast cancer patients. Increasing evidence indicates that SARS-CoV-2 infection may directly impact breast cancer biology, but the effects of SARS-CoV-2 on breast tumor cells are still unknown. Here, we analyzed the molecular events occurring in the MCF7, MDA-MB-231 and HCC1937 breast cancer cell lines, representative of the luminal A, basal B/claudin-low and basal A subtypes, respectively, upon SARS-CoV-2 infection. Viral replication was monitored over time, and gene expression profiling was conducted. We found that MCF7 cells were the most permissive to viral replication. Treatment of MCF7 cells with Tamoxifen reduced the SARS-CoV-2 replication rate, suggesting an involvement of the estrogen receptor in sustaining virus replication in malignant cells. Interestingly, a metagene signature based on genes upregulated by SARS-CoV-2 infection in all three cell lines distinguished a subgroup of premenopausal luminal A breast cancer patients with a poor prognosis. As SARS-CoV-2 still spreads among the population, it is essential to understand the impact of SARS-CoV-2 infection on breast cancer, particularly in premenopausal patients diagnosed with the luminal A subtype, and to assess the long-term impact of COVID-19 on breast cancer outcomes.

Breast cancer incidence, stage distribution, and treatment shifts during the 2020 COVID-19 pandemic: a nationwide population-level study

BACKGROUND

The first COVID-19 wave in 2020 necessitated temporary suspension of non-essential medical services including organized cancer screening programs in Belgium. This study assessed the impact of the pandemic on breast cancer (BC) incidence, stage at diagnosis, and management in Belgium in 2020.

METHODS

All Belgian residents diagnosed with in situ or invasive BC in 2015-2020 in the nationwide, population-based cancer registry database were included. Incidence trends for 2015-2019 were extrapolated to predict incidence and stage distribution for 2020 and compared with the observed values. National healthcare reimbursement data were used to examine treatment strategies. Exact tumor diameter and nodal involvement, extracted from pathology reports, were analyzed for 2019 and 2020.

RESULTS

74,975 tumors were selected for analysis of incidence and clinical stage. Invasive BC incidence declined by -5.0% in 2020, with a drop during the first COVID-19 wave (Mar-Jun; -23%) followed by a rebound (Jul-Dec; +7%). Predicted and observed incidence (in situ + invasive) was not different in patients < 50 years. In the 50-69 and 70 + age groups, significant declines of -4.1% and - 8.4% respectively were found. Excess declines were seen in clinical stage 0 and I in Mar-Jun, without excess increases in clinical stage II-IV tumors in Jul-Dec. There was no increase in average tumor diameter or nodal involvement in 2020. Patients diagnosed in Mar-Jun received significantly more neoadjuvant therapy, particularly neoadjuvant hormonal therapy for patients with clinical stage I-II BC.

CONCLUSIONS

BC incidence decline in 2020 in Belgium was largely restricted to very early-stage BC and patients aged 50 and over. Delayed diagnosis did not result in an overall progression to higher stage at diagnosis in 2020. Observed treatment adaptations in Belgium were successful in prioritizing patients for surgery while preventing tumor progression in those with surgical delay. Continuation of monitoring BC incidence and stage in the future is crucial.

Impact of COVID-19 on patients with metastatic breast cancer: REthink Access to Care and Treatment survey results

Aim: Patients with metastatic breast cancer (MBC) may be vulnerable to changes in healthcare management, safety standards and protocols that occurred during the COVID-19 pandemic.Materials & methods: The REthink Access to Care & Treatment (REACT) survey assessed USA-based patient perspectives on COVID-19-related impacts to their MBC treatment experience between 27 April 2021 and 17 August 2021.Results: Participants (n = 341; 98.5% females, mean age 50.8 years) reported that overall oncology treatment quality was maintained during the pandemic. Delayed/canceled diagnostic imaging was reported by 44.9% of participants while telemedicine uptake was high among participants (80%).Conclusion: Overall, MBC care was minimally affected by the pandemic, possibly due to the expanded use of telemedicine, informing MBC management for future public health emergencies.

Feasibility of Symptom Monitoring During the First Year of Endocrine Therapy for Early Breast Cancer Using Patient-Reported Outcomes Collected via Smartphone App

PURPOSE

Treatment-associated symptoms drive early discontinuation of adjuvant endocrine therapy (ET) for breast cancer. We hypothesized that symptom monitoring with electronic patient-reported outcomes (ePROs) during adjuvant ET will enhance symptom detection, symptom management, and persistence.

METHODS

Eligible patients were initiating ET for stage 0-III breast cancer. Participants completed ePRO surveys via smartphone at baseline and 1, 3, 6, and 12 months. Measures included Patient-Reported Outcomes Measurement Information System Anxiety, Depression, Fatigue, and Vaginal Discomfort; plus Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events items assessing joint pain, hot flashes, vaginal dryness, concentration problems, and memory problems. Scores surpassing prespecified thresholds triggered alerts, and recommended symptom management pathways were provided to clinicians. The primary objective was to evaluate feasibility, assessed by survey completion rates, with targets of >65% for the baseline survey and ≥1 follow-up survey during the first 6 months. Secondary objectives included 12-month ET discontinuation rate (target: ≤15%), describing symptoms and evaluating pathway implementation.

RESULTS

Among 250 participants, 73.2% completed the baseline survey and 69.6% completed ≥1 follow-up survey during the first 6 months. Thirty-one percent of participants had ≥1 symptom alert at baseline and 74% had ≥1 symptom alert during follow-up. The proportions of participants for whom pathway-concordant symptom management was documented at each time point ranged from 12.8% to 36.6%. Twenty-eight participants (11.2%) discontinued ET by 12 months.

CONCLUSION

Symptom monitoring with ePROs during adjuvant ET is feasible. Despite infrequent documentation of pathway-concordant symptom management after symptom alerts, ePROs were associated with favorable short-term ET persistence.

Mortality of COVID-19 in patients with hematological malignancies versus solid tumors: a systematic literature review and meta-analysis

Cancer patients are more vulnerable to COVID-19 compared to the general population, but it remains unclear which types of cancer have the highest risk of COVID-19-related mortality. This study examines mortality rates for those with hematological malignancies (Hem) versus solid tumors (Tumor). PubMed and Embase were systematically searched for relevant articles using Nested Knowledge software (Nested Knowledge, St Paul, MN). Articles were eligible for inclusion if they reported mortality for Hem or Tumor patients with COVID-19. Articles were excluded if they were not published in English, non-clinical studies, had insufficient population/outcomes reporting, or were irrelevant. Baseline characteristics collected included age, sex, and comorbidities. Primary outcomes were all-cause and COVID-19-related in-hospital mortality. Secondary outcomes included rates of invasive mechanical ventilation (IMV) and intensive care unit (ICU) admission. Effect sizes from each study were computed as logarithmically transformed odds ratios (ORs) with random-effects, Mantel-Haenszel weighting. The between-study variance component of random-effects models was computed using restricted effects maximum likelihood estimation, and 95% confidence intervals (CIs) around pooled effect sizes were calculated using Hartung-Knapp adjustments. In total, 12,057 patients were included in the analysis, with 2,714 (22.5%) patients in the Hem group and 9,343 (77.5%) patients in the Tumor group. The overall unadjusted odds of all-cause mortality were 1.64 times higher in the Hem group compared to the Tumor group (95% CI: 1.30-2.09). This finding was consistent with multivariable models presented in moderate- and high-quality cohort studies, suggestive of a causal effect of cancer type on in-hospital mortality. Additionally, the Hem group had increased odds of COVID-19-related mortality compared to the Tumor group (OR = 1.86 [95% CI: 1.38-2.49]). There was no significant difference in odds of IMV or ICU admission between cancer groups (OR = 1.13 [95% CI: 0.64-2.00] and OR = 1.59 [95% CI: 0.95-2.66], respectively). Cancer is a serious comorbidity associated with severe outcomes in COVID-19 patients, with especially alarming mortality rates in patients with hematological malignancies, which are typically higher compared to patients with solid tumors. A meta-analysis of individual patient data is needed to better assess the impact of specific cancer types on patient outcomes and to identify optimal treatment strategies.

Therapy delay due to COVID-19 pandemic among European women with breast cancer: prevalence and associated factors

PURPOSE

This study investigates the impact of the COVID-19 pandemic on breast cancer (BC) care, analyzing treatment delays and factors associated with them.

METHODS

This retrospective cross-sectional study analyzed data from the Oncology Dynamics (OD) database. Surveys of 26,933 women with BC performed between January 2021 and December 2022 in Germany, France, Italy, the United Kingdom, and Spain were examined. The study focused on determining the prevalence of treatment delays due to the COVID-19 pandemic, considering factors such as country, age group, treating facility, hormone receptor status, tumor stage, site of metastases, and Eastern Cooperative Oncology Group (ECOG) status. Baseline and clinical characteristics were compared for patients with and without therapy delay using chi-squared tests, and a multivariable logistic regression analysis was conducted to explore the association between demographic and clinical variables and therapy delay.

RESULTS

The present study found that most therapy delays lasted less than 3 months (2.4%). Factors associated with higher risk of delay included being bedridden (OR 3.62; 95% CI 2.51-5.21), receiving neoadjuvant therapy (OR 1.79; 95% CI 1.43-2.24) compared to adjuvant therapy, being treated in Italy (OR 1.58; 95% CI 1.17-2.15) compared to Germany or treatment in general hospitals and non-academic cancer facilities (OR 1.66, 95% CI 1.13-2.44 and OR 1.54; 95% CI 1.14-2.09, respectively) compared to treatment by office-based physicians.

CONCLUSION

Addressing factors associated with therapy delays, such as patient performance status, treatment settings, and geographic location, can help guide strategies for improved BC care delivery in the future.

Neoadjuvant endocrine therapy in ER-positive breast cancer: evolution, indication, and tailored treatment strategy

In recent years, endocrine therapy (ET), an effective systemic treatment for the management of estrogen receptor (ER)-positive breast cancers, has regained interest as a neoadjuvant therapy based on evidence that ET can fulfill the aim of neoadjuvant systemic treatment for tumor shrinkage as well as elucidate important clinical information on endocrine sensitivity that enables the prognostication of patients. Moreover, neoadjuvant endocrine therapy (NET) potentially provides an opportunity for early assessment of the clinical efficacy of novel agents. Furthermore, recently reported trials have generated evidence for a more tailored approach for perioperative management of ER-positive breast cancer using clinical and molecular biomarkers, and this has provided a rationale that enables the broadening of clinical indications for NET. This review discusses the current evidence for NET, the evolution of NET trials, clinical indications, and NET-based treatment strategies.

Factors associated with the time to treat breast cancer in the pandemic period: an observational study

OBJECTIVES

to analyze the factors associated with the time to surgical treatment for breast cancer in patients seen at a reference mastology outpatient clinic in the State of Ceará.

METHODS

analytical, longitudinal study with medical charts from the Mastology Outpatient Clinic of Assis Chateaubriand Maternity School. We used 140 medical charts of breast cancer patients with surgeries performed during the pandemic.

RESULTS

the study evidenced associations between schooling and shorter time to treatment in patients who underwent biopsy before the first outpatient visit (p = 0.026; OR: 0.16; CI = 0.03-0.85); in the group who had the biopsy performed by the outpatient clinic, was associated the type of tumor (p = 0.019) and neoadjuvant therapy (p = 0.000).

CONCLUSIONS

the lesser educational level, tumor type, and use of neoadjuvant therapy were factors associated with the time to treatment during the pandemic period.

COVID-19 and Breast Cancer: Analysis of Surgical Management of a Large Referral Center during the 2020-2021 Pandemic Period

BACKGROUND

Coronavirus disease-19 (COVID-19) has spread worldwide since December 2019 and was officially declared a pandemic in March 2020. Due to the rapid transmission and the high fatality rate, drastic emergency restrictions were issued, with a negative impact on routine clinical activities. In particular, in Italy, many authors have reported a reduction in the number of breast cancer diagnoses and critical problems in the management of patients who accessed the breast units during the dramatic first months of the pandemic. Our study aims to analyze the global impact of COVID-19 in the two years of the pandemic (2020-2021) on the surgical management of breast cancer by comparing them with the previous two years.

METHODS

In our retrospective study, we analyzed all cases of breast cancer diagnosed and surgically treated at the breast unit of "Città della Salute e della Scienza" in Turin, Italy, making a comparison between the 2018-2019 pre-pandemic period and the 2020-2021 pandemic period.

RESULTS

We included in our analysis 1331 breast cancer cases surgically treated from January 2018 to December 2021. A total of 726 patients were treated in the pre-pandemic years and 605 in the pandemic period (-121 cases, 9%). No significant differences were observed regarding diagnosis (screening vs. no screening) and timing between radiological diagnosis and surgery for both in situ and invasive tumors. There were no variations in the breast surgical approach (mastectomy vs. conservative surgery), while a reduction in axillary dissection compared to the sentinel lymph node in the pandemic period was observed (p-value < 0.001). Regarding the biological characteristics of breast cancers, we observed a greater number of grades 2-3 (p-value = 0.007), pT stage 3-4 breast cancer surgically treated without previous neoadjuvant chemotherapy (p-value = 0.03), and a reduction in luminal B tumors (p-value = 0.007).

CONCLUSIONS

Overall, we report a limited reduction in surgical activity for breast cancer treatment considering the entire pandemic period (2020-2021). These results suggest a prompt resumption of surgical activity similar to the pre-pandemic period.

Palliative Care in Breast Cancer During the COVID-19 Pandemic: A Scoping Review

BACKGROUND

The COVID-19 pandemic has harmed the provision of palliative care (PC) services for women with breast cancer due to all the restrictions that came along with the virus.

OBJECTIVE

To map the available evidence on the situation of PC in breast cancer during the COVID-19 pandemic.

METHODS

A scoping review was carried out based on the methodology proposed by the Joanna Briggs Institute. The search was conducted in nine databases, one electronic repository, and one library, using controlled vocabularies.

RESULTS

Twenty-nine articles and seven documents were included. The majority (11.4% each) were published in the United Kingdom, Italy, and the United States, 38.9% addressed palliative radiotherapy (RT), and 47.2% consisted of recommendations. From the content analysis, five categories were obtained focused on the recommendations on changes in palliative treatment guidelines and the response of PC teams to the evolving crisis.

CONCLUSIONS

The evidence pointed to the management of general PC, palliative RT, palliative chemotherapy, management of metastatic breast cancer, and use of technologies in palliative care. No recommendations were found to manage frequent symptoms in PC, indicating the need to develop primary studies that investigate these aspects in detail in this vulnerable group.

IMPLICATIONS

The results contained in this document can provide professionals working in this field of care with a global view of how other teams have dealt with the pandemic, thereby identifying the best guidelines to apply in their reality, taking into account the clinical and social situation of each patient.

A Qualitative Study of the Impact of the COVID-19 Pandemic on Metastatic Breast Cancer Care

The COVID-19 pandemic substantially impacted the delivery of oncology care, particularly for individuals with metastatic cancers. The objective of this study was to qualitatively evaluate the impacts of COVID-19 on metastatic breast cancer (MBC) care among patients. This study consisted of 36 semi-structured qualitative interviews conducted virtually with people living with MBC, who were members of a patient support organization called Project Life. Project Life is an MBC patient-led, web-based wellness community. Responses were analyzed using Phronetic Iterative Analysis. Interviews were conducted from March 14, 2022, to May 31, 2022. Analysis from 36 individual in-depth qualitative interviews revealed the following themes during COVID-19: (1) variable preferences for telehealth (2) disruptions to care, (3) virtualization of social care. Wide variations existed in preferences surrounding telehealth, centered around ideas of convenience. Disruptions to care included delays to diagnostic care, isolation from caregivers, and interruptions associated with COVID-19 infection. These results call for adaptability in oncology care given wide-ranging preferences on telehealth and the shifting of available support services.

Neoadjuvant endocrine therapy in postmenopausal women with HR+/HER2- breast cancer

INTRODUCTION

While endocrine therapy is the standard-of-care adjuvant treatment for hormone receptor-positive (HR+) breast cancers, there is also extensive evidence for the role of pre-operative (or neoadjuvant) endocrine therapy (NET) in HR+ postmenopausal women.

AREAS COVERED

We conducted a thorough review of the published literature, to summarize the evidence to date, including studies of how NET compares to neoadjuvant chemotherapy, which NET agents are preferable, and the optimal duration of NET. We describe the importance of on-treatment assessment of response, the different predictors available (including Ki67, PEPI score, and molecular signatures) and the research opportunities the pre-operative setting offers. We also summarize recent combination trials and discuss how the COVID-19 pandemic led to increases in NET use for safe management of cases with deferred surgery and adjuvant treatments.

EXPERT OPINION

NET represents a safe and effective tool for the management of postmenopausal women with HR+/HER2- breast cancer, enabling disease downstaging and a wider range of surgical options. Aromatase inhibitors are the preferred NET, with evidence suggesting that longer regimens might yield optimal results. However, NET remains currently underutilised in many territories and institutions. Further validation of predictors for treatment response and benefit is needed to help standardise and fully exploit the potential of NET in the clinic.

The impact of the SARS-COV-2 pandemic on the quality of breast cancer care in EUSOMA-certified breast centres

AIMS

We analysed the impact of the SARS-CoV-2 pandemic (COVID-19) on the quality of breast cancer care in certified EUSOMA (European Society of Breast Cancer Specialists) breast centres.

MATERIALS AND METHODS

The results of the EUSOMA quality indicators were compared, based on pseudonymised individual records, for the periods 1 March 2020 till 30 June 2020 (first COVID-19 peak in most countries in Europe) and 1 March 2019 till 30 June 2019. In addition, a questionnaire was sent to the participating Centres for investigating the impact of the COVID-19 pandemic on the organisation and the quality of breast cancer care.

RESULTS

Forty-five centres provided data and 31 (67%) responded to the questionnaire. The total number of new cases dropped by 19% and there was a small significant higher tumour (p = 0.003) and lymph node (p = 0.011) stage at presentation. Comparing quality indicators (12,736 patients) by multivariable analysis showed mostly non-significant differences. Surgery could be performed in a COVID-free zone in 94% of the centres, COVID testing was performed before surgery in 96% of the centres, and surgical case load was reduced in 55% of the centres. Modifications of the indications for neoadjuvant endocrine therapy, chemotherapy, and targeted therapy were necessary in 23%, 23%, and 10% of the centres; changes in indications for adjuvant endocrine, chemo-, targeted, immune, and radiotherapy in 3%, 19%, 3%, 6%, and 10%, respectively.

CONCLUSION

Quality of breast cancer care was well maintained in EUSOMA breast centres during the first wave of the COVID-19 pandemic. A small but significantly higher tumour and lymph node stage at presentation was observed.

Current challenges and unmet needs in treating patients with human epidermal growth factor receptor 2-positive advanced breast cancer

Human epidermal growth factor receptor 2 oncogene (HER2-positive) overexpression/amplification occurs in less than 20% of breast cancers and has traditionally been associated with poor prognosis. Development of therapies that target HER2 has significantly improved outcomes for patients with HER2-positive advanced breast cancer (ABC). Currently available HER2-targeted agents include the monoclonal antibodies trastuzumab, pertuzumab, and margetuximab, the small-molecule inhibitors lapatinib, tucatinib, neratinib, and pyrotinib, as well as the antibody-drug conjugates trastuzumab emtansine and trastuzumab deruxtecan. Optimal sequencing of these agents in the continuum of the disease is critical to maximize treatment outcomes. The large body of clinical evidence generated over the past 2 decades aids clinicians in treatment decision-making. However, patients with HER2-positive ABC and specific disease characteristics and/or comorbidities, such as leptomeningeal disease, brain metastases, or cardiac dysfunction, are generally excluded from large randomized clinical trials, and elderly or frail patients are often underrepresented. In addition, there is great inequality in the accessibility of approved drugs across countries. This article addresses various challenging clinical situations when treating patients with HER2-positive ABC. The objective is to provide guidance to clinicians on how and when HER2-targeted therapies and additional treatments can be best implemented in routine clinical practice, on the basis of existing clinical evidence and expert opinion where needed.

Cancer Patients First Treated with Chemotherapy: Are They More Likely to Receive Surgery in the Pandemic?

Due to the ramping down of cancer surgery in early pandemic, many newly diagnosed patients received other treatments first. We aimed to quantify the pandemic-related shift in rate of surgery following chemotherapy. This is a retrospective population-based cohort study involving adults diagnosed with cancer between 3 January 2016 and 7 November 2020 in Ontario, Canada who received chemotherapy as first treatment within 6-months of diagnosis. Competing-risks regression models with interaction effects were used to quantify the association between COVID-19 period (receiving a cancer diagnosis before or on/after 15 March 2020) and receipt of surgical reSection 9-months after first chemotherapy. Among 51,653 patients, 8.5% (n = 19,558) of them ultimately underwent surgery 9-months after chemotherapy initiation. Receipt of surgery was higher during the pandemic than before (sHR 1.07, 95% CI 1.02-1.13). Material deprivation was independently associated with lower receipt of surgery (least vs. most deprived quintile: sHR 1.11, 95% CI 1.04-1.17), but did not change with the pandemic. The surgical rate increase was most pronounced for breast cancer (sHR 1.13, 95% CI 1.06-1.20). These pandemic-related shifts in cancer treatment requires further evaluations to understand the long-term consequences. Persistent material deprivation-related inequity in cancer surgical access needs to be addressed.

Comparison of Use of Neoadjuvant Systemic Treatment for Breast Cancer and Short-term Outcomes Before vs During the COVID-19 Era in Ontario, Canada

IMPORTANCE

In response to an increase in COVID-19 infection rates in Ontario, several systemic treatment (ST) regimens delivered in the adjuvant setting for breast cancer were temporarily permitted for neoadjuvant-intent to defer nonurgent breast cancer surgical procedures.

OBJECTIVE

To examine the use and compare short-term outcomes of neoadjuvant-intent vs adjuvant ST in the COVID-19 era compared with the pre-COVID-19 era.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective population-based cohort study in Ontario, Canada. Patients with cancer starting selected ST regimens in the COVID-19 era (March 11, 2020, to September 30, 2020) were compared to those in the pre-COVID-19 era (March 11, 2019, to March 10, 2020). Patients were diagnosed with breast cancer within 6 months of starting systemic therapy.

MAIN OUTCOMES AND MEASURES

Estimates were calculated for the use of neoadjuvant vs adjuvant ST, the likelihood of receiving a surgical procedure, the rate of emergency department visits, hospital admissions, COVID-19 infections, and all-cause mortality between treatment groups over time.

RESULTS

Among a total of 10 920 patients included, 7990 (73.2%) started treatment in the pre-COVID-19 era and 7344 (67.3%) received adjuvant ST; the mean (SD) age was 61.6 (13.1) years. Neoadjuvant-intent ST was more common in the COVID-19 era (1404 of 2930 patients [47.9%]) than the pre-COVID-19 era (2172 of 7990 patients [27.2%]), with an odds ratio of 2.46 (95% CI, 2.26-2.69; P < .001). This trend was consistent across a range of ST regimens, but differed according to patient age and geography. The likelihood of receiving surgery following neoadjuvant-intent chemotherapy was similar in the COVID-19 era compared with the pre-COVID-19 era (log-rank P = .06). However, patients with breast cancer receiving neoadjuvant-intent hormonal therapy were significantly more likely to receive surgery in the COVID-19 era (log-rank P < .001). After adjustment, there were no significant changes in the rate of emergency department visits over time between patients receiving neoadjuvant ST, adjuvant ST, or ST only during the ST treatment period or postoperative period. Hospital admissions decreased in the COVID-19 era for patients who received neoadjuvant ST compared with adjuvant ST or ST alone (P for interaction = .01 for both) in either setting.

CONCLUSIONS AND RELEVANCE

In this cohort study, patients were more likely to start neoadjuvant ST in the COVID-19 era, which varied across the province and by indication. There was limited evidence to suggest any substantial impact on short-term outcomes.

Breast cancer diagnosis and treatment during the COVID-19 pandemic in a nationwide, insured population

Purpose

The early months of the COVID-19 pandemic led to reduced cancer screenings and delayed cancer surgeries. We used insurance claims data to understand how breast cancer incidence and treatment after diagnosis changed nationwide over the course of the pandemic.

Methods

Using the Optum Research Database from January 2017 to March 2021, including approximately 19 million US adults with commercial health insurance, we identified new breast cancer diagnoses and first treatment after diagnosis. We compared breast cancer incidence and proportion of newly diagnosed patients receiving pre-operative systemic therapy pre-COVID, in the first 2 months of the COVID pandemic and in the later part of the COVID pandemic.

Results

Average monthly breast cancer incidence was 19.3 (95% CI 19.1–19.5) cases per 100,000 women and men pre-COVID, 11.6 (95% CI 10.8–12.4) per 100,000 in April–May 2020, and 19.7 (95% CI 19.3–20.1) per 100,000 in June 2020–February 2021. Use of pre-operative systemic therapy was 12.0% (11.7–12.4) pre-COVID, 37.7% (34.9–40.7) for patients diagnosed March–April 2020, and 14.8% (14.0–15.7) for patients diagnosed May 2020–January 2021. The changes in breast cancer incidence across the pandemic did not vary by demographic factors. Use of pre-operative systemic therapy across the pandemic varied by geographic region, but not by area socioeconomic deprivation or race/ethnicity.

Conclusion

In this US-insured population, the dramatic changes in breast cancer incidence and the use of pre-operative systemic therapy experienced in the first 2 months of the pandemic did not persist, although a modest change in the initial management of breast cancer continued.

Impact of COVID-19 Disease in Early Breast Cancer Management: A Summary of the Current Evidence

An expert panel on breast cancer and COVID-19 disease was convened to address the impact of the COVID-19 pandemic for early breast cancer (eBC) management.

Psychological distress among elderly surgical patients who had their surgery postponed during the COVID-19 pandemic

Background

Many institutions withheld elective lists and triaged surgeries during the peak of coronavirus disease 2019 (COVID-19) pandemic. As a result, older surgical patients have had to wait for rescheduled dates in a long waitlist. This study aimed to identify the psychological impact in these patients when they returned for surgery.

Methods

This was a cross-sectional study which included 153 patients aged ≥ 65 years undergoing elective surgery. Trained interviewers recruited and assessed psychological status pre-operatively with two validated questionnaires - Hospital Anxiety and Depression Scale (HADS) and 36-item Short Form Health Survey (SF-36). Specific questions were asked about their postponed surgeries, appetite and fear.

Results

A total of 36 out of 153 (23.5%) patients had their procedures deferred during the first wave of COVID-19 pandemic. Postponed cases were significantly based on the nature of surgery (p = 0.002), cancer diagnosis (p = 0.006) and surgical specialty (p = 0.023). Median HADS scores were higher for patients who were postponed (2.00 versus 4.00 for anxiety, p = 0.180 and 0.00 versus 1.00 for depression, p = 0.424) although no statistical significance was shown. In the whole study population, anxiety was a significant predictor for depression and vice versa (p < 0.001) with other predictive risk factors for anxiety that were age ≥ 85 years old (odds ratio [OR] 6.14, p = 0.018), female (OR 2.41, p = 0.024), cancer (OR 2.19, p = 0.039) and major surgery (OR 2.39, p = 0.023). Similarly, older patients ≥ 85 years old (OR 10.44, p = 0.003) and female (OR 6.07, p = 0.006) had higher risk for depression. Both anxiety and depression were significant risks for loss of appetite (p = 0.005 and 0.001). Lastly, the fear of disease progression due to rescheduling was more frequent in cancer patients (p = 0.035).

Conclusion

The mental health and disease burden of older surgical patients should be taken into careful consideration when cases need to be postponed in our healthcare system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-022-00242-7.

Care in the time of COVID-19: impact on the diagnosis and treatment of breast cancer in a large, integrated health care system

PURPOSES

To delineate operational changes in Kaiser Permanente Northern California breast care and evaluate the impact of these changes during the initial COVID-19 Shelter-in-Place period (SiP, 3/17/20-5/17/20).

METHODS

By extracting data from institutional databases and reviewing electronic medical charts, we compared clinical and treatment characteristics of breast cancer patients diagnosed 3/17/20-5/17/20 to those diagnosed 3/17/19-5/17/2019. Outcomes included time from biopsy to consultation and treatment. Comparisons were made using Chi-square or Wilcoxon rank-sum tests.

RESULTS

Fewer new breast cancers were diagnosed in 2020 during the SiP period than during a similar period in 2019 (n = 247 vs n = 703). A higher percentage presented with symptomatic disease in 2020 than 2019 (78% vs 37%, p < 0.001). Higher percentages of 2020 patients presented with grade 3 (37% vs 25%, p = 0.004) and triple-negative tumors (16% vs 10%, p = 0.04). A smaller percentage underwent surgery first in 2020 (71% vs 83%, p < 0.001) and a larger percentage had neoadjuvant chemotherapy (16% vs 11%, p < 0.001). Telehealth utilization increased from 0.8% in 2019 to 70.0% in 2020. Times to surgery and neoadjuvant chemotherapy were shorter in 2020 than 2019 (19 vs 26 days, p < 0.001, and 23 vs 28 days, p = 0.03, respectively).

CONCLUSIONS

During SiP, fewer breast cancers were diagnosed than during a similar period in 2019, and a higher proportion presented with symptomatic disease. Early-stage breast cancer diagnoses decreased, while metastatic cancer diagnoses remained similar. Telehealth increased significantly, and times to treatment were shorter in 2020 than 2019. Our system continued to provide timely breast cancer treatment despite significant pandemic-driven disruption.

The impact of misinformation on the COVID-19 pandemic

Since the inception of the current pandemic, COVID-19 related misinformation has played a role in defaulting control of the situation. It has become evident that the internet, social media, and other communication outlets with readily available data have contributed to the dissemination and availability of misleading information. It has perpetuated beliefs that led to vaccine avoidance, mask refusal, and utilization of medications with insignificant scientific data, ultimately contributing to increased morbidity. Undoubtedly, misinformation has become a challenge and a burden to individual health, public health, and governments globally. Our review article aims at providing an overview and summary regarding the role of media, other information outlets, and their impact on the pandemic. The goal of this article is to increase awareness of the negative impact of misinformation on the pandemic. In addition, we discuss a few recommendations that could aid in decreasing this burden, as preventing the conception and dissemination of misinformation is essential.

Time to treatment and hospital visits for patients undergoing neoadjuvant chemotherapy for breast cancer in a single payer system

BACKGROUND AND OBJECTIVES

Neoadjuvant chemotherapy (NAC) requires coordination of various services to ensure timely and accurate delivery of care. This can result in multiple hospital visits and extend time to treatment (TTT). The primary purpose of our study was to evaluate time to NAC for patients at a regional cancer centre. Healthcare resource use in the form of hospital visits before NAC was also evaluated.

METHODS

A retrospective chart analysis of patients with invasive breast cancer who underwent NAC between 1 January 2012 and 31 December 2018 was performed.

RESULTS

Overall, 286 patients underwent NAC. Median TTT was 22 days (range: 2-105). Median number of visits between first consultation and NAC was 5 (range: 0-12). Majority of additional visits were for diagnostic imaging/interventions, with a median number of 4 visits (range: 0-10). Each additional hospital visit increased time to NAC treatment by 14%.

CONCLUSIONS

Women undergoing NAC require multiple visits before initiating treatment-the majority of these visits are for diagnostic imaging. These results support the need for the coordination of multidisciplinary care and diagnostic imaging for breast cancer patients undergoing NAC to reduce hospital visits, improve the patient experience, and reduce TTT.

COVID-19 and its impact on cancer, HIV, and mentally ill patients

Severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) and its disease, COVID-19 is a global pandemic creating an unprecedented medical as well economic havoc across the world. Despite the wide spread global infection rates, the death rate is low for COVID-19. However, COVID-19 patients with other comorbid conditions face severe health complications irrespective of their gender or age. As the management of COVID-19 patients is taking up health resources, it is getting difficult to treat patients suffering from other dreadful diseases like cancer, HIV, and mental health issues. In this chapter, we discuss the effects of COVID-19 and management of cancer patients of main cancer subtypes (e.g., breast, lung, blood cancers), and patients affected with HIV and mental health issues. Finally, we also add a perspective on Ayurvedic treatment and its efficacy on COVID-19 patients.

Practical Consensus Recommendations for Optimizing Risk versus Benefit of Chemotherapy in Patients with HR Positive Her2 Negative Early Breast Cancer in India

Breast cancer is a public health challenge globally as well as in India. Improving outcome and cure requires appropriate biomarker testing to assign risk and plan treatment. Because it is documented that significant ethnic and geographical variations in biological and genetic features exist worldwide, such biomarkers need to be validated and approved by authorities in the region where these are intended to be used. The use of western guidelines, appropriate for the Caucasian population, can lead to inappropriate overtreatment or undertreatment in Asia and India. A virtual meeting of domain experts discussed the published literature, real-world practical experience, and results of opinion poll involving 185 oncologists treating breast cancer across 58 cities of India. They arrived at a practical consensus recommendation statement to guide community oncologists in the management of hormone positive (HR-positive) Her2-negative early breast cancer (EBC). India has a majority (about 50%) of breast cancer patients who are diagnosed in the premenopausal stage (less than 50 years of age). The only currently available predictive test for HR-positive Her2-negative EBC that has been validated in Indian patients is CanAssist Breast. If this test gives a score indicative of low risk (< 15.5), adjuvant chemotherapy will not increase the chance of metastasis-free survival and should not be given. This is applicable even during the ongoing COVID-19 pandemic.

Young Women with Breast Cancer: Chemotherapy or Surgery First? An Evaluation of Time to Treatment for Invasive Breast Cancer

Background

Breast cancer in young women (ages 18–40 years) is rare, yet remains a leading cause of cancer-related death. Time to treatment (TTT) is an increasingly important factor in breast cancer outcomes, specifically time to systemic therapy. Our objective was to review patterns of care for young women presenting with invasive breast cancer and compare TTT for surgery first versus neoadjuvant chemotherapy (NAC).

Patients and Methods

A retrospective chart review of young women with non-metastatic, non-inflammatory invasive breast cancer between 2012 and 2018 at a single institution was completed. The primary outcome was time to first treatment (surgery or NAC).

Results

One hundred forty-two young women were treated for invasive breast cancer during the study period. The majority of patients underwent surgery first (57.7%) compared with NAC (42.3%). Women who underwent NAC were more likely to have abnormal lymph nodes on imaging (p = 0.002) and clinical exam (p < 0.0001) and were also more likely to have larger tumor sizes (p < 0.05). The majority of triple negative patients underwent NAC first (88% [14/16]). Median TTT was significantly longer for surgery (27 [range 7–70] days) versus (20.5 [3–50] days) chemotherapy (p = 0.004). Median number of additional hospital visits prior to surgery was 4 (range 1–8) versus 5 (0–11) for NAC (p < 0.001).

Conclusions

Young women with breast cancer who undergo NAC have a shorter TTT and clinically similar median number of hospital visits compared with women undergoing surgery first. These results support the use of NAC in young women, when indicated, as additional workup and consultations prior to NAC do not delay care.

Management of Diarrhea in Patients with HER2-Positive Breast Cancer Treated with Neratinib: A Case Series and Summary of the Literature

INTRODUCTION

Neratinib and neratinib-based combinations have demonstrated efficacy for treatment of human epidermal growth factor receptor 2-positive (HER2+) early-stage and metastatic breast cancers. However, diarrhea has been reported as a common adverse event leading to neratinib discontinuation. Results from the CONTROL trial suggest that proactive diarrhea management with antidiarrheal prophylaxis or dose escalation of neratinib from a lower starting dose to the full FDA-approved dose of 240 mg/day can reduce the incidence, duration, and severity of neratinib-associated diarrhea in patients with early-stage breast cancer. Dose escalation has been included in the FDA-approved label for both early-stage and metastatic HER2+ breast cancer since June 2021.

CASE SERIES

This series of five cases details real-world clinical implementation of strategies for management of neratinib-induced diarrhea in patients with early-stage and metastatic HER2+ breast cancer, including a patient with a pre-existing gastrointestinal disorder.

MANAGEMENT AND OUTCOME

In four of five cases, diarrhea was managed with neratinib dose escalation, and antidiarrheal prophylaxis with loperamide plus colestipol was used in the remaining case. Management of diarrhea allowed all patients to remain on therapy.

DISCUSSION

This case series shows that neratinib-associated diarrhea can be managed effectively with neratinib dose escalation from a lower initial starting dose and/or prophylactic antidiarrheal medications in a real-world clinical setting. The findings highlight the importance of patient-provider communication in proactive management of adverse events. Widespread implementation of the strategies described here may improve adherence and thereby clinical outcomes for patients with HER2+ breast cancer treated with neratinib.

Delays in operative management of early-stage, estrogen receptor-positive breast cancer during the COVID-19 pandemic: A multi-institutional matched historical cohort study

Background

During the COVID-19 pandemic, guidelines recommended that breast cancer centers delay estrogen receptor–positive breast cancer surgeries with neoadjuvant endocrine therapy. We aimed to evaluate pathologic upstaging of breast cancer patients affected by these guidelines.

Methods

Female patients with stage I/II breast cancer receiving neoadjuvant endocrine therapy were prospectively identified and were matched to a historical cohort of stage I/II estrogen receptor–positive breast cancer patients treated with upfront surgery ≤35 days. Primary outcomes were pathologic T and N upstaging versus clinical staging.

Results

After matching, 28 neoadjuvant endocrine therapy and 48 control patients remained. Median age in each group was 65 (P = .68). Most patients (78.6% and 79.2%) had invasive ductal carcinoma with a clinical tumor size of 0.9 cm vs 1.7 cm (P = .056). Time to surgery was 68 days in the neoadjuvant endocrine therapy group and 26.5 days in the control (P < .001). A total of 23 neoadjuvant endocrine therapy patients (82.1%) had the same or lower pT-stage compared with 31 (64.5%) control patients (P = .115). Only 3 (10.7%) neoadjuvant endocrine therapy patients had increased pN-stage vs 14 (29.2%) control patients (P = .063).

Conclusion

Despite 2.5-times longer delays, patients with early-stage estrogen receptor–positive breast cancer receiving neoadjuvant endocrine therapy did not experience pathologic upstaging during the COVID-19 pandemic. These findings may support the use of neoadjuvant endocrine therapy in similar patients if delays to surgery are projected.

Breast Reconstruction during the COVID-19 Pandemic: A Systematic Review

Introduction

The COVID-19 pandemic posed unique challenges for breast reconstruction. Many professional organizations initially placed restrictions on breast reconstruction, leading surgeons to conceive innovative protocols for offering breast reconstruction. This study reviewed the current evidence on breast reconstruction during the COVID-19 pandemic to provide guidance for surgeons facing future crises.

Methods

The MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews were searched for studies (1) describing implant and autologous breast reconstruction following mastectomy and (2) occurring during or pertaining to the COVID-19 pandemic.

Results

Of the 1347 studies identified, 26 were included. Studies discussed type of reconstruction (18, 69%), complications (11, 42%), timing of reconstruction (10, 38%), protocols (10, 38%), COVID-19 screening (7, 27%), and length of hospital stay (7, 27%). The type of reconstruction varied depending on the stage of the pandemic: early on, autologous breast reconstruction was halted to preserve resources, but was later resumed. Within implant-based reconstruction, direct-to-implant was favored over serial tissue expansion. Several protocols were developed, with many emphasizing multidisciplinary collaborations for patient selection, use of specialized measures to reduce risk of COVID-19 transmission, and optimization of same-day discharge. Complication rates following breast reconstruction were similar to pre-pandemic rates.

Conclusions

The COVID-19 pandemic has forever changed the landscape of breast reconstruction by raising important questions about delivery of care, cost, and resource utilization. The findings of this review may inform surgeons as they plan for similar future crises or strive for improved patient care and efficacy even during nonpandemic times.

Impact of the first lockdown for coronavirus 19 on breast cancer management in France: A multicentre survey

Objective

This study examined the impact of lockdown for SARS-CoV-2 on breast cancer management via an online survey in a French multicentre setting.

Material and methods

This is a multicentre retrospective study, over the strict lockdown period from March 16th to May 11th, 2020 in metropolitan France. 20 centres were solicited, of which 12 responded to the survey.

Results

50% of the centres increased their surgical activity, 33% decreased it and 17% did not change it during containment. Some centres had to cancel (17%) or postpone (33%) patient-requested interventions due to fear of SARS-CoV-2. Four and 6 centres (33% and 50%) respectively cancelled and postponed interventions for medical reasons. In the usual period, 83% of the centres perform their conservative surgeries on an outpatient basis, otherwise the length of hospital stay was 24 to 48 h. All the centres except one performed conservative surgery on an outpatient basis during the lockdown period, for which. 8% performed mastectomies on an outpatient basis during the usual period. During lockdown, 50% of the centres reduced their hospitalization duration (25% outpatient /25% early discharge on Day 1).

Conclusion

This study explored possibilities for management during the first pandemic lockdown. The COVID-19 pandemic required a total reorganization of the healthcare system, including the care pathways for cancer patients.

Neoadjuvant Chemotherapy, Endocrine Therapy, and Targeted Therapy for Breast Cancer: ASCO Guideline

PURPOSE

To develop guideline recommendations concerning optimal neoadjuvant therapy for breast cancer.

METHODS

ASCO convened an Expert Panel to conduct a systematic review of the literature on neoadjuvant therapy for breast cancer and provide recommended care options.

RESULTS

A total of 41 articles met eligibility criteria and form the evidentiary basis for the guideline recommendations.

RECOMMENDATIONS

Patients undergoing neoadjuvant therapy should be managed by a multidisciplinary care team. Appropriate candidates for neoadjuvant therapy include patients with inflammatory breast cancer and those in whom residual disease may prompt a change in therapy. Neoadjuvant therapy can also be used to reduce the extent of local therapy or reduce delays in initiating therapy. Although tumor histology, grade, stage, and estrogen, progesterone, and human epidermal growth factor receptor 2 (HER2) expression should routinely be used to guide clinical decisions, there is insufficient evidence to support the use of other markers or genomic profiles. Patients with triple-negative breast cancer (TNBC) who have clinically node-positive and/or at least T1c disease should be offered an anthracycline- and taxane-containing regimen; those with cT1a or cT1bN0 TNBC should not routinely be offered neoadjuvant therapy. Carboplatin may be offered to patients with TNBC to increase pathologic complete response. There is currently insufficient evidence to support adding immune checkpoint inhibitors to standard chemotherapy. In patients with hormone receptor (HR)-positive (HR-positive), HER2-negative tumors, neoadjuvant chemotherapy can be used when a treatment decision can be made without surgical information. Among postmenopausal patients with HR-positive, HER2-negative disease, hormone therapy can be used to downstage disease. Patients with node-positive or high-risk node-negative, HER2-positive disease should be offered neoadjuvant therapy in combination with anti-HER2-positive therapy. Patients with T1aN0 and T1bN0, HER2-positive disease should not be routinely offered neoadjuvant therapy.Additional information is available at www.asco.org/breast-cancer-guidelines.

When the World Throws You a Curve Ball: Lessons Learned in Breast Cancer Management

In the care of patients with operable breast cancer, there has been a shift toward increasing use of neoadjuvant therapy. There are benefits to neoadjuvant therapy, such as monitoring for response, as well as an increased rate of breast conservation and reduction of potential morbidity associated with breast surgery, including axillary management. Among patients with highly proliferative tumors, such as HER2-positive or triple-negative breast cancer, those with residual disease are at higher risk of recurrence, which informs the recommended systemic therapy in the adjuvant setting. For instance, in patients with residual disease after neoadjuvant chemotherapy and HER2-targeted therapy, there is a role for adjuvant trastuzumab emtansine for those with residual disease at the time of surgery. The same holds true regarding the role of adjuvant capecitabine in patients with residual disease after neoadjuvant chemotherapy. With the added complexities of treating patients in the era of the COVID-19 outbreak, additional considerations are critical, including initiation of surgery within an appropriate time from completion of neoadjuvant therapy. National consensus guidelines on time to surgery must be developed to improve measurement and comparison across systems. In addition, there is emerging radiation treatment management research addressing a number of factors, including hypofractionation, role of proton beam therapy, safe omission of radiotherapy, and preoperative radiotherapy with or without drug combination. In this article, the multidisciplinary approach of treating patients with operable breast cancer is highlighted, with updates and future considerations described.

Triple-Negative Breast Cancer and the COVID-19 Pandemic: Clinical Management Perspectives and Potential Consequences of Infection

Simple Summary

The Coronavirus disease (COVID-19) pandemic has resulted in challenges to cancer management, exacerbated by limited clinical resources and caution in preventing COVID-19 transmission between patients and healthcare professionals. The neglect of breast cancer (in particular, triple-negative breast cancer (TNBC)) patients during the outbreak could negatively impact their overall survival, as delays in treatment and consultations provide vital time for tumor progression and metastasis. Herein, we review the shifting clinical management of TNBCs during the COVID-19 outbreak. The suggested treatment recommendations can hopefully minimize virus exposure without sacrificing patient care during times when healthcare systems are overburdened. Further, we review published RNA-seq data to assess the theoretical infectability of metastatic TNBCs to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. These analyses highlight the potential of the virus to infect TNBC cells. Given the known increased susceptibility of cancer cells to viral infection, this additional host cell reservoir may make patients with metastatic disease particularly vulnerable to COVID-19 morbidities.

Abstract

The COVID-19 pandemic has caused the need for prioritization strategies for breast cancer treatment, where patients with aggressive disease, such as triple-negative breast cancer (TNBC) are a high priority for clinical intervention. In this review, we summarize how COVID-19 has thus far impacted the management of TNBC and highlighted where more information is needed to hone shifting guidelines. Due to the immunocompromised state of most TNBC patients receiving treatment, TNBC management during the pandemic presents challenges beyond the constraints of overburdened healthcare systems. We conducted a literature search of treatment recommendations for both primary and targeted TNBC therapeutic strategies during the COVID-19 outbreak and noted changes to treatment timing and drugs of choice. Further, given that SARS-CoV-2 is a respiratory virus, which has systemic consequences, management of TNBC patients with metastatic versus localized disease has additional considerations during the COVID-19 pandemic. Published dataset gene expression analysis of critical SARS-CoV-2 cell entry proteins in TNBCs suggests that the virus could in theory infect metastasized TNBC cells it contacts. This may have unforeseen consequences in terms of both the dynamics of the resulting acute viral infection and the progression of the chronic metastatic disease. Undoubtedly, the results thus far suggest that more research is required to attain a full understanding of the direct and indirect clinical impacts of COVID-19 on TNBC patients.

The Impact of the COVID-19 Pandemic on Breast Imaging

"Starting in Wuhan, China, followed quickly in the United States in January 2020, an outbreak of a novel coronavirus, or COVID-19, escalated to a global pandemic by March. Significant disruptions occurred to breast imaging, including deferred screening mammography, triaging diagnostic breast imaging, and changes in breast cancer care algorithms. This article summarizes the effect of the global pandemic-and efforts to curtail its spread-on both breast cancer care and on breast imaging practices including effects on patients, clinical workflow, education, and research."

Cross Talk between COVID-19 and Breast Cancer

Cancer patients are more susceptible to COVID-19; however, the prevalence of COVID-19 in different types of cancer is still inconsistent and inconclusive. Here, we delineate the intricate relationship between breast cancer and COVID-19. Breast cancer and COVID-19 share the involvement of common comorbidities, hormonal signalling pathways, gender differences, rennin- angiotensin system (RAS), angiotensin-converting enzyme-2 (ACE-2), transmembrane protease serine 2 (TMPRSS2) and dipeptidyl peptidase-IV (DPP-IV). We also shed light on the possible effects of therapeutic modalities of COVID-19 on breast cancer outcomes. Briefly, we conclude that breast cancer patients are more susceptible to COVID-19 in comparison with their normal counterparts. Women are more resistant to the occurrence and severity of COVID-19. Increased expressions of ACE2 and TMPRSS2 are correlated with occurrence and severity of COVID-19, but higher expression of ACE2 and lower expression of TMPRSS2 are prognostic markers for overall disease free survival in breast cancer. The ACE2 inhibitors and ibuprofen therapies for COVID-19 treatment may aggravate the clinical condition of breast cancer patients through chemo-resistance and metastasis. Most of the available therapeutic modalities for COVID-19 were also found to exert positive effects on breast cancer outcomes. Besides drugs in clinical trend, TMPRSS2 inhibitors, estrogen supplementation, androgen deprivation and DPP-IV inhibitors may also be used to treat breast cancer patients infected with SARS-CoV-2. However, drug-drug interactions suggest that some of the drugs used for the treatment of COVID-19 may modulate the drug metabolism of anticancer therapies which may lead to adverse drug reaction events.

Cancer or COVID-19? A Review of Guidelines for Safe Cancer Care in the Wake of the Pandemic

In the wake of the COVID-19 pandemic, due to reasons beyond control, health care workers have struggled to deliver treatment for the patients with cancer. The concern for otherwise healthy patients with curable cancers that require timely intervention or therapy is the risk of contracting COVID-19 may outweigh the benefits of cancer treatment. Lack of international guidelines leaves health care providers with a case-to-case approach for delivering optimal cancer care in the wake of the pandemic. Transition to telemedicine has somewhat bridged the gap for in-office visits, but there is a continuing challenge of delays in cancer screening or significant decline of new diagnoses of cancers due to the pandemic. We aim to propose a balance in risk from treatment delay versus risks from COVID-19 with emphasis on treatment modality (surgery, radiation, and systemic therapy) as well as supportive care for cancer patients, and therefore have reviewed the publications and recommendations from international societies and study groups available as of October 2020.

Management of early breast cancer during the COVID-19 pandemic in Brazil

PURPOSE

The COVID-19 pandemic has impacted early breast cancer (EBC) treatment worldwide. This study analyzed how Brazilian breast specialists are managing EBC.

METHODS

An electronic survey was conducted with members of the Brazilian Society of Breast Cancer Specialists (SBM) between April 30 and May 11, 2020. Bivariate analysis was used to describe changes in how specialists managed EBC at the beginning and during the pandemic, according to breast cancer subtype and oncoplastic surgery.

RESULTS

The response rate was 34.4% (503/1462 specialists). Most of the respondents (324; 64.4%) lived in a state capital city, were board-certified as breast specialists (395; 78.5%) and either worked in an academic institute or one associated with breast cancer treatment (390; 77.5%). The best response rate was from the southeast of the country (240; 47.7%) followed by the northeast (128; 25.4%). At the beginning of the pandemic, 43% changed their management approach. As the outbreak progressed, this proportion increased to 69.8% (p < 0.001). The southeast of the country (p = 0.005) and the state capital cities (p < 0.001) were associated with changes at the beginning of the pandemic, while being female (p = 0.001) was associated with changes during the pandemic. For hormone receptor-positive tumors with the best prognosis (Ki-67 < 20%), 47.9% and 17.7% of specialists would recommend neoadjuvant endocrine therapy for postmenopausal and premenopausal women, respectively. For tumors with poorer prognosis (Ki-67 > 30%), 34% and 10.9% would recommend it for postmenopausal and premenopausal women, respectively. Menopausal status significantly affected whether the specialists changed their approach (p < 0.00001). For tumors ≥ 1.0 cm, 42.9% of respondents would recommend neoadjuvant systemic therapy for triple-negative tumors and 39.6% for HER2 + tumors. Overall, 63.4% would recommend immediate total breast reconstruction, while only 3.4% would recommend autologous reconstruction. In breast-conserving surgery, 75% would recommend partial breast reconstruction; however, 54.1% would contraindicate mammoplasty. Furthermore, 84.9% of respondents would not recommend prophylactic mastectomy in cases of BRCA mutation.

CONCLUSIONS

Important changes occurred in EBC treatment, particularly for hormone receptor-positive tumors, as the outbreak progressed in each region. Systematic monitoring could assure appropriate breast cancer treatment, mitigating the impact of the pandemic.

Changing trends in dermatology practice during COVID-19 pandemic: A single tertiary center experience

The aim of this study was to evaluate the changing trends in dermatology clinical practice at a tertiary center during the coronavirus disease 2019 (COVID‐19) pandemic. This retrospective cohort study was conducted on patients who were admitted to Ufuk University Hospital with dermatologic complaints/diseases before and during the pandemic. The patients were divided into two groups: (a) the pre‐pandemic period (March‐May 2019) and (b) the Pandemic period (March‐May 2020). Demographic features, clinical characteristics, dermatologic diseases/complaints, dermatologic procedures/interventions, hospitalization rate, and use of biologic agents were compared between the two groups. Total number of hospital admissions have decreased from 1165 to 717. Admission rates for acne, dermatophytosis, and benign neoplasm of the skin significantly lower during the pandemic period (P values were .02, .04, and .006, respectively). Contact dermatitis, acne accompanying dermatitis, cicatricial hair loss, lichen planus, and zona zoster infection rates were significantly higher (P values were .007, <.001, .009, .04, and .03, respectively). Rates of biopsy and electrocautery procedures were decreased significantly (P values were <.001 and .002, respectively). The hospitalization rate was similar between the groups (P = .51). However, the use of biologic agents significantly decreased during the pandemic period (P = .01). Updated clinical protocols should be established for the new normal period in accordance with these findings.