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.

Abstract P5-14-01: National claims data analysis of breast cancer diagnosis and treatment before versus during the COVID-19 pandemic

Background: The COVID-19 pandemic imposed great burden on the healthcare system and has required patients and their physicians to make unprecedented choices about cancer care. Hospital-based retrospective reviews have suggested changes in breast cancer management during 2020 compared to previous years, including greater use of preoperative therapy. We used insurance claims data to understand the impact of the pandemic on breast cancer diagnosis and treatment at a national level. Methods: We identified new diagnoses of breast cancer from 2017-2020 in the Optum Clinformatics claims data set, consisting of claims records linked to electronic health records. The overall population (enrolled in Optum for at least 6 months with at least one diagnosis of any condition and no prior breast cancer diagnosis) included an average of 8 million adult Americans per year. A new breast cancer diagnosis was defined as a first-ever ICD code for breast cancer with a breast diagnostic biopsy procedure code (considered the cancer diagnosis date) within 6 months before to 3 months after that ICD code. Each year’s cohort of breast cancer cases was limited to those diagnosed between February 1 and May 30, with follow-up through June 30 of the diagnosis year. First treatment after diagnosis was classified as either endocrine therapy, chemotherapy, or surgery. Geographic area was defined by the 9 Census Bureau regions. We used a Poisson regression to compare the rate of breast cancer diagnosis in 2020 compared to 2017-2019 and a Chi-squared test to compare the distribution of first treatment in 2020 compared to 2017-2019. To investigate differences in the impact of the pandemic on rate of diagnosis (Poisson regression) or use of preoperative therapy (logistic regression) by race/ethnicity, income, or geographic area, we included each of these covariates as well as its interaction with year (2020 vs 2017-2019) in separate models. Results: There were 2,841 breast cancer diagnoses February-May 2020 (0.037% of overall population), compared to 3,880 in 2019 (0.045%), 3,509 in 2018 (0.043%), and 2,999 in 2017 (0.041%). In 2020 compared to 2017-2019, new breast cancer diagnoses decreased by 12.3% (95% CI 8.6%-15.9%; p < 0.0001). No significant differences were observed in this reduction in diagnoses by race/ethnicity, income level, or geographic area. Median date of diagnosis was earlier in 2020 (March 11) compared to 2017-2019 (March 29, April 1, and April 1 respectively), a result of a larger drop in diagnoses later in the time interval in 2020. Among patients who received treatment during follow-up (83.1% in 2017-2019 vs 86.2% in 2020, a difference likely reflecting this shift in diagnosis date), there was a marked reduction in surgery as first treatment in 2020 compared to previous years (88.7% in 2017-2019 vs 69.3% in 2020), while both preoperative chemotherapy (6.1% in 2017-2019 vs 10.7% in 2020) and preoperative endocrine therapy (5.2% in 2017-2019 vs 20.1% in 2020) increased (p < 0.0001). There were no differences in the shift toward preoperative therapy by race/ethnicity or income, but there was a significant difference by geographic area (p=0.0003): the Mountain region had least change in use of preoperative therapy (odds ratio 2.46 [95% CI 1.75-3.47] of preoperative therapy during vs before the pandmic) while the Middle Atlantic region had the greatest (odds ratio 5.64 [95% CI 3.79-8.38]). Conclusions: Among insured U.S. patients, new breast cancer diagnoses decreased by 12.3% during February-May 2020 compared to the same period in the previous three years, and use of preoperative therapy, largely endocrine, increased by 2.7-fold. The impact of the pandemic on choice of first treatment differed by geographic area, but not by race/ethnicity or income in this insured population. We will monitor with continued follow-up of claims data to assess the longer-term impact of these pandemic-related changes on treatment patterns, cost, and patient outcomes.

Citation Format: Jennifer L Caswell-Jin, Maryam N Shafaee, Lan Xiao, Mina Liu, Natasha Purington, Esther M John, Melissa L Bondy, Allison W Kurian. National claims data analysis of breast cancer diagnosis and treatment before versus during the COVID-19 pandemic [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-14-01.

Abstract P5-14-03: National claims data analysis of breast cancer diagnosis and treatment before versus during the COVID-19 pandemic

Background: The COVID-19 pandemic imposed great burden on the healthcare system and required patients and their physicians to make unprecedented choices about cancer care. Hospital-based retrospective reviews suggested changes in breast cancer management during 2020 compared to previous years, including greater use of preoperative therapy. We used insurance claims data to understand the impact of the pandemic on breast cancer diagnosis and treatment at a national level. Methods: We identified new diagnoses of breast cancer from 2017-2020 in the Optum data set, consisting of claims records linked to electronic health records. The overall population (enrolled in Optum for at least 6 months with at least one diagnosis of any condition and no prior breast cancer diagnosis) included an average of 8 million adult Americans per year. A breast cancer diagnosis was defined as a first-ever ICD code for breast cancer with a breast diagnostic biopsy procedure code (considered the cancer diagnosis date) within 6 months before to 3 months after that ICD code. Each year’s cohort of breast cancer cases was limited to those diagnosed between February 1 and May 30, with follow-up through June 30 of the diagnosis year. First treatment after diagnosis was classified as either endocrine therapy, chemotherapy, or surgery. Geographic area was defined by the 9 Census Bureau regions. We used a Poisson regression to compare the rate of breast cancer diagnosis in 2020 versus 2017-2019 and a Chi-squared test to compare the distributions of first treatment. To investigate differences in the impact of the pandemic on rate of diagnosis (Poisson regression) or use of preoperative therapy (logistic regression) by race/ethnicity, income, or geographic area, we included each of these covariates as well as its interaction with year (2020 vs 2017-2019) in separate models. Results: There were 2,841 breast cancer diagnoses February-May 2020 (0.037% of overall population), compared to 3,880 in 2019 (0.045%), 3,509 in 2018 (0.043%), and 2,999 in 2017 (0.041%). In 2020 compared to 2017-2019, new breast cancer diagnoses decreased by 12.3% (95% CI 8.6%-15.9%; p < 0.0001). No significant differences were observed in this reduction in diagnoses by race/ethnicity, income level, or geographic area. Median date of diagnosis was earlier in 2020 (March 11) compared to 2017-2019 (March 29-April 1), a result of the diagnosis rate dropping more in later months. Among patients who received treatment during follow-up (83.1% in 2017-2019 vs 86.2% in 2020, a difference likely reflecting this shift in diagnosis date), there was a marked reduction in surgery as first treatment in 2020 compared to previous years (88.7% in 2017-2019 vs 69.3% in 2020), while both preoperative chemotherapy (6.1% in 2017-2019 vs 10.7% in 2020) and preoperative endocrine therapy (5.2% in 2017-2019 vs 20.1% in 2020) increased (p < 0.0001). There were no differences in the shift toward preoperative therapy by race/ethnicity or income, but there was a significant difference by geographic area (p=0.0003): the Mountain region had the least change in use of preoperative therapy (odds ratio 2.46 [95% CI 1.75-3.47] of preoperative therapy during vs before the pandemic) while the Middle Atlantic region had the greatest (odds ratio 5.64 [95% CI 3.79-8.38]). Conclusions: Among insured U.S. patients, new breast cancer diagnoses decreased by 12.3% during February-May 2020 compared to the same period in the previous three years, and use of preoperative therapy, largely endocrine, increased by 2.7-fold. The impact of the pandemic on choice of first treatment differed by geographic area, but not by race/ethnicity or income in this insured population. We will monitor with continued follow-up of claims data to assess the longer-term impact of these pandemic-related changes on treatment patterns, cost, and patient outcomes.

Citation Format: Jennifer L Caswell-Jin, Maryam N Shafaee, Lan Xiao, Mina Liu, Natasha Purington, Esther M John, Melissa L Bondy, Allison W Kurian. National claims data analysis of breast cancer diagnosis and treatment before versus during the COVID-19 pandemic [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-14-03.

Genetic Counseling Referral Rates in Long-Term Survivors of Triple-Negative Breast Cancer

Background: Inherited BRCA gene mutations (pathogenic variants) cause 10% of breast cancers. BRCA pathogenic variants predispose carriers to triple-negative breast cancer (TNBC); around 30% of patients with TNBC carry BRCA pathogenic variants. The 2018 NCCN Guidelines for Genetic/Familial High-Risk Assessment: Breast and Ovarian recommend genetic counseling referrals for patients with TNBC diagnosed at age ≤60 years. This study sought to describe genetic counseling referral patterns among long-term TNBC survivors at The University of Texas MD Anderson Cancer Center. Methods: This single-institution retrospective analysis of female long-term (disease-free for ≥5 years) TNBC survivors sought to determine the rate of genetic counseling referral among patients diagnosed at age ≤60 years between 1992 and 2008. Patients who underwent treatment and surveillance visits at our institution and were followed until 2017 were included. We collected BRCA pathogenic variant status among tested patients. Descriptive statistical methods and a univariate analysis were used to identify patient characteristics associated with genetic counseling referral. Results: We identified 646 female long-term TNBC survivors with a median age at diagnosis of 47 years. Of these, 245 (38%) received a recommendation for a genetic counseling referral. Among those referred, 156 (64%) underwent genetic testing, and 35% of those tested had BRCA pathogenic variants. Interestingly, among those referred, 20% declined genetic testing. The rate of genetic referrals improved over time, from 25% among TNBC survivors whose last surveillance visit was between 2011 and 2013 to 100% among those whose last surveillance visit was between 2014 or later. Younger age and premenopausal status at diagnosis and a family history of breast or ovarian cancer were associated with an increased rate of referral for genetic counseling. Conclusions: Among long-term TNBC survivors, the rate of referral to genetic counseling increased over time, and among those tested, 35% carried a BRCA pathogenic variant. Survivorship care provides an excellent opportunity to refer eligible patients for genetic counseling.

Abstract GS2-02: Direct regulation of estrogen receptor-α (ER) transcriptional activity by NF1

Inactivating germline mutations in the NF1 gene (encoding neurofibromin) cause neurofibromatosis type 1. In addition to peripheral nervous system tumors, NF1 patients are at higher risk for other cancers, including breast cancer. Tumor exome-sequencing studies demonstrate that approximately 20% of all human cancers have somatic NF1 mutations. NF1 has been best known for its ability to inactivate Ras as a GAP (GTPase Activating Protein). However, this function is served by a small GAP domain in a very large protein. Recurrent missense mutations inactivating the GAP activity are infrequent. In contrast, it is common to detect frameshift (FS) and nonsense (NS) NF1 mutations, which can create an NF1-null state deleting not only GAP, but also, potentially, undefined NF1 functions whose loss could also drive tumorigenesis.

As we reported at SABCS previously, in 600+ patients treated by tamoxifen adjuvant monotherapy, we found that FS/NS NF1 mutations independently correlate with relapse risk (HR=2.6, p=0.03). To explore this finding, we silenced NF1 in preclinical models of ER+ breast cancer, which markedly enhanced ER transcriptional activities, causing estradiol (E2) hypersensitivity and converted tamoxifen into an agonist (in vitro and in vivo). Most important, these activities depend on ER, but not on NF1's GAP activity. These findings readily explain the poor patient outcomes associated with NS/FS NF1 mutations, and reveal a previously unrecognized function for NF1 in ER regulation.

In the presence of an agonist, liganded ER repels co-repressors and recruits co-activators, while the reverse is true with an antagonist such as tamoxifen. Many co-regulators contain leucine/isoleucine rich motifs, which bind directly to the ligand-binding domain (LBD) in ER. NF1 has several of these motifs that are much more highly conserved in species with a functional ER pathway, and some of these are mutated in cancers (e.g., in our patient cohort). Furthermore, we found that NF1 canbind directly to ER, and that this binding is mediated between the ER LBD and the NF1 leucine-rich regions. Like a classic co-repressor, wildtype NF1 (but not mutants lacking GAP activity or the Leu-rich motif) binds to ER, and is recruited by ER to the ERE in the presence of tamoxifen, but not E2.

Further preclinical treatment studies indicate that while NF1-deficient ER+ breast cancer should not be treated by tamoxifen or AIs, fulvestrant remains effective. Furthermore, when fulvestrant is combined with dabrafinib and trametinib to inhibit Ras effectors Raf and MEK, apoptosis is induced in vitro, and tumor regression is observed in vivo. In conclusion, we have demonstrated that NF1 is a dual negative regulator at the intersection of two potent oncogenic signaling pathways, Ras and ER, and that NF1-deficient ER+ breast cancer patients may be more effectively treated by co-targeting the Ras and ER signaling. These patients, up to 10% of those with advanced ER+ breast cancer, can be readily identified for treatment by ctDNA analysis. A clinical trial is under development.

Citation Format: Chang EC, Zheng Z, Philip L, Burcu C, Lei J, Singh P, Anurag M, Chan D, Li JD, Du XP, Shafaee MN, Banks K, Sacker S, Song W, Nguyen T, Cao J, Chen X, Haricharan S, Kavuri M, Kim B-J, Zhang B, Gutmann DH, Lanman RB, Foulds C, Ellis M. Direct regulation of estrogen receptor-α (ER) transcriptional activity by NF1 [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr GS2-02.

Role of students in global health delivery

What role do students have in global health activities? On one hand, students have much to offer, including innovative ideas, fresh knowledge and perspective, and inspiring energy. At the same time, students lack technical credentials and may drain resources from host communities. Here, we examine the dynamic, contemporary roles of students in global health activities, including health delivery. We focus on 3 themes that guide engagement: (1) fostering an enabling policy environment (eg, toward greater health equity); (2) understanding and working within the local context and governments' needs; and (3) leading bidirectional partnerships. We next study the implications of short-term exposure and long-term engagement programs. We conclude with 4 recommendations on how to better equip students to engage in the next frontier of global health education and future action.