The impact of COVID-19 on breast cancer management -- and a path forward

May 13, 2020 -- COVID-19 has forced restrictions and delays of breast screening, diagnostic exams, and surgical procedures at hospitals and breast centers across the country. This is causing an unprecedented disruption in the diagnosis and treatment of the 325,000 projected cases of breast cancer in 2020.

These delays will impact care delivery as physicians and hospitals strategize how to effectively manage the backlog of breast cancer patients. As restrictions are lifted, physicians and administrators are grappling with rescheduling procedures and scheduling new appointments.

But perhaps more telling are the profound changes that COVID-19 has made to how we will care for breast cancer patients for the foreseeable future.

At Pennsylvania Hospital in Philadelphia, Dr. Brian Englander, chairman of the department of radiology, estimates that since his facility has been deferring routine radiology screenings, there are more than 3,000 patients who need to be rescheduled. As screening mammography comes back online, the centers plan to be open all day Saturday and until 8 p.m. on weekdays.

"We are also discussing Sunday hours," Englander said. "We want to make it easier for women as they return to work, many have been forced to use PTO time during this time, so we are trying to accommodate them to be able to schedule appointments on weekends and before and after work."

Englander said we will also see the use of virtual waiting rooms at breast centers.

"Our breast center waiting room has collapsed from a 20-person area down to six or seven-person capacity so we can accommodate social distancing. Also, we are in the city, so we do not have the luxury of the suburban areas where a patient can wait in their car, and many of our patients walk or take public transportation," he noted. "Patients will register online, give verbal consent, and will receive a text or call 10 minutes ahead of when we are ready to see them. Once they arrive, they will be taken directly to the procedure room."

Englander also noted that not only patient care areas are being affected. Many of the hospital common areas, such as large lobbies and conference rooms, may well be a thing of the past. These areas will be converted into staff work areas to help achieve staff social distancing.

Dr. Vincent Reid, a surgical oncologist at Mercy's Hall-Perrine Cancer Center in Cedar Rapids, IA, shared some notable changes in triaging patients at his facility. He said that the number one priority was easing the stress and anxiety of patients during this difficult time, not only about their cancer but now COVID-19 as well.

At Mercy, all breast cancer patients are being evaluated by a multidisciplinary group to develop a recommended care plan. Some patients are having surgery delayed. And for those patients where it is appropriate, they are going to either neoadjuvant chemotherapy (NAC) or endocrine therapy prior to surgery.

"At our center we are localizing these previously diagnosed patients with SCOUT®, which can safely and effectively be placed, even though they will not go to surgery for several months," Reid said. "This will streamline the process once they are ready to go to surgery. If immediate surgery is indicated, those patients proceed to surgery."

Reid also mentioned that Mercy had just begun placing SCOUT at time of biopsy for highly suspicious lesions.

"At Mercy, a number of our patients drive long distances for treatment. When we can eliminate an entire localization procedure, we eliminate a travel day, decrease patient and physician interaction, and preserve PPE -- that is significant all around," Reid said.

"We place SCOUT now at biopsy for BI-RADS 5 and 4C and have recently added BI-RADS 4Bs when the patient is going to surgery," Englander said. "This is minimizing the interactions and helping us to manage future triage. It is decompressing the schedule allowing surgeons to operate as soon as they can."

Englander and Reid stressed that the most important message for patients is the reassurance that no matter what the recommended course of treatment, they are not being put at risk. Physicians are thoughtfully evaluating safe options, and even in the COVID environment where patient and provider safety is paramount, cancer care is not being compromised. Patients need to be reassured that once restrictions are lifted, they can get their screening, diagnostic exams, and surgery in a timely manner.

Merit Café was initiated to connect physicians across the country facing all the same challenges. It is an online forum for healthcare providers to come together to share best practices and experiences in an online, interactive platform every Friday. The small group discussions focus on triaging breast patient care during the COVID-19 pandemic, minimizing patient/provider exposure and procedure efficiency, and planning for the downstream burden on physicians and facilities post-COVID-19. Both Englander and Reid have served as moderators for Merit Café.

"Everything has changed and it's an adventure as we work towards recovery. We have always been here for our patients and will continue to do so. It will just look different and we need to be creative to make it all work. Sharing ideas is enlightening," Englander said.

Reid agreed.

"The outcome of COVID-19 that I find most enlightening is that we are all united in a powerful way," he said. "I am virtually connecting with colleagues that I might have never had the opportunity to meet, and we are sharing and learning from each other."

Copyright © 2020

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