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

Abstract

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.

Prompt Resumption of Screening Programme Reduced the Impact of COVID-19 on New Breast Cancer Diagnoses in Northern Italy

“…By comparing the tumour size with those reported by AIOM (the Italian Association of Medical Oncology) in Italy [ 33 ], we observed a similar trend: a modest decrease in T1a and T1c tumours and a slight increase in T1b tumours, even if on the whole the registered tumours in our province represent smaller dimensions than the national and international data [ 33 , 34 ].…”

“…In the Netherlands, a decline in in situ and stage I cancers was observed in 2020 (from 12% to 6% and from 40% to 36%, respectively) [ 20 ]. The suspension of screening programmes resulted in a decrease in screen-detected cancers [ 29 , 34 ], and an early tumour reduction, according to expectations but without a shift towards more advanced forms [ 35 ]. Even cancers diagnosed in out-of-range screening women do not appear to have been affected by the pandemic [ 29 ].…”

Telemedicine implementation trends in surgical specialties before and after COVID-19 shelter in place: Adjusting to a changing landscape

“…In addition, our organization’s capitated model and EHR-integrated telemedicine practice may not generalize directly to other payment models for surgical practice or standalone telehealth models that are not as well integrated with patient’s ongoing medical history and documentation, and fee-for service reimbursement models may limit the ability of some practices to implement changes based on our findings ( 17 , 32 , 33 , 39 ). While we did not find differences in telemedicine use across patient characteristics in our large and diverse population, further research is needed to continue to examine equitable use of telemedicine ( 11 , 15 , 20 , 21 , 35 , 40 , 41 , 42 , 43 , 44 ) .…”

“…We were also not able to directly study the efficiency of telemedicine based on number or type of preoperative encounters. However, in a smaller KPNC study evaluating breast cancer care during COVID-19 restrictions, the number of visits prior to breast surgery was not significantly impacted ( 32 ).…”

Utilization of a rapid diagnostic centre during the COVID-19 pandemic reduced diagnostic delays in breast cancer

“…Although the reduced patient volume may have contributed to this, modifications to our workflow during the pandemic may have also led to the reduction in wait times. While there have been some studies assessing wait times and volumes of breast cancer patients treated, 5 , 6 this is the first to assess the impact of the presence of a rapid diagnostic centre on breast investigations and treatment during the pandemic.…”