The Impact of COVID-19 on Breast Cancer Treatment: A Systematic Review

Abstract

Background: During the COVID-19 pandemic, health resources were stretched, access was impacted by lockdowns and there were concerns about exposure to the virus during visits to hospitals. The purpose of this study was to examine how breast cancer treatments (presentation, surgery, radiotherapy, chemotherapy and/or endocrine therapy) changed or were adapted during the early phase of the pandemic. Methods: A systematic review was conducted using PRISMA guidance. Eligible studies presented original data reporting changes to early breast cancer treatment by comparing ‘pandemic’ treatment to a ‘pre-pandemic’ cohort or to ‘ideal’ treatment of individual cases. Data were extracted into evidence tables and narrative synthesis was used to analyse results. Results: Fifteen studies with paired design were eligible. These reported outcomes for 6,353 people treated for early breast cancer (January 2020–June 2021). All studies reported some change to treatment due to the pandemic. The nature of reported changes was inconsistent. Changes included: tumours more advanced at presentation compared to pre-pandemic, increase in breast conserving surgery; increase in simple mastectomy (without breast reconstruction); trend towards increased wait times, delays to start of treatment, shorter post-operative hospital stay and hypofractionation or omission of radiotherapy. Centres used more or less neoadjuvant chemotherapy or endocrine therapy. Conclusion: In the early stage of the pandemic, fewer early-stage breast cancer cases were treated many centres. Treatment for breast cancer was impacted and various local solutions were developed. These included less complicated breast surgery, increased use of neoadjuvant therapy, and changes to radiotherapy regimens. Surgery was frequently delayed and breast reconstruction was often unavailable. These results have implications for breast cancer services during the pandemic recovery as a ‘catch-up’ increase in cancer diagnoses is expected. Women may wish to access breast reconstruction, unavailable due to COVID-19. The impact of changes to treatment on long-term quality of life should be evaluated.

Did the COVID-19 pandemic delay treatment for localized breast cancer patients? A multicenter study

“…Such comparisons were likely to reflect not only the changes caused by the pandemic, but also the trends in BC treatment protocols that have resulted in changes in treatment delays over time, and might thus have overestimated the pandemic effect on delays [9,15]. In light of the pandemic, BC care has a degree of flexibility that makes possible changes to treatment regimens and delivery settings [5,18,19,29,30]. Our analysis, carried out at the patient level, and taking into account heterogeneous regional pandemic stages and restriction policies that evolved over time had the advantage of providing our model with higher statistical power for detecting the actual effect of the pandemic on treatment delay.…”

“…This helped preserve the capacity to treat patients with curative intent, particularly those requiring NACT or postoperative adjuvant chemotherapy. BC surgeries were limited to simple mastectomies, with reconstructive surgery being resumed once pandemic restrictions were lifted [5]. Finally, variations in the time to treatment were more strongly correlated with factors other than those…”

“…This increase in time, whether due to COVID-related precautions or the load of COVID patients itself, led to delayed surgeries in many countries because of a restricted number of beds available and overburdened clinicians. The increase in lag time to a cancer diagnosis resulted in more advanced tumor stages at presentation during the late-pandemic period compared to the prepandemic period [5][6][7][8]. Delays in cancer diagnosis were associated with expected increased deaths, up to five years after diagnosis, as reported by a UK population-based modelling study [6].…”

“…Regarding breast cancer (BC), which is the focus of our study presented below, essential surgical (i.e., oncologic surgery) and medical oncology were not suspended. Cancer centers adjusted treatment type and regimen during the COVID-19 period and performed more breast conserving surgery and simple mastectomies, as well as more neoadjuvant therapy [5,12], and used hypofractionation radiotherapy to reduce admission frequency [5]. This was part of the official French guidelines to protect cancer patients against SARS-CoV-2 infection, along with adjusted dosing schedules of chemotherapy and access to telemedicine (i.e., remote consultations via telephone or videoconference) [13,14].…”

Will Surgery Be Disappeared From The Treatment Of Breast Cancer?

“…10 However, oncology is constantly evolving, and in radiotherapy, the COVID pandemic helped to develop hypo-fractionation decreasing the six weeks treatment to 15 fractions and even 5 fractions in the fast and fast forward trials in post-operative treatment. 11 Obviously, in case of conservative treatment, irradiation becomes necessary and discussions may arise on the benefitof the boost on the site of the tumor that has disappeared. 5 More recently, localized partial irradiations, (APBI) associated with medical treatment have made it possible to obtain complete responses in some patients.…”