Change in breast cancer risk perception related to perceived COVID-19 risk: A WISDOM sub-population analysis

Background: Obstacles to access to care due to the perceptions of the risk posed by COVID-19 have led to unprecedented disruptions in cancer care. Yet, little is understood about whether perceived COVID- 19 risk influences perceptions of cancer risk. We examined how COVID-19 risk perception was associated with perceptions of breast cancer risk over one year of the pandemic among women enrolled in the WISDOM study, a PCORI-funded pragmatic trial testing risk-based cancer screening that began before the pandemic. Methods: We conducted four longitudinal surveys among the 13,002 women enrolled in the WISDOM study from May - December 2020. Responses from 8,285 women are eligible for inclusion in this analysis leading to a total sample size of 16,859 survey responses. Surveys were conducted online and asked women's perceived lifetime chance of developing breast cancer (0- 100%). COVID-19 risk perception was reported on a 5-point scale from Very Low to Very High. We computed the difference between breast cancer risk perception at each COVID-19 survey to pre-COVID breast cancer risk perception, measured as a secondary aim of the WISDOM study, and compared that to COVID-19 risk perception at each time point. Results: Across the four survey waves, most women perceived low COVID risk: 29% very low, 42% moderately low, 23% neither high nor low and 6% high or very high. Overall, breast cancer risk perception declined for those with very low COVID-19 risk perception and rose for women in the highest levels of COVID-19 risk perception. However, changes in breast cancer risk perception associated with COVID risk perception were small. For example, in survey wave 4, breast cancer risk change was -2.4% very low, -1.4% low, 2.5% not high or low and 3.1% high or very high. (Table). Conclusions: Among women participating in a pragmatic trial testing riskbased cancer screening, COVID risk perception had a small relationship with change in breast cancer risk perception. Change in breast cancer risk perception paralleled COVID-19 risk perception. This calls for exploration of the underpinnings of these risk changes and may have implications for changes in cancer screening behavior related to COVID-19.

Real world evidence demonstrates replacement of 2D mammography with 3D mammography among insured women

Background Digital breast tomosynthesis (DBT), also called 3D mammography, was first approved by the Federal Drug Administration in 2011. The goal of 3D mammography is to improve accuracy compared to 2D digital mammography (DM), by increasing sensitivity and decreasing recall rates. To capture the broad utilization of DBT in populations receiving both screening and diagnostic imaging, this analysis investigates DBT usage over time in a longitudinal sample from 2016 through 2020 for adult women ranging from 18-74 years of age. Methods Retrospective analyses were conducted using de-identified administrative claims data from a large national U.S. health insurer. The study cohort consisted of women who were continuously enrolled in a commercial or Medicare Advantage plan from 1/2016 to 12/2020 and aged 18 to 74 years old as of 2016. All procedures were identified based on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes. For each study year, receipt of breast cancer screening with DM (S-DM) or including DBT (S-DBT) were captured. Receipt of DM and DBT not specified for screening based on CPT code descriptions were categorized as diagnostic, D-DM and D-DBT respectively. Women that received both DBT and DM in the same year were included in the DBT group. In addition, women who received MRI and ultrasound were also captured. Rates of each procedure by study year, insurance type, and age categories that align with recommended screening guidelines (<40 years old, 40-49 years old and 50-74 years old) were examined. Results Approximately 3.8 million women met study criteria;85% were commercially insured and 15% were Medicare Advantage. Table 1 shows rates of adult women who received mammography, MRI and ultrasound over the study period. About 74% of study subjects receiving screening were 50-74 years old at the start of the study period, 25% were 40-49 years and 1% were under 40 years old. In 2020, there were fewer women (3%-13%) receiving imaging procedures compared to counts in 2019. During the 5-year study period, there was a 3.5-fold increase in the number of women who received S-DBT. In 2016, 23% of women who received a screening mammogram received S-DBT and by 2020, this percent increased to 82%. The percent of women who received a diagnostic mammogram using D-DBT compared to D-DM also increased overtime;29% of women received a D-DBT in 2016 and this increased to 77% in 2020. The number of women with receipt of ultrasound and MRI were similar in each study year. The percent diagnostic/screening tests (including DBT and DM) were in the range of 18.5%-20.2% each year. Conclusion Among this cohort of women who were continuously enrolled in the health plan throughout the 5-year study period, this analysis shows that screening and diagnostic DBT utilization rates increased from 2016 to 2020 while DM screening and diagnostic imaging utilization concomitantly decreased. The percentages of women that received S-DBT and D-DBT were highest in 2020, even though 8%-13% fewer women had evidence of mammography than in 2019, which is largely due to COVID-19 related healthcare service disruptions. The rate of diagnostic tests as a percent of screening tests did not decrease with the adoption of DBT. Further analyses investigating rates of follow-up procedures and downstream costs are warranted.

Health maintenance and breast cancer screening during the COVID-19 pandemic

Background: WISDOM is a large (target enrollment>40,000) healthy women preference-tolerant, pragmatic study comparing traditional annual screening to personalized risk-based breast screening. Cancer screening, routine health care, and elective procedures were disrupted due to attempts to manage resources during the COVID-19 pandemic. Understanding of the impact on COVID-19 on trial participants is important to gain a broader understanding of the effect of the pandemic on healthcare activities. Methods: Women aged 40-74 years with no history of breast cancer or DCIS, and no previous double mastectomy can join the WISDOM (NCT02620852) study online at wisdomstudy.org. A total of 28,600 women have consented to participate. As part of the trial, each patient completes a baseline and interval surveys through a Salesforce platform. In May, the study IRB was amended to add a COVID specific survey with questions related to participants COVID risk perceptions, coexisting conditions, and receipt of healthcare services in the 2 months prior to the survey. An initial survey was sent May 2020, with follow-up surveys planned every 2 months. In addition, national surveys on a population-based cross section of individuals across the nation will be performed in parallel. Data was collected, de-identified, and then analyzed using basic descriptive analysis, chi-2 analysis, and logit regression. Results: A total of 7,523 individuals in WISDOM responded to the survey (response rate 27%). Of those that responded, the average age at the time of the survey was 59 (range 40-79). The population was 87% Caucasian, 6% Hispanic, and 4% African-American. Only 3.6% of the sample felt they had COVID-19 either by symptoms or through testing. However, 10.0% felt they were at higher risk compared to similar individuals their age to get COVID-19. Of the sample, 29% had some form of high-riskcoexisting condition that put them at higher risk for COVID-19. In terms of healthcare utilization in the prior 2months, 43% had a routine medical visit cancelled by their primary care provider or health system, whereas 26%cancelled an appointment themselves. In terms of breast cancer screening, 16% had their screening visit eithercancelled or delayed. Individuals who believed they were at higher risk (and more likely to have shorter intervalscreening recommendations on this trial) had a higher Odds Ratio (1.66) for a screening cancellation (p<0.001).Those individuals who held the belief that COVID-19 was no more dangerous than the seasonal flu were more likelyto have medical visits and routine care in the preceding 2 months than those that did not share that belief. (OR 1.18,p=0.032). Individuals were significantly more worried about COVID-19 than developing breast cancer (43%moderate to severely worried about COVID compared to 8.2% for breast cancer). Those worried about COVID weremore likely to have screening cancellation (OR 1.18, P<0.001) and those more worried about breast cancer wereless likely to have a screening cancellation (OR. 0.83, P<0.001). Conclusions: Health maintenance, prevention,and specifically breast cancer screening are important, but these health activities have been significantly disrupteddue to the COVID-19 pandemic. Given that the pandemic will likely continue for many months until there is either avaccine, treatment, or herd immunity, it will be important to define the drivers and messages (healthcare andscreening) to ensure patients receive proper health maintenance and prevention to reduce the risks associated withother diseases that are not COVID-19. The preliminary data presented as part of this Abstract submission are theearly results of an effort to develop a predictive model and targeted strategies for communication and interventionfor cancer screening during the course of the COVID-19 pandemic.