ABSTRACT
Background: During the SARS-CoV-2 pandemic in 2020, the use of routine screening mammography (SM) and diagnostic mammography (DM) was limited for several months in order to reduce patient exposure and redeploy medical personnel. Previous studies suggest such delays result in more late-stage breast cancer diagnoses. We hypothesized that this impact would vary between institutions depending on regional variations in shutdown periods and the ability and willingness of patients to resume screening. Methods: Patients diagnosed with invasive breast cancers from 2016-2020 were identified using the Beth Israel Deaconess Medical Center (BIDMC) and the Duke University Medical Center (DUMC) cancer registries. Rates of mammography were ascertained from billing data. Baseline patient characteristics, demographics, and clinical information were gathered and cross-referenced with the electronic medical record. Late-stage was defined as Anatomic Stage III-IV disease (AJCC 8th edition). Chi-squared analysis was used to examine monthly distributions in stage at presentation for diagnosis in 2016-2019 compared to in 2020 at each institution. Results: There were 5907 patients diagnosed with invasive breast cancer between 2016-2019 (1597 at BIDMC and 4310 at DUMC) and 1075 in 2020 (333 and 742, respectively). Mammography was limited from 3/16/20-6/8/20 at BIDMC and from 3/16/20-4/20/20 Sa t DUMC. There were fewer SM at each institution during their respective shutdown periods in 2020 than in the same months in 2019: BIDMC 1713 versus 8566 (80% reduction) and at DUMC 1649 versus 5698 (71% reduction). Following the pandemic shutdown, SM volume increased in July-December 2020 compared to July-December 2019 (108% at BIDMC and 116% at DUMC). The proportion of patients diagnosed with late-stage disease at BIDMC was greater in 2020 than in 2016-2019, at 12.6% and 6.6%, respectively (p < 0.001);86% of late-stage diagnoses and 68% of all diagnoses in 2020 at BIDMC occurred from July-December following the initial shutdown period. The proportion of patients diagnosed with late-stage disease at DUMC in these two cohorts were 14.3% in 2020 and 16.2%% in 2016-2019 (p = 0.1);50% of late-stage diagnoses and 51% of all diagnoses in 2020 at DUMC occurred in the period following the initial shutdown from July-December. Conclusion: We identified variation between two large academic medical centers in the impact of the SARS-CoV-2 pandemic shutdown on the proportion of late-stage breast cancer diagnoses. These dissimilar outcomes may be the result of differences in referral patterns as well as regional differences in the approach to SM during the pandemic. In particular, a shorter closure time and substantial increase in SM volume following the initial shutdown period in the Southeast region may have prevented an increase in late-stage diagnoses. Further information and analysis may help suggest additional strategies to minimize adverse effects of reduced cancer screening in future public-health emergencies.
ABSTRACT
Background: During the SARS-CoV-2 pandemic, routine screening mammography (SM) was stopped and diagnostic mammography (DM) was limited for several months across the United States in order to reduce patient exposure and redeploy medical personnel. We hypothesized that this delay would result in patients presenting with later-stage disease following the initial shutdown. Methods: Patients diagnosed with invasive breast cancers from 2016-2020 were identified using the Beth Israel Deaconess Medical Center Cancer Registry. Baseline patient characteristics, demographics, and clinical information were gathered and cross-referenced with our electronic medical record. Late-stage disease was defined as initial anatomic stage III-IV disease in the AJCC 8th edition staging system. The control cohort consisted of patients diagnosed from 2016-2019;patients diagnosed in 2020 were the test cohort. Chi-squared analysis was used to compare monthly distributions in stage at diagnosis between the control and test cohorts. Multivariate analysis was performed using a logistic regression model. Results: There were 1597 patients diagnosed with invasive breast cancer between 2016-2019 and 333 in 2020. Median age at diagnosis was 60 years;99% were female, and 69.1% were white. Mammography was limited from 3/16/20-6/8/20, with 90% reduction in volume during this time. The number of screening studies performed in March, April, May, and June of 2020 were 987, 1, 4, and 721 compared to 2042, 2141, 2241, and 2142 in 2019. The volume of new diagnoses per month decreased substantially during the shutdown (see table). The proportion of patients diagnosed with late-stage disease was 6.6% in the control cohort compared to 12.6% in the 2020 test cohort (p < 0.001);92.9% of late-stage diagnoses in 2020 occurred from June to December following the shutdown period. On multivariate analysis, year of diagnosis (2020 vs 2016-2019;OR = 4.25 95% CI 0.035-0.095, p < 0.001), lower income (<200% of the federal poverty level;OR = 2.73 95% CI 0.016-0.099, p = 0.006) and increased Charlson Comorbidity Index (OR = 12.01 95% CI 0.037-0.052, p < 0.001) were associated with later stage at diagnosis. Conclusions: Patients were more likely to be diagnosed with late-stage breast cancer following the global shutdown due to the SARSCoV-2 pandemic. Patients with lower income and medical comorbidities were disproportionately affected. These data raise significant concerns regarding the impact of SARS-CoV-2 on cancer diagnoses and long-term outcomes, especially in vulnerable patient populations. (Table Presented).