ABSTRACT
Background: Neoadjuvant endocrine therapy has traditionally been considered a treatment option for locallyadvanced and/or surgically high-risk women with hormone positive disease. Early stage hormone-positive breast cancer, on the other hand, is usually managed with upfront surgery, with post-operative hormone therapy as a risk-reducing adjunct. During the COVID-19 pandemic, however, widespread closures of operating rooms throughout thecountry resulted in many breast cancer patients being offered presurgical endocrine therapy as a bridge to surgery.We explored the demographic and clinicopathologic characteristics of these patients and quantified their rate of uptake. Methods: The Institutional Breast Cancer Database was queried for all patients who were diagnosed withER+ stage 0, I, or II breast cancer and were offered presurgical endocrine therapy (tamoxifen or aromatase inhibitor)by a medical oncologist from 3/12/2020 to 4/30/2020. Variables of interest included demographics, tumorcharacteristics, and rate of medication uptake and compliance. Results: Of 192 newly diagnosed breast cancerpatients seen at NYU Perlmutter Cancer Center during this time period, 136 patients had early stage ER+ breast cancer. Forty-five patients had not yet undergone surgery, and were recommended to receive presurgical hormonaltherapy as a bridge given the COVID-19 pandemic (Table 1). The average age was 60.5 years old (SD=13.8 years, range 31-89), and all were female. Thirty-four of 44 patients were post-menopausal (75.6%), while 10 were premenopausal (22.2%), and one was perimenopausal (2.2%). Twenty-six patients were white (57.8%), 12 were black (26.7%) 3 were Asian (6.7%), and 4 were other (8.9%). Thirty-four patients (75.6%) had invasive disease, while 8 had ductal carcinoma in situ (DCIS, 17.8%), and 3 had DCIS with microinvasion (6.7%). Nine patients (20%)did not take the medication for various reasons: 1 contracted COVID-19, 1 refused any treatment, 1 decided totransfer care out of state, 1 preferred to take a homeopathic remedy instead of endocrine therapy, 1 preferred towait for surgery without medication, and 4 were scheduled for surgery sooner than anticipated and did not start themedication. The remaining 36 patients (80%) took medication for an average of 43.6 days (SD=27.3 days, range 9-101 days) prior to surgery. Twenty-eight patients (77.8%) took an aromatase inhibitor, and 8 (22.2%) took tamoxifen.Forty-two patients have now undergone surgery (93.3%);the remainder include the patient who is refusing alltreatment, the patient who transferred out of state, and one patient who has not yet scheduled surgery, but isreportedly still taking an aromatase inhibitor. Conclusion: Improving adherence to long-term adjuvant endocrinetherapy is an urgent need as patient acceptance is low. Reported completion rates range around 50%, and have notbeen improved by educational or technology-based interventions. The unique situation posed by the current COVID-19 pandemic has temporarily changed the management of early-stage breast cancer, and resulted in a high initialacceptance of endocrine therapy (80%), although duration is shorter in this presurgical setting. Furtherinvestigations will evaluate length of use, the psychosocial and behavioral factors that influence willingness to takeendocrine therapy, and apply these lessons to management of early-stage hormone-positive breast cancer.
ABSTRACT
Treatment of patients with cancer in hospitals or clinics is resource-intensive and imposes a burden on patients. 'Flexible care' is a term that can be used to describe treatment administered outside the oncology ward, oncological outpatient clinic or office-based oncologist setting. Programmes that reduce travel burden by bringing cancer treatment to the patient's home, workplace or closer to the patient's home, in the form of satellite clinics or mobile cancer units, expand treatment capacity and are well received. Clinical trial data show that, compared with intravenous administration, subcutaneous (s.c.) administration of trastuzumab is preferred by patients with breast cancer (BC), saves healthcare professionals' (HCPs) time, reduces drug preparation and administration time and reduces direct and indirect costs. As such, s.c. trastuzumab is well suited to flexible care. The results of a Belgian study (BELIS) show that home administration of s.c. trastuzumab is feasible and preferred by patients with BC. Numerous programmes and pilot studies in Europe show that s.c. trastuzumab can be administered effectively in the patient's home, in primary care settings or local hospitals. Such programmes require planning, training, careful patient selection and technology to link patients, caregivers and specialists in oncology clinics. Once these elements are in place, flexible care offers patients with BC a choice of how treatment may be delivered and lead to improved quality of life, while reducing pressure on HCPs and hospitals. The concept of flexible care is particularly relevant amid the COVID-19 pandemic where guidelines have been developed encouraging remote care.