Challenges in breast cancer management during the pandemic:
1. Patients with hormone receptor-positive tumours were universally put on hormone therapy in the initial phases of the pandemic, but all of them have now returned to conventional treatment. 2. A long period ensured stage migration in approx. 30-40% patients, with most often complaints of a significant increase in the size of primary tumour or appearance of a new axillary lump, forcing a medical consultation.
3. Fear of inadvertent encounter with Covid-19 patients at larger centres led to patients seeking treatment at smaller, lesser-equipped centres. These patients landed with margin positive tumour removals and hence re-surgery.
4. Patients from smaller cities, who travel to Delhi-NCR for treatment, were also affected because of the lack of travel options. Patients from foreign countries who were planning for complex breast reconstruction surgery had to settle for mastectomy in their native countries due to travel restrictions.
5. Approx 5% of patients seen in the early phase of Covid-19 lockdown were those who had to shift from their earlier place of treatment, due to changes driven by the pandemic of their earlier hospital.
6. Less than 5% of patients had a delay due to contracting Covid-19.
October is observed as Breast Cancer Awareness Month with the aim of increasing awareness of the disease and raising funds for relevant research. Breast cancer is the most common invasive cancer in women and staying aware of its symptoms and screening oneself regularly are important ways of reducing risks. However, over the past few months, women grappling with the fear of contracting Covid-19 have been found to be avoiding symptoms and delaying consultations.
A recent survey of 535 women by SurvivorNet, a health media company for cancer information, analysed if they are still taking preventative measures for breast health risks. 1 in 3 women claimed that coronavirus has negatively impacted breast care, and 29% of the respondents admitted that their breast health has become a lower priority since the beginning of the outbreak. Annual mammograms are the most effective tool in catching breast cancer early, yet 1 in 3 women reported that they have delayed taking the test. At least 45% women also said that the outbreak has made them nervous about visiting their physicians.
Decreased consultations and delayed surgeries
Dr Deepak Jha, Clinical Lead, Breast Surgery and Senior Consultant, Surgical Oncology at Artemis Hospital, Gurugram says that almost all patients delayed coming to the hospital, and hence delayed their treatment. The period of delay among patients varied between two to six months.
Dr Pranjali Gadgil, consultant and breast surgeon at Jupiter Hospital, Pune also reports, “Our clinic has been observing a reduced number of patients. Fewer breast cancer surgeries are being performed than usual. This is worrying as we may see a potential rebound in the number of cases, once the fear of coronavirus abates.”
“The fact that breast cancer lumps are often painless and women don’t have any functional limitation in the early stages makes it particularly easy to ignore breast cancer symptoms,” says Dr Gadgil. However, even women with lumps, nipple discharge and breast pain have not come to the hospital due to the coronavirus scare, reports Dr Tejinder Kataria, Chairperson, Radiation Oncology at Cancer Institute, Medanta – The Medicity, Gurugram. Consequences of delaying treatment What can happen if a woman who may have breast cancer ignores the symptoms because of the fear of contracting Covid? Among women who underwent a biopsy in September, several admitted noticing symptoms as early as March or April. Since they waited six months before consulting a doctor, they are now being diagnosed with advanced stages of the cancer.
Cancers that could have been treated with a smaller lumpectomy in March may now need a mastectomy, says Dr Pranjali Gadgil. A larger tumour may also need chemotherapy for shrinking its size before surgery can be performed. “The more advanced the stage at the start of treatment, the greater the risk of future recurrence, and the lesser the success rate of a complete cure,” she says.
Dr Kataria also says that delays in screening mammograms have resulted in advanced stages at patients’ first presentation after the lockdown and increasing the morbidity due to breast cancer. “Screening can identify breast cancers less than 5-7 mm whereas a doctor can feel tumours between 10-15 mm and a patient can only feel the lump once it is beyond 20 mm, thereby necessitating additional treatment. Delays mean that screendetected cancers, which have been missed previously, could become clinically significant now,” she says.
“Although we are following the usual standards of care, the outcomes of cancer treatment may be adversely affected. It may be a few years before we can assess the full extent of this pandemic on breast cancer mortality,” says Dr Gadgil.
For these reasons, doctors are exhorting women to not neglect breast-related complaints. Dr Archana Dhawan Bajaj, OB/ GYN and IVF Expert at Nurture IVF Centre, Delhi, advises against delaying any required treatment due to fear of the coronavirus. Dr. Bajaj emphasises, “If there is suspicion of symptoms, a diagnosis is recommended at the earliest as breast cancer may develop into an advanced stage quickly.”
“Extra care should also be taken by breast cancer patients in these times. Treatments like chemotherapy, targeted therapies, and immunotherapy affect the immune system and make patients immunocompromised. They could be more prone to lung infection and, if infected by the virus, could face a life-threatening health condition,” she highlights.
Pandemic should not stop breast cancer treatment
Regular preventive checks and imaging promote early detection, but have been significantly impacted by not just the lockdown and social distancing rules, but also the diversion of resources to coronavirus management. Most cancer centres were not even carrying out preventive checks until recently.
Dr Atul Narayankar, consultant of medical oncology at Wockhardt Hospital, Mumbai, says that breast cancer screening, diagnostic exams and surgical procedures were being restricted or postponed at hospitals. However, this is restarting gradually, informs Dr. Rajiv Bhatt, Head of Surgical Oncology and Breast Specialist, HCG Cancer Centre, Vadodara. Radiation treatment protocols are continuing normally and most patients do complete the recommended treatment schedule, he reports.
“Cancer is a life-threatening disease and hence its treatment cannot be stopped. Despite the ongoing situation, when women noticed a lump and came to my clinic, we have been treating them with all precautions and are following Covid-19 safety protocols. Surgeries are being done, and chemotherapy and radiation therapy are given as per the stage of cancer,” says Dr Reshma Palep, Breast Oncosurgeon at Apollo Spectra hospital, Mumbai.
Dr Narayankar informs that for those patients, where it is appropriate, they are going for either neoadjuvant chemotherapy (NAC) or endocrine therapy prior to the surgery to shrink down the tumour. Chemotherapies and systemic therapies are not being delayed. He continues, “Patients on palliative therapy have been advised to shift to oral formulations whenever possible and modifying chemotherapy protocols to reduce the number of hospital visits. The hospital has also implemented a telemedicine program to deliver these services to the patients.”
What to do if you are at risk?
“Depending upon the severity and stage, one should opt for a video consultation or hospital visit,” says Dr Bajaj. To circumvent the barrier of anxiety around hospital visits, video consultations are being offered to all patients, informs Dr Gadgil. Reviewing of reports and counselling can also be done easily via teleconsultation, thereby minimising time and the number of hospital visits needed. These measures can also help doctors distinguish between complaints that can wait from those which need urgent attention. Guidelines are also being published by various organisations and societies sharing the common goal of minimising patient and physician exposure, Dr Narayankar adds.
Healthcare professionals say that, as opposed to common perception, cancer treatment can be safe during these times if both healthcare providers and patients follow all safety norms and protection. Breast cancer patients may continue treatment and follow-ups as planned. Hospitals are adopting all safeguards, trying to limit appointments, and ensuring to make patients’ stays shorter.