Study Finds Impact of Surgical Delay on Women with Breast Cancer Due to COVID-19

A study published in the Journal of the American College of Surgeons indicated that a longer time from diagnosis to surgical treatment does not lower the overall survival (OS) of women with early-stage breast cancer who had to delay operations due to the coronavirus disease 2019 (COVID-19) pandemic.

In addition, researchers found no survival decrease with operative delays in women with estrogen receptor (ER)-positive early-stage breast cancer who received neoadjuvant endocrine therapy. Typically, this patient population receives anti-estrogen therapy following surgical removal of the tumor or breast; however, according to lead study author Christina Minami, MD, MS, an associate surgeon at Brigham and Women's Hospital in Boston, endocrine therapy was recommended nationwide as the initial treatment of ER-positive breast cancer due to pandemic-related surgical delays.

"Usually we take these patients with very small tumors directly to surgery, so it is a big change in practice to first put those patients on tamoxifen or an aromatase inhibitor," Minami explained in a press release. "What we can say from our findings is that despite the delay in surgical therapy, because you were on neoadjuvant endocrine therapy, we do not think that your survival will at all be impacted."

To better understand the impact of COVID-19 related surgical delay tactics, researchers utilized data from 378,839 patients included in the National Cancer Database with either ductal carcinoma in situ (DCIS) or ER-positive cT1-2N0 breast cancer treated from 2010 to 2016. Time to surgery (TTS) was then recorded and analyses were stratified by disease stage and initial treatment strategy.

Overall, increased TTS was associated with increased odds of pathological upstaging in patients with DCIS breast cancer, though women with ER-positive DCIS had a slightly increased odds of pathologic upstaging with a surgical delay surpassing 60 days (OR, 1.15; 95% CI, 1.08-1.22). Patients whose DCIS was ER-negative had a higher risk of upstaging only if they underwent an operation more than 120 days after diagnosis (OR, 1.36; 95% CI, 1.01-1.82).

“We can tell our patients they can still expect an excellent prognosis from their early-stage hormone receptor-positive cancer and that their excellent prognosis is not negatively impacted by this delay they have experienced,” senior study author Elizabeth Mittendorf, MD, PhD, FACS, professor of surgery at Brigham and Women's Hospital, explained in the release.

Notably, the applicability of these study findings is limited given that the populations experiencing delays in surgical therapy who were selected for neoadjuvant endocrine therapy in this retrospective analysis were more select then the patients who have experienced a surgery delay during the pandemic. Study participants who received neoadjuvant endocrine therapy from 2010 to 2016 did so for specific reasons according to researchers, such as older age and coexisting illnesses. However, the investigators also indicated that these data are the best currently available to study the possible outcomes of oncologic surgical delays.

“While the applicability of these data to the patients experiencing surgical delays during the COVID-19 pandemic is limited, surgeons and patients may find some reassurance in these findings, as these two groups represent patients significantly affected by the surgical triage recommendations of the COVID-19 Pandemic Breast Cancer Consortium,” the authors wrote. “Future study of outcomes of patients treated during this time will be required to determine the actual impact of COVID-related surgical delays and delay strategies.”

References:

1. Minami CA, Kantor O, Weiss A, Nakhlis F, King TA, Mittendorf EA. Association between Time to Operation and Pathological Stage in Ductal Carcinoma in Situ and Early-Stage Hormone Receptor-Positive Breast Cancer. Journal of the American College of Surgeons (2020). doi: 10.1016/j.jamcollsurg.2020.06.021.

2. Delay in breast cancer operations due to COVID-19 pandemic appears to be non-life-threatening for women with early-stage disease [news release]. Chicago. Published August 6, 2020. Accessed August 11, 2020. https://www.facs.org/media/press-releases/2020/breast-080620