Breast cancer and Covid-19 - A look back and reflection

In the developed world, shortly after the pandemic started, professional organisations realised the detrimental effect that the pandemic would have on screening and treatment for the disease. As breast cancer is the most common cancer world-wide in females, guidelines¹ were released as soon as possible on the management of breast cancer during a pandemic. These guidelines stressed that any screening and diagnostics, as well as treatment should be transferred, as far as possible, to non-hospital outpatient settings and that treatment should, as far as possible, follow the existing guidelines.

As it became clear that close contact between women coming for screening and imaging staff at screening would pose a particular risk of infection, professional organisations recommended that screening examinations to be postponed for “a few weeks or months”².

Says Dr Justus Apffelstaedt, a specialist surgeon in breast cancer: “Despite these recommendations, patients were reluctant to book for screening or the management of breast lumps. Hospital treatments, surgeries in particular, were delayed due to capacity constraints as medical staff were withdrawn from theatres to care for Covid-19 patients in need of ventilation or were themselves infected or isolating after a high-risk exposure. This inevitably led to delayed diagnoses and disrupted treatment sequences with detrimental effects on outcomes for patients.”

Many people feared cancer treatment during a pandemic. However, early reviews of cancer therapies and their interaction with cancer therapy found that there is very little, if any, adverse interaction of a Covid-19 infection and cancer therapy for solid tumours³.

“In clinical practice, we observed that our cancer patients did not seem to suffer disproportionately from a Covid-19 infection,” says Apffelstaedt. “We speculate that this is due to most cancer treatments in breast cancer (surgery, hormonal therapy, biologicals and radiation) not having any significant impact on the immune system. On the other hand, the mechanisms of Covid-19 disease indicate that most damage is done by the body’s immune system overreacting to the infection and damaging tissues far and wide. Chemotherapy may suppress this overreaction to some extent and therefore not be as detrimental as initially feared.”

Can the impact of Covid-19 on breast cancer outcomes be estimated now?

It has become clear that Covid-19 disproportionately affects disadvantaged communities. These communities are already known to have poorer outcomes of breast cancer due to socioeconomic barriers such as access to health care and lack of screening and treatment opportunities⁴. In evaluating the impact of the Covid-19 pandemic, barriers to accessing health care were emphasised in developing countries and notably in South Africa. The prolonged closure of public health care facilities is just one example. The reluctance to travel to access more advanced treatment options such as oncoplastic and immediate reconstructive surgery is another; particularly when these are not available in all provinces or in countries surrounding South Africa.

“The Covid-19 attributable mortality is relatively easily to measure as most infected patients either die within four weeks after infection or survive,” says Apffelstaedt. “In contrast, a woman whose diagnosis of breast cancer has been delayed and where the cancer has progressed to a more advanced stage and treatment sequences have been disrupted, does not die immediately, but years later. This excess mortality will be only be apparent – if at all, after about 10 years and requires big data sets to filter out. Therefore, only projections of an excess cancer mortality can be made.”

A literature search revealed only one such projection of breast cancer over-mortality for the US⁵. It comes to the conclusion that by 2030 an additional 2,500 women will have died due to breast cancer because of Covid-19 related disruptions.

Concludes Apffelstaedt: “Breast cancer is already a disease with far worse outcomes for the disadvantaged. We speculate that, once again, the burden of unfortunate global events such as this pandemic will fall disproportionately on the poor and vulnerable.”

About Dr Justus Apffelstaedt

Dr Justus Apffelstaedt, specialist surgeon with an interest in breast, thyroid and parathyroid health as well as soft tissue surgical oncology.

Apffelstaedt is a former associate professor of Surgery and head: Surgical Oncology Service, University of Stellenbosch. Apffelstaedt earned a medical degree and a Doctorate in Medicine in Germany, as well as an MMed and FCS(SA) in South Africa and an MBA from Bond University in Australia. He was co-founder of and has represented developing countries on the council of Breast Surgery International (BSI) and is a founding member and first chairman of the Breast Interest Group of Southern Africa (Bigosa). He is a fellow and life member of the International Union Against Cancer (UICC) Fellows.

He is excellent at translating complex medical terminology into easily understood language and is a proponent of proactive breast health management through extensive dissemination of information to the general public. His breast service is the only one in Africa to publish peer-reviewed data comparable to international breast practices in breast screening. He is also the author and co-author of several publications in peer-reviewed national and international journals on breast cancer screening and breast health issues.

His current interest and field of practice includes breast health, thyroid, parathyroid and soft tissue tumours.

He has been proudly supporting one of South Africa’s oldest, national non-profit breast cancer support groups, Reach for Recovery, to raise awareness and funds for their Ditto Project since 2018.

He has practices in Cape Town, South Africa and Windhoek in Namibia.
Website: www.apffelstaedt.com.

References:
¹ESMO Management and treatment adapted recommendations in the COVID-19 era: Breast Cancer.
de Azambuja E, Trapani D, Loibl S, Delaloge S, Senkus E, Criscitiello C, Poortman P, Gnant M, Di Cosimo S, Cortes J, Cardoso F, Paluch-Shimon S, Curigliano G. ESMO Open. 2020 May;5(Suppl 3):e000793. doi: 10.1136/esmoopen-2020-000793. PMID: 32439716 Free PMC article. Review.
Recommendations for prioritization, treatment, and triage of breast cancer patients during the COVID-19 pandemic. the COVID-19 pandemic breast cancer consortium.
Dietz JR, Moran MS, Isakoff SJ, Kurtzman SH, Willey SC, Burstein HJ, Bleicher RJ, Lyons JA, Sarantou T, Baron PL, Stevens RE, Boolbol SK, Anderson BO, Shulman LN, Gradishar WJ, Monticciolo DL, Plecha DM, Nelson H, Yao KA. Breast Cancer Res Treat. 2020 Jun;181(3):487-497. doi: 10.1007/s10549-020-05644-z. Epub 2020 Apr 24. PMID: 32333293 Free PMC article.
14. Canadian Society of Breast Imaging and Canadian Association of Radiologists Joint Position Statement on COVID-19. 2020. https://csbi.ca/wp-content/uploads/2020/03/Covid-19-statement-CSBI_CAR-1.pdf
15. Society of Breast Imaging Statement on Screening in a Time of Social Distancing. 2020. https://www.sbi-online.org/Portals/0/Position%20Statements/2020/SBI-statement-on-screening-in-a-time-of-social-distancing_March-17-2020.pdf
16. Pediconi F., Mann R.M., Gilbert F.J. on behalf of the EUSOBI Executive Board. EUSOBI recommendations for breast imaging and cancer diagnosis during and after the COVID-19 pandemic. 2020. https://www.eusobi.org/content-eusobi/uploads/EUSOBI-Recommendations_Breast-Imaging-during-COVID.pdf
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Smith BL, Nguyen A, Korotkin JE, Kelly BN, Specht MC, Spring LM, Moy B, Isakoff SJ, Gadd MA. Breast Cancer Res Treat. 2020 Oct;183(3):515-524. doi: 10.1007/s10549-020-05792-2. Epub 2020 Jul 25. PMID: 32712878

³The effect of anticancer treatment on cancer patients with COVID-19: A systematic review and meta-analysis.
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Comprehensive review of implications of COVID-19 on clinical outcomes of cancer patients and management of solid tumors during the pandemic.
Madan A, Siglin J, Khan A. Cancer Med. 2020 Dec;9(24):9205-9218. doi: 10.1002/cam4.3534. Epub 2020 Oct 20. PMID: 33078903

⁴Curr Breast Cancer Rep. 2021 Aug 6;1-3. doi: 10.1007/s12609-021-00419-x. Online ahead of print. Breast Cancer Disparities Through the Lens of the COVID-19 Pandemic. Lisa Newman 1, Laura Fejerman 2, Tuya Pal 3, Eralda Mema 4, Geraldine McGinty 4, Alex Cheng 5, Mia Levy 5, Adeyiza Momoh 6, Melissa Troester 7, Bryan Schneider 8, Lorna McNeil 9, Melissa Davis 1, Kemi Babagbemi 4, Kelly Hunt 10. PMID: 34394841 PMCID: PMC8344389 DOI: 10.1007/s12609-021-00419-x
Similarities in Risk for COVID-19 and Cancer Disparities.
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Barriers to breast cancer screening are worsened amidst COVID-19 pandemic: A review.
Tsapatsaris A, Babagbemi K, Reichman MB. Clin Imaging. 2022 Feb;82:224-227. doi: 10.1016/j.clinimag.2021.11.025. Epub 2021 Dec 7. PMID: 34896935

⁵Impact of the COVID-19 Pandemic on Breast Cancer Mortality in the US: Estimates From Collaborative Simulation Modeling.
Alagoz O, et al. J Natl Cancer Inst. 2021. PMID: 34258611