Trends in diagnosis and treatment of early breast cancer (eBC) in the United States (US) during the COVID-19 era.

227 Background: Recent studies have demonstrated a decline in cancer screening and diagnosis during the COVID-19 pandemic. This study explored trends in the diagnosis and management of eBC at a sample of cancer clinics across the US early on in the pandemic. Methods: Patients were selected from the Flatiron Health Research Database (FHRD), an electronic health record-derived de-identified database comprising approximately 280 US cancer clinics (̃800 sites of care). Eligible patients had an ICD code for breast cancer, at least two clinical encounters, and a confirmed eBC (Stage I-III) diagnosis from unstructured documents. Patients were selected into two cohorts based on diagnosis date: a) COVID-19 era cohort diagnosed between February 1, 2020 through June 30, 2020 and b) pre-COVID-19 era cohort diagnosed from February 1, 2019 through June 30, 2019. Descriptive statistics were used to assess diagnosis trends in each time frame. Initial treatment received following eBC diagnosis was categorized as surgery, radiation or systemic therapy and was compared between the two cohorts. Initial treatment modalities for each cohort were further stratified by clinical stage and biomarker subtype (HER2+, HR+/HER2-, triple negative [TN] or unknown). Results: A total of 278 and 253 patients were selected for the pre-COVID-19 era and COVID-19 era cohorts, with a median age at diagnosis of 65 and 64 years, respectively. A 35% decrease in the number of eBC diagnoses was observed in April/May 2020 compared to March 2020, yet this reduction in diagnoses was not observed during the equivalent months in the pre-COVID-19 era cohort. Compared to the pre-COVID-19 era, a greater proportion of patients diagnosed with eBC during the COVID-19 era initiated systemic therapy as their first treatment modality (16.5% vs 29.6%) including patients with HER2+ (27.5% vs. 60%), HR+/HER2- (13.5% vs. 24.9%) and TN (30.8% vs. 40.0%) disease. This trend was observed in patients with stage I (11.7% vs. 24.1%) or II (55.9% vs. 73.0%) but not in patients with stage III (81.2% vs. 77.3%) eBC. Notably, among patients with HR+/HER2- eBC who received systemic therapy as their first treatment, endocrine therapy was most commonly used in keeping with recent recommendations from professional societies due to COVID-related anticipated surgical delays. Conclusions: This study demonstrates that COVID-19 was associated with a decreased incidence of eBC which could be, at least in part, attributed to previously reported delays in routine screening and pandemic healthcare utilization. Further efforts are required to understand who was affected by these delays and the impact on cancer outcomes. Follow-up data are needed to understand if the observed trends in cancer screening and treatment persist and their impact on long-term cancer outcomes.

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The impact of the COVID-19 pandemic on stage at diagnosis of breast and colorectal cancers.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.6501 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. 6501-6501

Author(s):

Jade Zhou ◽

Shelly Kane ◽

Celia Ramsey ◽

Melody Ann Akhondzadeh ◽

Ananya Banerjee ◽

...

Keyword(s):

Breast Cancer ◽

Colorectal Cancer ◽

Cancer Screening ◽

Late Stage ◽

Stage Iv ◽

Stage I ◽

Screening Programs ◽

Stage Distribution ◽

Number Of Patients ◽

The Impact

6501 Background: Effective cancer screening leads to a substantial increase in the detection of earlier stages of cancer, while decreasing the incidence of later stage cancer diagnoses. Timely screening programs are critical in reducing cancer-related mortality in both breast and colorectal cancer by detecting tumors at an early, curable stage. The COVID-19 pandemic resulted in the postponement or cancellation of many screening procedures, due to both patient fears of exposures within the healthcare system as well as the cancellation of some elective procedures. We sought to identify how the COVID-19 pandemic has impacted the incidence of early and late stage breast and colorectal cancer diagnoses at our institution. Methods: We examined staging for all patients presenting to UCSD at first presentation for a new diagnosis of malignancy or second opinion in 2019 and 2020. Treating clinicians determined the stage at presentation for all patients using an AJCC staging module (8th edition) in the electronic medical record (Epic). We compared stage distribution at presentation in 2019 vs 2020, both for cancers overall and for colorectal and breast cancer, because these cancers are frequently detected by screening. Results: Total numbers of new patient visits for malignancy were similar in 2019 and 2020 (1894 vs 1915 pts), and stage distribution for all cancer patients was similar (stage I 32% in 2019 vs 29% in 2020; stage IV 26% in both 2019 and 2020). For patients with breast cancer, we saw a lower number of patients presenting with stage I disease (64% in 2019 vs 51% in 2020) and a higher number presenting with stage IV (2% vs 6%). Similar findings were seen in colorectal cancer (stage I: 22% vs 16%; stage IV: 6% vs 18%). Conclusions: Since the COVID-19 pandemic, there has been an increase in incidence of late stage presentation of colorectal and breast cancer, corresponding with a decrease in early stage presentation of these cancers at our institution. Cancer screening is integral to cancer prevention and control, specifically in colorectal and breast cancers which are often detected by screening, and the disruption of screening services has had a significant impact on our patients. We plan to continue following these numbers closely, and will present data from the first half of 2021 as it becomes available.

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Effect of type and timing of systemic therapy on risk of radiation necrosis in patients with HER2+ breast cancer brain metastases.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e14002 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e14002-e14002

Author(s):

Christine Park ◽

Evan Buckley ◽

Amanda E.D. Van Swearingen ◽

Will Giles ◽

James Emmett Herndon ◽

...

Keyword(s):

Breast Cancer ◽

Brain Metastases ◽

Systemic Therapy ◽

Radiation Necrosis ◽

Treatment Modalities ◽

Conformity Index ◽

Her2 Breast Cancer ◽

Breast Cancer Brain Metastasis ◽

The Impact ◽

Systemic Therapies

e14002 Background: It is estimated that 30% of patients with metastatic human epidermal growth factor receptor 2-positive (HER2+) breast cancer will develop brain metastases. Current standard of care options for HER2+ breast cancer brain metastasis (BCBrM) includes radiation therapy (stereotactic radiosurgery [SRS] or whole brain radiation), brain permeable systemic therapies, and in select cases, neurosurgical resection. A multimodal approach combining these different treatment modalities has improved the overall survival and functional outcomes of patients with BCBrM. Some HER2-directed systemic therapies, however, may increase the risk of radiation necrosis (RN), a longer-term consequence of SRS. This study explores the impact of timing and type of systemic therapies on the development of RN in patients treated with SRS for HER2+ BCBrM. Methods: This was a single-institution, retrospective study including patients ≥18 years of age with HER2+ BCBrM who received SRS between 2013 and 2018 at Duke University with at least 12-month post-SRS follow-up. Presence of RN was determined at one-year post-SRS. Demographics, radiotherapy parameters (total dose, fractions, clinical target volume [CTV], gross tumor volume [GTV], conformity index [CI], volume receiving 12 gray [V12Gy]), and timing (during [within 4 weeks of SRS] vs. not during SRS) and type of systemic therapy (HER2-directed therapy, mitosis inhibitors, DNA synthesis inhibitors, others) were evaluated. Results: Among 46 patients with HER2+ BCBrM who received SRS, 28 (60.9%) developed RN and 18 (39.1%) did not. Age at time of SRS did not differ between those who developed RN and those who did not (mean 53.3 vs 50.4 years, respectively). There was a higher percentage of African Americans in the RN group (28.6% vs 11.1%, p = 0.3). There were no significant differences between the measured radiotherapy parameters—including dose, fraction, CTV, GTV, CI, V12Gy—between the two groups (all p > 0.05). Receipt of any type of systemic therapy during SRS did not differ between patients who did or did not develop RN (60.7% vs 55.6%, p = 0.97). However, patients who developed RN more commonly received more than one line of HER2-directed therapy independent of SRS timing compared to those who did not develop RN (75.0% vs 44.4%, p = 0.08). In fact, a significantly higher proportion of those who developed RN received more than one line of HER2-directed therapy during SRS compared to those did not develop RN (35.7% vs 5.6%, p<0.05). Conclusions: Patients with HER2 BCBrM who receive multiple lines of HER2-directed therapy during SRS for BCBrM may be at higher risk of RN. This data supports a practice of holding HER2-directed therapy during SRS if medically acceptable. Further investigation of next generation HER2-directed therapies in a larger cohort of patients should be investigated to help guide best practice to minimize RN.

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Disability as a predictor of breast cancer screening uptake: A population-based study of 57,328 women

Journal of Medical Screening ◽

10.1177/0969141319888553 ◽

2019 ◽

Vol 27 (4) ◽

pp. 194-200

Author(s):

Emma Ross ◽

Aideen Maguire ◽

Michael Donnelly ◽

Adrian Mairs ◽

Clare Hall ◽

...

Keyword(s):

Breast Cancer ◽

Cancer Screening ◽

Northern Ireland ◽

Breast Cancer Screening ◽

Breast Screening ◽

The United States ◽

Ageing Population ◽

Screening Uptake ◽

National Breast ◽

The Impact

Objective Despite a growing body of evidence suggesting inequalities in breast cancer screening uptake in the United States for women with disabilities, few attempts have been made to examine whether this association applies to the United Kingdom. We conducted the first population-wide study investigating the impact of disability on uptake of breast cancer screening in Northern Ireland. Methods Breast screening records extracted from the National Breast Screening System were linked to the Northern Ireland Longitudinal Study. This identified a cohort of 57,328 women who were followed through one complete three-year screening cycle of the National Health Service Breast Screening Programme in Northern Ireland. The presence of disability was identified from responses to the 2011 Census. Results Within this cohort, 35.8% of women reported having at least one chronic disability, and these individuals were 7% less likely to attend compared with those with no disability (odds ratio 0.93; 95% confidence interval 0.89–0.98). Variation in the degree of disparity observed was evident according to the type and number of comorbid disabilities examined. Conclusion This is the first population-wide study in Northern Ireland to identify disparities in breast screening uptake for women with chronic disabilities, in particular, those with multimorbidity. This is of particular concern, given the projected rise in the prevalence of disability associated with the ageing population.

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The Impact of Race, and Insurance Status on Breast Cancer Screening: Results from the Behavioral Risk Factor Surveillance System Data

10.21203/rs.3.rs-427806/v1 ◽

2021 ◽

Author(s):

Salamata Yoda ◽

Jennifer Mallow ◽

Laurie A. Theeke

Keyword(s):

Breast Cancer ◽

Health Insurance ◽

Cancer Screening ◽

Breast Cancer Screening ◽

Multinomial Logistic Regression ◽

The United States ◽

Minority Women ◽

Insurance Status ◽

The Past ◽

The Impact

Abstract Purpose Breast cancer is the second major cause of cancer-related death of women in the United States 1, yet current gaps exist in breast cancer screening for minority women 2. The purpose of this study is to address these gaps by assessing the relationships among race, health insurance coverage, and breast cancer screening in a nationally representative sample of women. Design: A cross-sectional descriptive analysis of the 2018 BRFSS survey data was used to meet the study purpose. BRFSS participants who declared themselves to be of female sex and who were adults with the age ≥ of 40 years were selected for inclusion. Methods Data were analyzed using SPSS version 26. Exploratory and descriptive analyses were performed, followed by comparative analyses based on the variable type. Relationships between race, insurance status, and mammogram screening were examined. Chi-square, logistic, and multinomial logistic regression were used. Findings: The original 2018 BRFSS dataset included 437,436 participants and 145,837 women were selected based on inclusion criteria. Participant age ranged from 40 to 74 years. The majority were White only non-Hispanic (78.1%), reported having a mammogram in the past two years (76.1%), had earned < a 4-year college degree (61.1%), had an annual income of < $75,000 (58.4%) and married (58.2%). Less than half had a healthcare plan through an employer (44.9%) and were employed (40.5%). Participants who had a plan purchased through an employer or union were more likely to have a mammogram in the past two years when compared with other health coverage. Furthermore, White only, non-Hispanics were 1.25 times more likely and Black only, non-Hispanics were 1.98 times more likely to have a mammogram in the past two years compared to participants from other racial and ethnic groups. Conclusion The findings of this study provide an additional indication that race, and health insurance status do impact breast cancer screening. Clinical Relevance: Knowledge gained from this study can be used by practicing nurses to educate racial and ethnic minority women on the significance of breast cancer screening and prevention.

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Screening Mammography: Guidelines versus Clinical Practice

Journal of Breast Imaging ◽

10.1093/jbi/wbaa003 ◽

2020 ◽

Vol 2 (3) ◽

pp. 217-224 ◽

Cited By ~ 1

Author(s):

Rebecca Oudsema ◽

Esther Hwang ◽

Sharon Steinberger ◽

Rowena Yip ◽

Laurie R Margolies

Keyword(s):

Breast Cancer ◽

Clinical Practice ◽

Cancer Screening ◽

Medical Students ◽

Breast Cancer Screening ◽

The United States ◽

Screening Mammography ◽

Medical Specialties ◽

Patients Âgés ◽

The Impact

Abstract Objective To understand physicians’ comprehension of breast cancer screening guidelines and the existing literature on breast cancer screening, and whether this contributes to how patient screening is implemented in clinical practice. Methods A survey of 18 questions was distributed across the United States via e-mail and social media resources to physicians and medical students of all disciplines and levels of training. Responses from 728 physicians and medical students were reviewed. Respondents were from over 200 different institutions and over 60 different medical specialties. Results Our survey demonstrates that more than half of the participants felt uncomfortable in their knowledge of breast cancer screening recommendations (399/728, 54.8%) and existing literature on breast cancer screening (555/728, 76.2%). When stratified based on level of training, those at the attending level reported a greater level of comfort in their knowledge of breast cancer screening recommendations (168/238, 70.6%) and literature (95/238, 39.9%) compared with respondents at the trainee level. Attending physicians are also more likely to recommend screening for patients between the ages of 40–49 years old (209/238, 87.7%) compared to those at the trainee level. Responses on whether to screen based on age were most consistent for patients ages 50–74, with greater than 90% of the respondents endorsing screening mammogram for this age group in all levels of training. There were greater inconsistencies in the support to screen age groups 40–49 and 75+ . Conclusions The results showed a disparity in screening practices by clinicians in all levels of training, particularly for patients ages 40–49 and 75+ , and for the interval of screening. Later initiation with less frequent intervals between screens may reduce the impact of screening on mortality reduction.

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Endocrine Therapy Plus Anti-HER2 Therapy as Adjuvant Systemic Therapy for Luminal HER2-Positive Breast Cancer: An Analysis of the National Cancer Database

Breast Cancer Basic and Clinical Research ◽

10.1177/1178223420945694 ◽

2020 ◽

Vol 14 ◽

pp. 117822342094569

Author(s):

Zeina A Nahleh ◽

Elizabeth B Elimimian ◽

Leah C Elson ◽

Brian Hobbs ◽

Wei Wei ◽

...

Keyword(s):

Breast Cancer ◽

United States ◽

Endocrine Therapy ◽

Systemic Therapy ◽

The United States ◽

Stage I ◽

Adjuvant Systemic Therapy ◽

National Cancer Database ◽

Her2 Positive ◽

Positive Breast Cancer

Background: Guidelines regarding the usage of adjuvant systemic therapy in patients with small human epidermal growth factor receptor 2 (HER2)-positive and estrogen receptor/progesterone receptor–positive (luminal HER2 positive) tumors are nonspecific. Outcomes of chemotherapy followed by endocrine therapy (ET), with or without anti-HER2 therapy, vs ET alone (no chemotherapy) have not been widely studied in this disease subtype. We sought to examine the usage and outcomes of adjuvant systemic therapy (ET vs chemotherapy with or without trastuzumab) in stage I luminal HER2-positive breast cancer (BC), based on the large National Cancer Database. Methods: We conducted a retrospective analysis of patients with luminal HER2-positive stage I BC, diagnosed between 2010 and 2015, in the United States, using univariable and multivariable logistic regression analyses. The Kaplan-Meier method estimated overall survival (OS). Results: A total of 37 777 patients were included in the analysis; of these, n = 32 594 (86%) received adjuvant ET and n = 5183 (14%) received chemotherapy. Around 40% of all patients received anti-HER2 therapy (trastuzumab). Patients who received trastuzumab had a better 5-year OS (93.4% vs 92.0%, P = .0002) compared with those who did not. Patients who received anti-HER2 therapy plus ET had the best OS rate at 5 years (93.5%, confidence interval [CI]: 89.2%-98%, P < .0001) compared with those receiving anti-HER2 therapy plus chemotherapy (92.7%, CI: 89.4%-96.1%, P < .0001). Conclusions: Most patients in the United States, with stage I luminal HER2 positive BC, received ET, not chemotherapy but most of them do not receive anti-HER2 therapy resulting in inferior outcome. Future trials exploring the de-escalation of systemic adjuvant therapy for early-stage luminal HER2-positive BC to ET plus anti-HER2 therapy would be desirable.

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Patterns and Outcomes Of First-Line Management Strategies In Older Adults With Low-Grade Follicular Lymphoma (FL)

Blood ◽

10.1182/blood.v122.21.1805.1805 ◽

2013 ◽

Vol 122 (21) ◽

pp. 1805-1805

Author(s):

Ashish Rai ◽

Loretta J. Nastoupil ◽

Joseph Lipscomb ◽

Kevin Ward ◽

David H. Howard ◽

...

Keyword(s):

Older Adults ◽

Management Strategies ◽

The United States ◽

Stage I ◽

Stage Iii ◽

Treatment Modalities ◽

Low Grade ◽

First Line ◽

The Impact ◽

Line Management

Abstract Background Therapeutic decision making for patients with low-grade (grade 1 and 2) FL involves deciding whether to treat, when to treat, and which among the numerous treatment modalities to administer. The lack of trials comparing outcomes of these treatment modalities makes it a complex process. This study seeks to examine the evolving treatment paradigm and evaluate the outcomes of first-line management strategies for low-grade FL in adults aged ≥ 66. Methods We used the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify 4,233 low grade FL patients (pts) aged 66 years and older diagnosed between 1995 and 2009. We ascertained first-line management strategies from Medicare claims made within 90 days of diagnosis. We used Kaplan-Meier estimators stratified by stage to evaluate survival functions for first-line management strategies. We used multivariate Cox proportional hazards models—stratified by stage and adjusted for patient demographics, comorbidity index, and year of diagnosis—to compare the impact of first-line management strategies on overall survival (OS). Results Of the 4,233 pts, 57% were female, 3% were African American, 93% were White, 51% resided in big metropolitan areas, 70% were diagnosed after 2000, 44% had stage III/IV disease, and 38% had extranodal involvement. The median age at diagnosis was 74 years (interquartile range 70-80). Common first-line management strategies were: observation (obs), 47%; chemotherapy (chemo) plus rituximab (R), 20%; chemo alone, 12%; R alone, 9%; and radiotherapy (XRT) alone, 9%. Among pts receiving chemo plus R (R-chemo), the most commonly used regimens were: R-CHOP (R, cyclophosphamide, doxorubicin, vincristine, and prednisone; 36%), R-CVP (R, cyclophosphamide, vincristine, and prednisone; 47%), R-Fludarabine based (9%), and R-other (7%). The table displays median survival and hazard ratios (HRs) for first-line management strategies. Among stage I/II cases, most favorable outcomes were observed in cases receiving XRT alone, whereas among stage III/IV cases most favorable outcomes were observed in the group that received R-chemo. In the subset of stage III/IV pts that received R-chemo, R-CHOP was associated with the most favorable outcomes. HRs decreased steadily with increasing years of diagnosis. Conclusion First-line R-chemo is commonly used in older adults with low-grade FL in the United States and is associated with most favorable survival outcomes. XRT is associated with very favorable outcomes in stage I/II pts. Outcomes have improved steadily in the past 10 years. CVP–cyclophosphamide, vincristine, prednisone; CHOP- cyclophosphamide, doxorubicin, vincristine, prednisone Disclosures: No relevant conflicts of interest to declare.

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Women's considerations and experiences for breast cancer screening and surveillance during the COVID-19 pandemic in the United States: A focus group study

Preventive Medicine ◽

10.1016/j.ypmed.2021.106542 ◽

2021 ◽

Vol 151 ◽

pp. 106542

Author(s):

Karen E. Schifferdecker ◽

Danielle Vaclavik ◽

Karen J. Wernli ◽

Diana S.M. Buist ◽

Karla Kerlikowske ◽

...

Keyword(s):

Breast Cancer ◽

United States ◽

Cancer Screening ◽

Focus Group ◽

Breast Cancer Screening ◽

The United States ◽

Focus Group Study ◽

Screening And Surveillance

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The impact of sociodemographic factors on the utilization of radiation therapy in breast cancer patients in Estonia: a register-based study

International Journal for Equity in Health ◽

10.1186/s12939-021-01497-0 ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Fereshteh Shahrabi Farahani ◽

Keiu Paapsi ◽

Kaire Innos

Keyword(s):

Breast Cancer ◽

Radiation Therapy ◽

Cancer Registry ◽

Psychosocial Support ◽

Sociodemographic Factors ◽

Stage I ◽

Equal Access ◽

Administrative Databases ◽

The Impact ◽

Over Time

Abstract Background Radiation therapy is an important part of multimodal breast cancer treatment. The aim was to examine the impact of sociodemographic factors on radiation therapy use in breast cancer (BC) patients in Estonia, linking cancer registry data to administrative databases. Methods Estonian Cancer Registry provided data on women diagnosed with BC in Estonia in 2007–2018, including TNM stage at diagnosis. Use of radiation therapy within 12 months of diagnosis was determined from Estonian Health Insurance Funds claims, and sociodemographic characteristics from population registry. Receipt of radiation therapy was evaluated over time and by clinical and sociodemographic factors. Poisson regression with robust variance was used to calculate univariate and multivariate prevalence rate ratios (PRR) with 95 % confidence intervals (CI) for receipt of radiation therapy among stage I–III BC patients age < 70 years who underwent primary surgery. Results Overall, of 8637 women included in the study, 4310 (50 %) received radiation therapy within 12 months of diagnosis. This proportion increased from 39 to 58 % from 2007 to 2009 to 2016–2018 (p < 0.001). Multivariate regression analysis showed that compared to women with stage I BC, those with more advanced stage were less likely to receive radiation therapy. Receipt of radiation therapy increased significantly over time and was nearly 40 % higher in 2016–2018 than in 2007–2009. Use of radiation therapy was significantly lower for women with the lowest level of education compared to those with a university degree (PRR 0.88, 95 % CI 0.80–0.97), and for divorced/widowed women (PRR 0.95, 95 % CI 0.91–0.99) and single women (PRR 0.92, 95 % CI 0.86–0.99), compared to married women. Age at diagnosis, nationality and place of residence were not associated with receipt of radiation therapy. Conclusions The study showed considerable increase in the use of radiation therapy in Estonia over the study period, which is in line with increases in available equipment. The lack of geographic variations suggests equal access to therapy for patients living in remote regions. However, educational level and marital status were significantly associated with receipt of radiation therapy, highlighting the importance of psychosocial support in ensuring equal access to care.

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