key: cord-0926475-2gxix7gq authors: Zhang, Zi; Ojutiku, Oreoluwa; Mango, Victoria L. title: Breast cancer patients’ response to COVID-19 related imaging and treatment delays: An online forum analysis date: 2020-09-07 journal: J Am Coll Radiol DOI: 10.1016/j.jacr.2020.09.027 sha: 721a9be15dbcef2b0819bc5804a47828fc06a6f0 doc_id: 926475 cord_uid: 2gxix7gq nan The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) associated disease (COVID-19) has rapidly spread globally, and been declared a pandemic by the World Health Organization 1 . The COVID-19 pandemic has affected every aspect of health care, including the delivery of standard of care cancer screening and treatment. In addition, cancer itself and anticancer therapy may lead to a weakened immune system, further increasing the risk of COVID-19 infection and complications 2 . Breast cancer is the most common non-skin cancer among women in the United States. Given that social distancing is a primary means of reducing COVID-19 spread, during the initial peak of the pandemic, the Society of Breast Imaging (SBI) recommended that facilities delay screening breast exams 3 . Moreover, breast cancer has been considered a low risk cancer 4 , and thus, the American College of Surgeons guideline recommended postponing of such surgery if possible or performing the procedure at an ambulatory surgery center 4 . Although these clinical services have been resumed in several states, many states have reported increased rates of COVID-19 infection, and suspended elective, non-urgent and nonemergency procedures, and screening services again. The goals of these recommendations are to protect patients and staff from exposure to the virus in the hospital setting, to conserve personal protective equipment, as well as to create hospital capacity to care for COVID-19 patients 5 . However, many patients are concerned about delayed breast cancer detection and treatment, because the timing of these interventions impacts successful outcomes. Due to the implementation of social distancing, many patients have turned to online forums J o u r n a l P r e -p r o o f for support. Thus, we evaluated breast cancer patient response to COVID-19 related breast imaging and treatment delays via online forum posts to inform patient care and prioritize services most concerning to patients when preparing for the second wave. Breastcancer.org, one of the largest nonprofit United States (US) based online breast cancer community, was utilized. We The Institutional Research Board has determined our study as non-human subject research, because the data does not include any individually identifiable information, and the posts were publicly accessible on an online forum. In total, 45 topics including 678 posts from 192 users with 14,164 views were analyzed. Of the 678 posts, 16%, 26%, 21%, 15%, 15% and 7% were posted in the first, second, third, fourth, fifth, and sixth week, respectively. Figure 1 shows the percentage of posts per week overtime from 3/11/2020 to 4/23/2020. We grouped the topics into 9 categories based on the content. Table 1 Over this 6-week period, there was a shift of posts from initial concerns and stress to more focused on coping and sharing experiences. Among 35 users who posted under the category of self-cancelation of imaging and clinical visits, the most common visit that they debated to cancel was mammography (n=11), followed by Zoladex/Lupron injection (n=3), radiation (n=2) and chemotherapy (n=1). Among the 81 users who posted regarding concerns of diagnosis and treatment delays, they were most concerned about delays of mastectomy, lumpectomy, re-excision and axillary dissection for cancer (n=17), reconstruction (n=9), and excisional biopsy for diagnosis and high-risk lesion (n=3), and radiation (n=2), but did not report delays of diagnostic imaging or core-needle biopsy. Among the 23 users posted regarding healthcare changes, patients favored telemedicine (n=5) and preferred to keep them. The online forum provides a great platform for breast cancer patients to cope with the worries and loneliness. Our analysis showed that the number of posts peaked during 3/19/2020-3/25/2020, when increasingly non-urgent visits and elective procedures were canceled or delayed in various States following the Centers for Disease Control and Prevention (CDC) guideline 6 . In addition to stress and concerns about COVID-19, patients were most concerned about breast cancer diagnosis and treatment delays, especially delays of various breast cancer surgeries. Patients did not report delays of diagnostic imaging or core-needle biopsy. This is consistent with the recommendations that urgent diagnostic imaging and biopsies should proceed as usual 7 . Our findings suggested the importance of prioritizing J o u r n a l P r e -p r o o f pre-surgical imaging evaluation and biopsy, as well as shifting to non-wire localization when possible so that patients can be rapidly scheduled as operating room availability opens up, with the goal of addressing patient concerns. In our study, patients discussed self-cancelation of imaging and clinical visits. The SBI recommended delaying screening during the pandemic to promote social distancing 3 . In addition, guidelines have been published to help physicians make risk-benefit decisions weighing concerns that treatment of cancer may increase the risk of COVID-19 and worsening its complications against the risk that delay in treatment may compromise oncologic outcomes 5 . Patients' debate of self-cancellation highlights the importance of implementing safety measures to assure patients when providing screening and clinical services, such as spreading out the appointments and having separate waiting areas to implement social distancing. Patients in our analysis also expressed interests to keep the telemedicine visits post pandemic. The COVID-19 pandemic has driven rapid expansion of telemedicine use for urgent and non-urgent health care visits, which could transform the way physicians provide care going forward 8 . In Breast Imaging, virtual consult also has been used to deliver the imaging and biopsy results while implementing social distancing 7 . First, we evaluated breast cancer patients' response to the imaging and treatment delays, as they may be more susceptible to COVID-19 infection and mortality, and the delays may have a great impact on them. We did not use multiple forums to gain more insight on the delay of mammography in the general population. Second, patients posted J o u r n a l P r e -p r o o f on the online forum may not represent all breast cancer patients whose care was affected by the pandemic. Third, the locations and states of the forum users were not available to analyze the impact of the pandemic on various geographic regions at different times. Finally, although we analyzed patients' concerns regarding the COVID- World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19 A Practical Approach to the Management of Cancer Patients During the Novel Coronavirus Disease 2019 (COVID-19) Pandemic: An International Collaborative Group ACS Guidelines for Triage and Management of Elective Cancer Surgery Cases During the Acute and Recovery Phases of Representatives from the American College of Radiology ACoS Pandemic Breast Cancer Consortium's Considerations for Re-entry Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic Response to COVID-19 in Breast Imaging COVID-19 transforms health care through telemedicine: evidence from the field