key: cord-0949448-7xlarbri
authors: Koca, Bulent; Yildirim, Murat
title: Delay in breast cancer diagnosis and its clinical consequences during the coronavirus disease pandemic
date: 2021-06-17
journal: J Surg Oncol
DOI: 10.1002/jso.26581
sha: 27b0cb9f7eacd8f35e6fc1e348d6441204f26a80
doc_id: 949448
cord_uid: 7xlarbri

OBJECTIVE: At the end of 1 year of the coronavirus disease (COVID‐19) pandemic, we aimed to reveal the changes in breast cancer cases in the context of cause and effect based on the data of surgically treated patients in our institution. PATIENTS AND METHODS: Patients with breast cancer were divided into two groups. Group 1 consisted of patients who were operated in the year before the COVID‐19 pandemic, and Group 2 consisted of patients who were operated within the first year of the pandemic. Tumor size, axillary lymph node positivity, distant organ metastasis status, neoadjuvant chemotherapy, and type of surgery performed were compared between the two groups. RESULTS: The tumor size, axillary lymph node positivity, and neoadjuvant chemotherapy were higher in Group 2 than in Group 1 (p = .005, p = .012, p = .042, respectively). In addition, the number of breast‐conserving surgery + sentinel lymph node biopsy were lower, while the number of mastectomy and modified radical mastectomy were higher in Group 2 than in Group 1 (p = .034). CONCLUSION: Patients presented with larger breast tumors and increased axillary involvement during the pandemic. Moreover, distant organ metastases may increase in the future.

literature emerged with articles seeking an answer to the question, "How can we treat cancer patients safely in terms of patients and healthcare providers?". [1] [2] [3] When the first panic period was over, it was understood that the pandemic would be prolonged and a second phase would start. In the second stage, the answer to the question, typical examples of the third period. 8, 9 The fourth period is likely to be the actual clinical results, explained by the longer follow-up periods and patient numbers. In this study, we aimed to reveal the changes in breast cancer cases at the end of 1 year during the pandemic in the context of cause and effect based on the data of surgically treated patients in our institution. We hope to be able to open the door to the fourth term in this study. periods. Multiplicate records of the same patient were deleted, and a single application was recorded for each patient to avoid false results. We investigated the changes in the number of outpatient clinic admissions, screening mammography, and number of newly diagnosed breast cancer cases between the two periods. Newly diagnosed breast cancer patients were divided into two groups based on the date (March 11, 2020) when the first COVID-19 case was observed in Turkey. Group 1 consisted of patients who were operated in the year before the COVID-19 pandemic, and Group 2 consisted of patients who were operated within a year after the pandemic started. This study was conducted as a retrospective cohort study and the study approval was obtained from the TOGU Ethics Committee. Patient records, surgery notes, and pathology reports of the patients included in this study were retrieved from our hospital's database. Three patients with incomplete information were excluded from the study. To evaluate the clinical effects of the pandemic, tumor size, axillary lymph node positivity, distant organ metastasis status, neoadjuvant chemotherapy (NAC) status, and the type of surgery performed were recorded for both groups before and during the pandemic. Tumor sizes were classified as follows: T1: tumor size <2 cm; T2: tumor size >2 cm and <5 cm; T3: tumor size >5 cm; and T4: tumors of any size that spread directly to the chest wall or skin, breast edema, ulceration, and inflammatory breast cancer. Tumor size and axillary lymph node positivity were obtained from pathology reports. The operations were grouped as breast-conserving surgery (BCS) + sentinel lymph node biopsy (SLNB), BCS + axillary lymph node dissection, mastectomy + SLNB, simple mastectomy, and modified radical mastectomy (MRM).

The data were recorded using the Statistical Package for the Social Sciences 15 program. The Student's t test was used to compare the mean age between the groups. The Pearson's χ 2 test was used to evaluate whether there was a significant difference between Group 1 and Group 2 in terms of tumor size, positivity of axillary lymph nodes, distant organ metastasis, and the types of surgery performed.

Statistical significance was set at p < .05. Table 1 .

In the 1-year period before the pandemic, the number of patients who applied to health institutions because of benign or malignant breast diseases in our city was 8807, and this number decreased to 6483 in the first year during the pandemic. We found a 26. Table 2 .

During the pandemic period, our clinic continued its normal function, since all other ministry hospitals throughout the city were structured into pandemic hospitals, the number of breast cancer surgeries in our clinic increased slightly. The number of patients who underwent surgery for newly diagnosed breast cancer increased from 70 to 78.

However, this increase is not sufficient to compensate for the decrease in the city in general as the number of patients that underwent operation in the pandemic has decreased by 86 compared to the previous year.

Breast cancer accounts for 24% of all cancers and for 15% of all cancer-related deaths. 10 It is a serious public health problem in terms of its prevalence and mortality. As in case of all cancers, early diagnosis of breast cancer is the most important factor in increasing treatment success and decreasing mortality. Early diagnosis can be ensured through cancer screening programs.

Screening mammography is the most powerful tool available, which performed in women aged 50-69 years reduces mortality due to breast cancer by 16.5%. 11 During the COVID-19 pandemic, both cancer screening rates and admissions to breast outpatient clinics have decreased. 12 In a study conducted in Taiwan, Tsai et al. 5 reported that admissions to breast outpatient clinics in hospitals decreased by 37% during the lockdown period,

and breast cancer screening decreased by 22%. In our study, we found that the number of admission to breast outpatient clinics decreased by 26.3% and the number of screening mammography decreased by 79.8% throughout our city in 1 year during the pandemic. Cancer diagnosis is also decreasing because of the decrease in number of patients in the outpatient clinics and cancer screening rates. 13 In the UK, compared to the first 6 months of 2019, the diagnosis of breast cancer decreased by 16% in the first 6 months of 2020, especially during the period when screening centers were closed. 14 In our study, the reduction rate in the diagnosis of breast cancer in 1 year was 47.7%.

Considering that 3 months of data reported from England are included in the pandemic, our rates are in proximity to each other. Furthermore, there were disruptions in the diagnosis of breast cancer in the COVID-19 pandemic. In a study conducted on cancelation of outpatient appointments, 97% of patients canceled their appointments owning to the fear of virus. 9 COVID-19 anxiety is effective in making decisions regarding treatment options in patients with breast cancer. 4 "Stay at home" campaigns have also been effective in preventing patients from attending outpatient and cancer screening programs. 15 The UK Office for National Statistics reported that during the pandemic, there was a significant increase in mortality rates due to diagnostic difficulties, a decrease in referral rates, and limitations of elective surgical procedures. 6 In this emerging picture, it seems that the priority of cancer treatment is postponed and ignored. 13 The possibility of patients presenting with larger masses or even with increased metastases, due to the disruptions experienced during the pandemic, has been emphasized in various studies. [16] [17] [18] [19] The estimated doubling time for breast cancer ranges between 45 and 260 days. 20 In a study conducted in Italy, it was calculated that 43.7% (approximately 6000 cases) of T1 tumors would convert to T2 in a 6-month delay in breast cancer screening, and 600 T2 tumors would convert to T3. 8 Axillary lymph node positivity was 56.4% (Group 2), which was 20.7% higher than the prepandemic rate (Group 1). In our study, we observed no difference in terms of metastasis. We believe that this result is because of our short follow-up period, and we assume that when we increase the follow-up period and repeat this study, there will be a significant difference in distant organ metastases. In a study conducted in the UK regarding the COVID-19 pandemic, a 3-month delay in diagnosis was reported that could increase the 10-year mortality rate in breast cancer cases by 30%. 9 We estimate that studies with more definite results on disease-free survival and overall survival will be conducted over the next 5-10 years. 

The data that support the finding soft his study areavailable on request from th corresponding author. The data arenot publicy available duo to privacy or ethical resrictions. 

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