|Year : 2022 | Volume
| Issue : 1 | Page : 23-28
Delays and disruptions in breast cancer care due to coronavirus disease-2019 pandemic: Real-World data from India
Ankita Gupta1, Budhi Singh Yadav1, Venkata Krishna Vamsi Gade1, Diksha Rana1, Divya Bharti1, Divya Dahiya2
1 Department of Radiotherapy and Oncology, Regional Cancer Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||30-Nov-2021|
|Date of Decision||31-Dec-2021|
|Date of Acceptance||31-Dec-2021|
|Date of Web Publication||15-Jun-2022|
Dr. Budhi Singh Yadav
Department of Radiotherapy and Oncology, Regional Cancer Centre, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
PURPOSE: This study aimed to identify and categorize the delays and disruptions in breast cancer care and its impact on disease outcome during the first wave of the coronavirus disease-2019 (COVID-19) pandemic.
METHODS: Patients with newly diagnosed or relapsed breast cancer who were treated between May 2020 and March 2021 were evaluated. Patients who had experienced COVID-19 related delays in cancer diagnosis or treatment initiation and/or disruption in ongoing treatment were included for analysis. All delays in cancer diagnosis, surgery, or a delay/disruption in radiotherapy or systemic therapy for each patient were identified. The reasons for delays and disruptions were evaluated. Any modification (s) in ongoing treatment, failure to complete planned treatment, and the effect on disease status were noted.
RESULTS: Of the 415 eligible patients with breast cancer, we identified 70 (15.5%) patients who experienced COVID-19-related delay in diagnosis, or a delay or disruption in cancer-directed therapy. Forty (57.1%) patients experienced delays in initiation of their breast cancer treatment and ongoing treatment was disrupted in 30 (42.9%) patients. Majority of the delays (17, 42.5%) and disruptions (17, 60%) were noted in chemotherapy. The median duration of treatment delays was 156 days (interquartile range [IQR] 82–209 days) and that of treatment disruptions was 90 days (IQR 48–261 days). Logistic constraints were responsible for majority of the delays and disruptions. Overall, 32 (45.7%) patients suffered cancer upstaging or progression.
CONCLUSION: We observed significant rates of disease progression among patients with breast cancer who suffered treatment delays and disruptions during the first wave of the COVID-19 pandemic. It is critical to identify and characterize these unprecedented delays and their impact to alienate them in the present and future surges, and to inform strategies to overcome the long-term oncological consequences of the pandemic.
Keywords: Breast cancer, coronavirus disease-2019 pandemic, delay and disruptions
|How to cite this article:|
Gupta A, Yadav BS, Vamsi Gade VK, Rana D, Bharti D, Dahiya D. Delays and disruptions in breast cancer care due to coronavirus disease-2019 pandemic: Real-World data from India. Ann Oncol Res Ther 2022;2:23-8
|How to cite this URL:|
Gupta A, Yadav BS, Vamsi Gade VK, Rana D, Bharti D, Dahiya D. Delays and disruptions in breast cancer care due to coronavirus disease-2019 pandemic: Real-World data from India. Ann Oncol Res Ther [serial online] 2022 [cited 2022 Sep 29];2:23-8. Available from: http://www.aort.com/text.asp?2022/2/1/23/347557
| Introduction|| |
The ongoing coronavirus disease-2019 (COVID-19) pandemic continues to alter the landscape of cancer care. The impact has been particularly devastating in low- and middle-income countries (LMICs) with preexisting gaps in access to cancer services, resulting in widespread delays and disruptions in cancer care.
COVID-19, the WHO designated term for the disease caused by severe acute respiratory syndrome coronavirus-2, was declared a pandemic on March 11, 2020. In India, a nationwide lockdown was imposed on March 24 and relaxations were subsequently introduced in a stepwise manner. The lockdown was characterized by extraordinary restrictions aimed to contain the spread of the virus. Suspension of public transport, strict travel curbs, and lack of accommodation disabled majority of patients from reaching the cancer care facilities for treatment. Low-income groups and those residing in smaller towns and villages were particularly affected. The concerns of getting infected, inadequate information about the disease, and status of availability of cancer services also contributed to the reluctance or inability of some patients to visit the health-care facilities. There was a continuous surge in the number of cases and the country experienced its first peak in September 2020.
Our Regional Cancer Center continued to provide cancer services throughout this period. Outpatient visits were restricted to those with new diagnosis of cancer or relapse and those getting active cancer-directed treatment, while routine follow-ups were catered to by the telemedicine services. It was ensured that scheduled treatments were not postponed or canceled and ongoing treatments (radiation and systemic therapy) continued while following all safety measures. Treatment plans were individually modified in some cases to limit the number of hospital visits.
However, due to the logistic constraints posed by the lockdown and the continuing rise in the number of infections, many patients were unable to access these services and experienced significant delays in their cancer diagnosis and treatment. Some were further affected by contracting the infection themselves.
Delays in cancer diagnosis or treatment have the potential to worsen disease outcomes, including increased chances of tumor upstaging or progression to incurable disease, ultimately impacting overall survival. Delays in the treatment of breast cancer have been linked to adverse oncological outcomes. Each 60-day delay in surgery has been shown to be associated with a 26% increased risk of breast cancer-related deaths in patients with early-stage invasive breast cancer., Worse overall survival and breast cancer-specific survival have been associated with delay in initiation of adjuvant chemotherapy, 91 or more days after surgery, the delay being particularly detrimental for patients with triple-negative breast cancer.
India is currently recovering from the second wave of the pandemic that had posed an unprecedented strain on the fragile health-care system and necessitated mobilization of all health-care resources toward COVID care. There was a rapid surge in the number of cases and numerous restrictions were in place to contain the virus. Oncology services were affected with the cancellation of elective surgeries. More delays and disruptions in cancer care are henceforth anticipated in the prevailing circumstances, potentially impacting future outcomes. Therefore, it is imperative to characterize the delays and their impact that can help inform systemic strategies for mitigating them in the present and future surges.
This study was conducted to identify and categorize the delays and disruptions in breast cancer care, and the initial impact on treatment plans and disease outcomes during the first wave of the COVID-19 pandemic. These findings could guide us in planning for the next steps on how to address the delays and their impact and how to deter such delays from happening in future. It will also help in allocation of health-care resources and cancer services during the current pandemic.
| Methods|| |
This cross-sectional analysis was conducted at a tertiary care center in North India. The study was approved by the Departmental Ethics Committee. Patients with newly diagnosed or relapsed breast cancer who were being treated in the Department of Radiotherapy and Oncology between the months of May 2020 and March 2021 were evaluated. Patients who had experienced COVID-19-related delays in cancer diagnosis or treatment initiation at diagnosis or relapse; or disruption in ongoing treatment were included for analysis. Patients who experienced delays in routine follow-up visits were excluded.
Demographic data, tumor, and treatment-related characteristics were recorded. Demographic data included age, gender, and the distance traveled to reach the treatment facility. Tumor characteristics included stage, histology, tumor grade, and receptor status. Treatment-related data included the intent of treatment (curative or palliative), previous and ongoing treatment. All delays in cancer diagnosis, surgery, or a delay/disruption in radiotherapy or systemic therapy (chemotherapy, targeted therapy, and endocrine therapy) for each patient were identified. Each delay was calculated from the day of scheduled appointment to the time of the actual visit for patients on or awaiting treatment. For patients with a new diagnosis of breast cancer, it was calculated from the day of awareness of symptoms till the time patient was able to reach a diagnostic facility. The reasons for delays/disruptions were evaluated and classified as logistic and medical. Logistic delays could be system related such as lockdown measures, travel restrictions, and nonavailability of public transport; patient related such as lack of finances, fear of getting infected, and lack of awareness on the availability of cancer services; or provider related like delay in appointments for diagnostic procedures, surgery, radiotherapy, or systemic therapy. Delay as a result of the patient contracting COVID-19 infection was considered as medical delay. The duration of delay or disruption in days was recorded. Any modification (s) in ongoing treatment, failure to complete planned treatment, and the effect on disease status (cancer upstaging or progression) were also noted.
Descriptive statistics were used for all data collected. Frequency tables were generated for categorical variables and means and medians were computed for continuous variables. All statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) v23 (IBM, Chicago, USA).
| Results|| |
Of the 415 eligible patients with breast cancer, we identified 70 (15.5%) patients who experienced a COVID-19-related delay in diagnosis, or a delay or disruption in cancer-directed therapy during the first wave of the COVID-19 pandemic. The median age of the entire cohort was 50 years (interquartile range [IQR] 40–57 years). All were females. These patients traveled a median distance of 125 km (IQR 64–246) to reach our treatment facility. Demographic, tumor, and treatment characteristics are listed in [Table 1].
Forty (57.1%) patients experienced delays in initiation of their breast cancer treatment [Table 2]. Late diagnosis was responsible for this delay in 12 (30%) patients, while 28 (70%) were awaiting treatment for their cancer diagnosis (n = 16) or relapse (n = 12). Chemotherapy was the most commonly delayed modality 17 (42.5%) among this group of patients. Radiotherapy was delayed in 14 (35%) patients, while a surgery was delayed in 8 (20%). One (2.5%) patient had a delay in initiation of endocrine therapy. The median duration of treatment delay was 156 days (IQR 82–209 days). Thirteen (32.5%) patients had cancer upstaging or progression. Locoregional progression was seen in 7 (17.5%) patients while 1 (2.5%) had distant progression. Five (12.5%) patients had both locoregional and distant progression. Radiological evidence of disease progression was reported in 8 (20%) patients. Four (10%) patients had deterioration in performance status. Logistic constraints were the most common reasons for the delays (37, 92.5%). Three (7.5%) patients contracted COVID-19 infection that resulted in the delay [Table 2].
Thirty (42.9%) patients who were already on treatment (radiotherapy or systemic therapy) before the lockdown experienced disruptions in their ongoing treatment [Table 3]. Most disruptions were experienced by patients on chemotherapy (17, 56.7%), followed by endocrine therapy (10, 30%), targeted therapy (2, 6.7%), and radiotherapy (1, 3.3%). Ten (33.3%) patients were being treated with a curative intent, while the rest 20 (66.7%) were on palliative treatment for metastasis or recurrence. The median duration of treatment disruptions for this group of patients was 90 days (IQR: 48–261 days). Impact on disease status was evident in 19 (63.3%) patients who had disease progression. Eight (26.6%) patients had progressed locoregionally, 8 (26.6%) had distant progression, while 3 (10%) had both locoregional and distant progression. Radiological evidence of disease progression was found in 13 (43.3%) patients and deterioration in performance status was seen in 6 (20%) patients. Seven (23.3%) patients were unable to complete the planned treatment, while 12 (40%) had their ongoing treatment plans modified. The most common reasons for treatment disruptions were logistic (28, 93.3%), while COVID-19 infections were reported only in 2 (6.7%) patients who were on treatment [Table 3].
| Discussion|| |
We observed remarkable delays and disruptions in breast cancer diagnosis and treatment among patients who were unable to access cancer services during the first wave of the COVID-19 pandemic. Majority of the delays were attributed to the logistic constraints posed by the pandemic. A substantial proportion of these patients suffered cancer upstaging or progression. These findings highlight the importance of streamlining cancer services and ensuring continuation of treatment in patients who are expected to suffer the most from the delays.
The COVID-19 pandemic has adversely affected the delivery of cancer services throughout the world. In addition to being considered at a higher risk of COVID-19 related morbidity and mortality, these patients are also witnessing delayed and suboptimal cancer care., This has led to growing concerns on the impact that these delays would have on oncological outcomes in the years to come. The National Cancer Institute (NCI) has predicted as many as 10,000 additional deaths during the next 10 years due to the delayed diagnosis of breast and colorectal cancers in the US as a result of the pandemic. The frequency of these delays and their impact is anticipated to be worse in LMICs, given the existing disparities in access to cancer care., A large multicenter study by the National Cancer Grid of India reported a considerable impact of the pandemic and national lockdown measures on the delivery of oncology services in the country. There was a substantial reduction in new patient registrations (54%), outpatient visits (46%), day-care admissions for chemotherapy (37%), major (49%) and minor (52%) surgeries, patients accessing radiotherapy services (23%), and palliative care referrals (29%) in 2020, compared with 2019. Such disruptions are expected to have a significant long-term impact on oncological outcomes.
Majority of the delays and disruptions in our study were observed in patients on or awaiting chemotherapy. Most patients were on three-weekly chemotherapy schedules and were unable to reach the hospital from their hometowns once the lockdown was imposed. On the other hand, patients who were on radiation usually stayed near the radiotherapy facility for their daily fractions and hence managed to continue treatment. Requirement of blood investigations prior to each chemotherapy cycle and of blood products in some cases could have posed additional difficulty for these patients in continuing treatment. Moreover, during the early phase of the pandemic, patients on chemotherapy were considered to be at higher risk of severe COVID-19 infections and associated mortality.
About 23% of the patients who suffered treatment interruptions were later unable to complete their scheduled treatment and 40% had their treatment plans modified, either due to logistic reasons or disease progression and deterioration in performance status. In a systematic review of 62 studies reporting delays or disruptions in cancer care during the pandemic, changes in treatment plans were reported by 1.6%–82% of centers, delays in cancer treatment by 26%–62.4% centers, and treatment interruptions by 77.5% of patients. These disruptions were mainly attributed to the reduction in service availability. Since cancer services were not hampered during the first wave of the pandemic at our center, most of the delays were a result of the logistic constraints posed by the lockdown such as travel curbs and lack of public transport.
In a single institutional retrospective analysis from the US, almost half of the breast cancer patients who did not have COVID-19 had their care disrupted during the early wave of the pandemic. Modification of treatment regimen (such as the use of endocrine bridge) contributed to 22.8% of the delays and/or changes. The authors also found racial-, socioeconomic-, and stage-wise disparities in the likelihood of delay/change. In a patient-reported survey conducted during the early phase of the pandemic in the US, 44% of the breast cancer survivors reported a delay in their cancer care during the pandemic. The authors pointed toward a risk for poorer outcomes due to the impact on cancer care.
More than 45% of our patients had cancer upstaging or progression when they were first assessed after the delay or disruption. Delays in breast cancer diagnosis and treatment have been linked to poorer outcomes in patients with breast cancer. A systematic review and meta-analysis showed that a delay longer than 4 weeks in initiation of adjuvant chemotherapy was associated with a 15% decrease in overall survival and 16% decrease in disease-free survival. In a recent observational study, patients treated 91 or more days from surgery experienced worse overall survival (hazard ratio [HR]: 1.34, 95% confidence interval [CI]: 1.15–1.57) and worse breast cancer-specific survival (HR: 1.27, 95% CI: 1.05–1.53). The outcomes were detrimental in patients with triple-negative breast cancer. Another retrospective analysis reported a worse disease-free survival with a delay of more than 90 days between breast cancer diagnosis and treatment initiation in patients with this subtype (HR: 3.40; 95% CI: 1.12–10.35). Decreased survival rates have been documented in breast cancer patients who suffer interruptions in radiotherapy and prolonged gaps or chemotherapy dose reductions.,,
If we go by the patient number, in 2018, 162,468 new cases of breast cancer were diagnosed in India. Hence, 55% of 162,468 new breast cancer cases mean more than 89,000 patients with breast cancer in the country could have possibly faced pandemic-related delay in diagnosis and 64,000 (40%) would have treatment interruptions. Of these, 48,000 (30%) would have disease progression, which is a great cause of concern for the country as such as it may increase the mortality in these patients.
The main limitation of our study is the small sample size and lack of a comparative group. It was a single institutional analysis, and hence, the results can be skewed by our practice patterns during the pandemic, which could be different from the rest of the centers in the country. Patients infected with COVID-19 represented a small proportion of the study cohort and comparisons in outcomes were not feasible. The logistic reasons for the delays were not discretely categorized for each patient. The long-term impacts of these COVID-19-related delays and disruptions on breast cancer outcomes are still unknown. Comparisons with prepandemic breast cancer cohorts to measure the actuarial impact of these delays are being conducted and shall be included in our future publications.
Since the beginning of the pandemic, numerous studies have reported substantial numbers of reductions, delays, or disruptions in cancer care and the projected or potential impact of such delays on oncological outcomes. There is a lack of real-world data on the true impact of these delays on a particular subset of cancer patients, especially from LMICs. In this study, we have reported a detailed analysis of COVID-19-related delays and their impact on disease status in patients with breast cancer who suffered the delay. The study period included the entire course of the first wave of the pandemic in the country, and therefore, a broad range of delay patterns were studied. Assessment of the delays and their impact during the initial surge can help understand the patterns and existing lacunae in care delivery. This can help mitigate potential disruptions and their impact in the present and future surges. At this time, when the country is recovering from a deadlier second wave of the pandemic, devastating consequences are expected. Therefore, it is important for providers to reach out to patients who are experiencing delays to ease concerns and inform about the status of availability of cancer services; streamline teleconsultation services to aid patients in accessing cancer care; and organize processes around replanning and rescheduling. This will, in the long run, help inform strategies to safely return to prepandemic standards and cope with the long-term oncological consequences of the pandemic.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed 2020;91:157-60.
Pulla P. Covid-19: India imposes lockdown for 21 days and cases rise. BMJ 2020;368:m1251.
John J, Kang G. Tracking SARS-CoV-2 infection in India with serology. Lancet Glob Health 2021;9:e219-20.
Bleicher RJ, Ruth K, Sigurdson ER, Beck JR, Ross E, Wong YN, et al.
Time to surgery and breast cancer survival in the United States. JAMA Oncol 2016;2:330-9.
Mateo AM, Mazor AM, Obeid E, Sigurdson ER, DeMora L, Handorf EA, et al
. Time to surgery and the impact of delay on triple negative breast cancers and other phenotypes. J Clin Oncol 2018;36 15 Suppl: e12606.
Chavez-MacGregor M, Clarke CA, Lichtensztajn DY, Giordano SH. Delayed initiation of adjuvant chemotherapy among patients with breast cancer. JAMA Oncol 2016;2:322-9.
Kar SK, Ransing R, Arafat SM, Menon V. Second wave of COVID-19 pandemic in India: Barriers to effective governmental response. EClinicalMedicine 2021;36:100915.
ElGohary GM, Hashmi S, Styczynski J, Kharfan-Dabaja MA, Alblooshi RM, de la Cámara R, et al
. The risk and prognosis of COVID-19 infection in cancer patients: A systematic review and meta-analysis. Hematol Oncol Stem Cell Ther 2020;1:565-7.
Riera R, Bagattini ÂM, Pacheco RL, Pachito DV, Roitberg F, Ilbawi A. Delays and disruptions in cancer health care due to COVID-19 pandemic: Systematic review. JCO Glob Oncol 2021;7:311-23.
ElGohary GM, Hashmi S, Styczynski J, Kharfan-Dabaja MA, Alblooshi RM, de la Cámara R, et al
. The risk and prognosis of COVID-19 infection in cancer patients: A systematic review and meta-analysis. Hematol Oncol Stem Cell Ther 2020 (Ahead of print) Available online at https://doi.org/10.1016/j.hemonc.2020.07.005
[Last Accessed on 2022 Jun 08.
Sharpless NE. COVID-19 and cancer. Science 2020;368:1290.
De Guzman R, Malik M. Dual challenge of cancer and COVID-19: Impact on health care and socioeconomic systems in Asia Pacific. JCO Glob Oncol 2020;6:906-12.
Nnaji CA, Moodley J. Impact of the COVID-19 pandemic on cancer diagnosis, treatment and research in African health systems: A review of current evidence and contextual perspectives. Ecancermedicalscience 2021;15:1170.
Ranganathan P, Sengar M, Chinnaswamy G, Agrawal G, Arumugham R, Bhatt R, et al.
Impact of COVID-19 on cancer care in India: A cohort study. Lancet Oncol 2021;22:970-6.
Clift AK, Coupland CA, Keogh RH, Diaz-Ordaz K, Williamson E, Harrison EM, et al.
Living risk prediction algorithm (QCOVID) for risk of hospital admission and mortality from coronavirus 19 in adults: National derivation and validation cohort study. BMJ 2020;371:m3731.
Satish T, Raghunathan R, Prigoff J, Wright J, Hillyer G, Trivedi M, et al.
Care delivery impact of the COVID-19 pandemic on breast cancer care. JCO Oncol Pract 2021;17:e1215-24.
Papautsky EL, Hamlish T. Patient-reported treatment delays in breast cancer care during the COVID-19 pandemic. Breast Cancer Res Treat 2020;184:249-54.
Yu KD, Huang S, Zhang JX, Liu GY, Shao ZM. Association between delayed initiation of adjuvant CMF or anthracycline-based chemotherapy and survival in breast cancer: A systematic review and meta-analysis. BMC Cancer 2013;13:240.
Li Y, Zhou Y, Mao F, Guan J, Lin Y, Wang X, et al.
The influence on survival of delay in the treatment initiation of screening detected non-symptomatic breast cancer. Sci Rep 2019;9:10158.
Johnson A. The timing of treatment in breast cancer: Gaps and delays in treatment can be harmful. Breast Cancer Res Treat 2000;60:201-9.
Chang J. Chemotherapy dose reduction and delay in clinical practice. Evaluating the risk to patient outcome in adjuvant chemotherapy for breast cancer. Eur J Cancer 2000;36 Suppl 1:S11-4.
Bese NS, Sut PA, Ober A. The effect of treatment interruptions in the postoperative irradiation of breast cancer. Oncology 2005;69:214-23.
Bhattacharyya GS, Doval DC, Desai CJ, Chaturvedi H, Sharma S, Somashekhar SP. Overview of breast cancer and implications of overtreatment of early-stage breast cancer: An Indian perspective. JCO Glob Oncol 2020;6:789-98.
[Table 1], [Table 2], [Table 3]