Delayed diagnosis and increased mortality risk: Assessing the effects of the COVID-19 pandemic on breast cancer recurrence

Mühlmann, Lindson; Pimentel, Franklin Fernandes; Tiezzi, Daniel Guimarães; Carrara, Hélio Humberto Angotti; Andrade, Jurandyr Moreira de; Reis, Francisco José Candido dos

doi:10.1016/j.clinsp.2024.100340

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Sumário

Original articles • Clinics 79 • 2024 • https://doi.org/10.1016/j.clinsp.2024.100340 copy

Delayed diagnosis and increased mortality risk: Assessing the effects of the COVID-19 pandemic on breast cancer recurrence

Authorship SCIMAGO INSTITUTIONS RANKINGS

Highlights

COVID-19 profoundly affected global healthcare including breast cancer management.

The pandemic delayed recurrence diagnosis and increased post-recurrence mortality.

Strategies for cancer patients' follow-up during health crises need improvements.

Abstract

Objectives

The COVID-19 pandemic has had a significant global impact since its declaration in March 2020. The COVID-19 pandemic has disproportionately impacted cancer patients, particularly those with breast cancer. This study aims to analyze the effects of the pandemic on women diagnosed with breast cancer recurrence.

Methods

A cohort study was conducted at a tertiary public hospital in São Paulo State, Brazil. Data were collected from electronic records. Patients diagnosed with breast cancer and experiencing recurrence between January 2011 and March 2022 were included. Survival analysis was performed using the Kaplan-Meier estimator and Cox regression.

Results

The study included 187 patients, 45 in the pandemic group (recurrence after March 23, 2020) and 142 in the pre-pandemic group. Distant recurrences were more frequent in both groups (pre-pandemic: 62.7 %, pandemic: 75.5 %). Compared to the pre-pandemic group (1.8 years), the pandemic group experienced a longer mean time to recurrence detection (2.9 years) and significantly decreased median survival (9 months vs. 22 months). The Cox regression analysis confirmed an increased risk of death for women diagnosed with breast cancer recurrence during the pandemic period (HR = 1.92, 95 % CI 1.19‒3.12).

Conclusion

The present study is among the first to investigate the pandemic's specific effects on breast cancer recurrence, revealing concerning delays in detection and a decrease in survival rates. Prompt diagnosis, timely treatment initiation, and comprehensive support are crucial during public health crises. These findings urge healthcare systems to prioritize tailored care for breast cancer patients during pandemics.

Keywords
Breast neoplasms; COVID-19; Disease recurrence

Variable	Pandemic	Pre-pandemic	p-value
Cases	n = 45	n = 142
Age (years)	58.8 (13.5)	58.1 (14.6)	0.78
Histological type
Invasive Ductal Carcinoma	44 (97.8 %)	131 (92.3 %)	0.39
Invasive Lobular Carcinoma	1 (2.2 %)	8 (5.6 %)
Others	0	3 (2.1 %)
Tumor grade
I	8 (17.8 %)	27 (19 %)	0.80
II	25 (55.6 %)	84 (59.2 %)
III	12 (26.7 %)	31 (21.8 %)
Anatomical staging
IA	4 (8.9 %)	9 (6.3 %)	0.89
IB	0	1(0,7 %)
IIA	7 (15.6 %)	20 (14.1 %)
IIB	7 (15.6 %)	30 (21.1 %)
IIIA	11 (24.4 %)	33 (23.2 %)
IIIB	15 (33.3 %)	41 (28.9 %)
IIIC	1 (2.2 %)	8 (5.6 %)
Prognostic staging
IA	4 (8.9 %)	10 (7 %)	0.81
IB	5 (11.1 %)	20 (14.1 %)
IIA	6 (13.3 %)	27 (19 %)
IIB	5 (11.1 %)	8 (5.6 %)
IIIA	10 (22.2 %)	26 (18.3 %)
IIIB	12 (20.7 %)	43 (30.3 %)
IIIC	3 (6.7 %)	8 (5.6 %)
Estrogen receptor
Negative	16 (35.6 %)	62 (43.7 %)	0.43
Positive	29 (64.4 %)	80 (56.3 %)
Progesterone receptor
Negative	26 (57.8 %)	75 (52.8 %)	0.68
Positive	19 (42.2 %)	67 (47.2 %)
HER2 Immunohistochemistry
0	18 (40 %)	51 (35.9 %)	0.90
1+	12 (26.7 %)	46 (32.4 %)
2+	5 (11.1 %)	16 (11.3 %)
3+	10 (22.2 %)	29 (20.4 %)
HER2 (status)
Negative	33 (73.3 %)	109 (76.8 %)	0.79
Positive	12 (26.7 %)	33 (23.2 %)
Subtype			0.39
HR+ HER2-	25 (55 %)	67 (47 %)
HR+ HER2+	4 (9 %)	15 (11 %)
HR- HER2+	8 (18 %)	18 (13 %)
HR- HER2-	8 (18 %)	42 (29 %)
Chemotherapy
Neoadjuvant	29 (64.4 %)	70 (49.3 %)	0.19
Adjuvant	8 (17.8 %)	40 (28.2 %)
Not received	8 (17.8 %)	32 (22.5 %)
Hormone therapy
No	16 (35.6 %)	66 (46.5 %)	0.26
Yes	29 (64.4 %)	76 (53.5 %)
Radiotherapy
No	10 (22.2 %)	26 (18.3 %)	0.72
Yes	35 (77.8 %)	116 (81.7 %)

Variable	HR	95 % Cl	p-value
Groups
Pre-pandemic	Ref
Pandemic	1.92	(1.19‒3.12)	0.008
Age	1.02	(1.01‒1.03)	0.01
Interval between follow-up and recurrence	0.99	(0.88‒1.12)	0.89
Histological type
Invasive Ductal Carcinoma	Ref
Invasive Lobular Carcinoma	1.5	(0.62‒3.58)	0.37
Others	0.33	(0.04‒2.73)	0.30
Anatomical staging
IA	Ref
IB	0.38	(0.05‒3.25)	0.38
IIA	0.82	(0.16‒4.2)	0.82
IIB	0.86	(0.2‒3.7)	0.84
IIIA	0.7	(0.19‒2.65)	0.60
IIIB	0.82	(0.28‒2.41)	0.71
IIIC	0.5	(0.13‒1.94)	0.32
Prognostic staging
IA	Ref
IB	0.48	(0.11‒2.1)	0.33
IIA	0.57	(0.16‒2.01)	0.38
IIB	0.36	(0.09‒1.52)	0.16
IIIA	0.85	(0.32‒2.25)	0.75
IIIB	0.97	(0.44‒2.12)	0.93
Tumor grade
I	Ref
II	0.84	(0.48‒1.45)	0.53
III	1.87	(0.93‒3.78)	0.08
Estrogen receptor
Positive	Ref
Negative	1.95	(1.12‒3.4)	0.02
HER2 (status)
Negative	Ref
Positive	0.71	(0.42‒1.2)	0.27

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E-mail: clinics@hc.fm.usp.br

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[1] * Corresponding author. E-mail address:fjcreis@usp.br (F.J. Candidodos Reis)