The impact of Covid-19 on breast cancer – a two-year reflection

The impact of Covid-19 on breast cancer – a two-year reflection
Dr Justus Apffelstaedt

The Covid-19 pandemic has had a significant impact on individuals affected by breast cancer that, in all probability, may continue for many years to come.

Dr Justus Apffelstaedt, a specialist surgeon in breast cancer says: “Guidelines [1] were released in early 2020 by professional organisations, stressing that any screening and diagnostics, as well as treatment, should be transferred as far as possible to non-hospital outpatient settings and that treatment should, as far as possible, follow the existing guidelines. However, patients were still reluctant to book for appointments for screening or the management of breast lumps.”

As it became clear that close contact between women attending and imaging staff at said screenings would pose a particular risk of infection, professional organisations recommended that screening examinations be postponed for “a few weeks or months” [2], leading to delayed diagnoses of now more advanced cancers.

Hospital treatments, surgeries in particular, were also delayed due to capacity constraints as medical staff were withdrawn from theatres to care for Covid-19 patients in need of ventilation or were themselves infected or isolating after a high-risk exposure.

Says Apffelstaedt. “This inevitably led to delayed diagnoses and disrupted treatment sequences with detrimental effects on outcomes for patients. In clinical practice, however, we observed that our cancer patients did not seem to suffer disproportionately from a Covid-19 infection. “We speculate that this is due to most cancer treatments in breast cancer (surgery, hormonal therapy, biologicals and radiation) not having any significant impact on the immune system. On the other hand, the mechanisms of the Covid-19 disease indicate that most damage is done by the body’s immune system overreacting to the infection and damaging tissues far and wide. Chemotherapy may suppress this overreaction to some extent and therefore not be as detrimental as initially feared.”

Research confirmed such observations: early reviews of cancer therapies, and their interaction with cancer therapy, found that there is very little, if any, adverse interaction of a Covid-19 infection and cancer therapy for solid tumours [3].

Can the total impact of Covid-19 on breast cancer outcomes be estimated now?

It has become clear that Covid-19 disproportionately affects disadvantaged communities. These communities are already known to have poorer outcomes of breast cancer due to socioeconomic barriers such as access to health care and lack of screening and treatment opportunities[4].

Existing barriers to accessing health care were raised in the pandemic in developing countries and notably in South Africa. The prolonged closure of public health care facilities is just one example. The reluctance to travel to access more advanced treatment options such as oncoplastic and immediate reconstructive surgery is another; particularly when these are not available in all provinces or in countries surrounding South Africa.

“The Covid-19 attributable mortality is relatively easy to measure as most infected patients either die within 4 weeks after infection or survive,” says Apffelstaedt. “In contrast, a woman whose diagnosis of breast cancer has been delayed and where the cancer has progressed to a more advanced stage and treatment sequences have been disrupted, does not die immediately, but years later.”

This excess mortality will be only be apparent – if at all, after about 10 years and requires big data sets to filter out. Therefore, only projections of an excess cancer mortality can be made.

Concludes Apffelstaedt: “Breast cancer is already a disease with far worse outcomes for the disadvantaged. We speculate that, once again, the burden of unfortunate global events such as this pandemic will fall disproportionately on the poor and vulnerable.”

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