What we’re missing in breast cancer care during COVID-19

One of the many concerning patterns seen in the wake of the 2020 COVID-19 pandemic has been the drop in breast cancer cases and other health conditions. This past year saw fewer breast screenings and now health systems are reporting a dramatic drop in the number of breast cancer diagnoses. But fewer diagnoses doesn’t mean that fewer people have breast cancer. People staying home to avoid catching or spreading COVID-19 have cancelled medical appointments like breast cancer screenings. This means there are many women who have breast cancer but don’t know it yet and are not getting treatment. The lack of cases this year also likely means many more cases will be diagnosed when people feel safe enough to go back to their normal activities.

To learn more about what is being missed in breast cancer care in 2020, Living Beyond Breast Cancer CEO Jean A. Sachs, MSS, MLSP, spoke with breast surgical oncologist Monique Gary, DO, MSc, FACS. They discussed what the missed cases mean for breast cancer care next year and for those people who will be diagnosed in the coming months, how it can make disparities in the healthcare system even worse, and what you can do now to keep up to date on your health and preventative care.

Monique Gary, DO, MSc, FACS
Dr. Gary is a board-certified, fellowship-trained breast surgical oncologist and medical director of the Grand View Health/Penn Cancer Network in Sellersville, Pennsylvania. She has served as director of the breast program there since its accreditation in 2015. She is the founder of the Cancer Genetic Risk and Prevention Program at Grand View Health, which provides genetic counseling and high risk management for those with a strong family history of cancer and those with known hereditary cancer syndromes. Read more.

Jean A. Sachs, MSS, MLSP

Chief Executive Officer, Living Beyond Breast Cancer

Jean began her work with LBBC in 1996 when she became the organization’s first executive director; she was named CEO in 2008. Jean brings a lifetime of women’s advocacy experience to her role as CEO. She lives LBBC’s mission everyday by speaking with newly diagnosed women about their needs and gaps in support. Read more.

 

Jean A. Sachs, MSS, MLSP:

Hello everyone. It's Jean Sachs, the CEO of Living Beyond Breast Cancer. Today, we are going to talk about what's not happening in breast cancer care during the pandemic. There are some really alarming reports regarding the drop in breast cancer screening and treatment, and unfortunately we know it is not because there is less breast cancer. We are here today to talk about the impact and what will it mean after the pandemic and what you can, or you should, do now.

I would first like to acknowledge Amgen for their generous support in bringing this important information to you today. Joining me is Dr. Monique Gary.

Monique Gary, DO, MSc, FACS:

Hi, how are you?

Jean A. Sachs, MSS, MLSP:

Great. It's so good to see you. For those of you who've been watching, Dr. Gary is not new to Living Beyond Breast Cancer, but for those of you that don't know her, she's a board certified, fellowship-trained breast surgical oncologist, and she is the medical director of the Grandview Health/Penn Cancer Network in Sellersville, Pennsylvania, which is very close to us in Philadelphia. For her full bio, please go to lbbc.org.

Thank you so much for joining us today and helping us understand what is really going on. I want to give some quick context: We just finished the annual San Antonio Breast Cancer Symposium and on the opening day, Dr. Annie Tang presented numbers from Kaiser Permanente Health System, which is right in Northern California. And they're alarming. They reported in that health system, there were 703 diagnoses of breast cancer in 2019. And at the same time this year, there are 250 in 2020, which means 64 percent fewer patients were diagnosed this year. So we're talking about 450 people. And that is just in one healthcare system.

What is the significance of this? Tell us your thoughts.

Monique Gary, DO, DSc, FACS:

One, I think it's symptomatic of what is happening, not just across the United States, but across the world right now, because COVID-19 has affected every single country and every health system. In places where routine screening is part of our daily lives, I think that we have all seen this decrease in the number of screenings and the number of diagnoses, and the pendulum is only swung halfway. I think we've got to anticipate what will happen in 2021 and beyond, and how that's really going to inform so much of our data, our statistics, our trials. All of our numbers are going to be changed as a result of this global pandemic. And not only that, patients' lives are going to be changed as a result of it. So I think that it highlights what we are seeing in every health system. But those numbers are staggering and they're so concerning.

Jean A. Sachs, MSS, MLSP:

And for health systems, once people start coming back in full swing, what do you anticipate that to be like?

Monique Gary, DO, DSc, FACS:

We’ve seen a little bit of that this fall, when we noticed our screening numbers had dropped dramatically over the summer, and as we began to encourage patients to come back and we developed protocols to manage the volume safely and to take precautions against the coronavirus, we noticed that we saw an uptick in the number of screenings. And even in the smallest quantities, it began to overload our health system a bit, from the standpoint of needing to space out appointments. We can't do as many screenings a day. We can't do as many biopsies a day, because in between we have to make sure we sterilize every single room and take every single precaution. And we're noticing that with the increased volume, we also see a lag at a wait time for some patients because we have to take extra precautions and that creates some more delays and backlogs.

So I think everybody has to have a little bit of grace and understanding that if you didn't get your screening in March, April, or May, and you get it in October, well, we've got the usual October volume plus all the May, and the June, and July people. And so it's a compounded effect upon our imaging centers, upon our diagnostics, upon our operating rooms, as well. And as COVID ramps up, we are now beginning to see that double peak phenomenon, if you will, where we've got the delay, we've got the demand, but we also now have increased virus within our hospitals and in our communities that may once again put some challenges on the operative side of things, as well.

Jean A. Sachs, MSS, MLSP:

So it's complicated. And what about for those people who are currently in treatment for breast cancer? Are there things that aren't happening in their care?

Monique Gary, DO, DSc, FACS:

So for people who are actively undergoing breast cancer care, there are some things that are happening. I think we are noticing that the ability to gather and to have support services in person is absent, and that has been so necessary for many of our patients. The ability to go to fitness centers and gyms and receive contact-types of therapies has been really hampered by the coronavirus. We've seen decreases in our clinical trial enrollment, and patients can't really bring their family members with them to their infusions, into their surgeries. This is a very strange and isolated time, at a time when patients already don't feel well, and they feel afraid, and all of that is, again, enhanced and compounded by the coronavirus.

Jean A. Sachs, MSS, MLSP:

I just talked to a young woman today who is finished her chemotherapy, but about to have surgery and then many weeks of radiation. And she said at the end, “I'm really not looking forward to doing all of this by myself.” For surgery, she can only be dropped off at curbside, not even walked into the hospital.

Monique Gary, DO, DSc, FACS:

It's unbelievable. At a time when you need your family the most. I can tell you instances years ago where I've had patients come with their church members and their pastors, and they want to pray together and we've had, 5-, 6-, 10-people families in the room, and it makes you feel so comforted. And this is a time when that can’t happen. For me, it represents an opportunity for the healthcare workers, for the physicians, the surgeons, the nurses – it's a chance for us to step up and step in and be that family for those people who can't have their family with them.

Jean A. Sachs, MSS, MLSP:

Which is a lot, because they're already doing a lot. We also know that there are racial, ethnic, and age disparities in breast cancer care. How could the drop in diagnoses impact this already existing disparity?

Monique Gary, DO, DSc, FACS:

Well, we know that African-American women are more likely to be diagnosed at a later stage. So if they have delayed their screening or foregone certain therapies, or pushed those things back, we can anticipate that there will be a greater burden of disease. We can anticipate that there will be later diagnoses and that there will be changes in treatment options as a result of it, because when cancer is diagnosed later, the treatment algorithms and the options change. Things like immediate reconstruction might not be a part of it. And maybe she might need post-mastectomy chemotherapy in breast conservation, lumpectomies might not be available to her as an option. I think that we are going to see some really stark racial and ethnic disparities, because people are already, distrustful of the healthcare system.

I read a great article, and I like the way they phrase it. They said it's not that black people are distrustful of the healthcare system, it’s that the healthcare system has not earned their trust. I thought that was so impactful and powerful. We've already got a system where people are a little bit leery about their care, and now they cannot bring their advocates and their family members. They now have to go through this alone. I think that the data's going to bear out. Unfortunately, we know that black women are not offered the opportunity to participate in clinical trials as much. I think if we are looking at a pandemic situation, and we're having fewer enrollments in clinical trials overall, well, what do you think is going to happen to the already low numbers on a decrease as well? So I think we have to be mindful as healthcare providers of that, and make sure that we offer the appropriate cultural, ethnic, racial support services that we can, to all women.

Jean A. Sachs, MSS, MLSP:

That's so important. Since the country is in a surge again, and in many ways it's even worse than what we were facing this spring, what would you say to someone out there who knows they're overdue for their mammogram? Should they go? What should they do?

Monique Gary, DO, DSc, FACS:

The one thing I think that works in our favor, is that we have learned the lessons of the spring in that we figured out, one, how to more effectively prevent the coronavirus in terms of the hand hygiene, the wipes, the disinfectants, all those sorts of things, the masking. For a while, when we first started this, it was, “do we wear masks? Do we not wear masks? What kind of mask do we wear?” And there were a lot of conflicting reports about what we should do to be safe. We have learned what it takes to be safe.

We have taken those precautions and really standardized them across the health systems, across the country, really across the world. So in places where screening is an option, I think that we should take advantage of that opportunity – because in some places in the world, screening is not an option and they only get diagnosed when they feel something. If we have the chance to screen and we understand that there are protocols in place, you can call your health system, call your imaging center, ask them, “What precautions are you taking to keep me safe?” You can go to lbbc.org, and you can see some of the videos that we've done earlier that talk about what women should do to be safe when they go for their imaging and for their clinical appointments.

They should take advantage of it, yes, for screening. Women and men should be doing their self-breast examination every month. This is something that I think we don't educate around enough. There has been conflicting data about the utility and the benefit of it, but we know our bodies first and best, and it is an extra tool that we have in our armamentarium. I think that every man and woman should be doing a self-breast examination, at least once a month.

Jean A. Sachs, MSS, MLSP:

And what about those who are in active treatment or need to have surgery? Should they feel comfortable going into the hospital?

Monique Gary, DO, DSc, FACS:

Absolutely. I know in our hospital, we have more patients who have coronavirus now than before, but we are safer now than we ever were. We take every precaution to make sure that our patients are separate from patients who have coronavirus. There's a completely different wing of the hospital for those patients. We now have enhanced recovery pathways where patients can go home even sooner. We've tweaked our system to try to make things better for patients. I think that if you need a surgery, you should not delay that surgery unless the hospital itself is not offering elective surgery. You should get your surgery. I had a hashtag all summer long, #CancerDoesntQuarantine. I told my hospital, I said, “You know, it's only elective if it's not your relative.” If it’s cancer operations, it needs to happen as long as it is safe to do so. And it is safe to do so.

Jean A. Sachs, MSS, MLSP:

I was in a hospital a week or so ago for my annual physical. I was screened when I walked in the door, the halls were empty. I didn't see a soul. There was no one in the waiting room. I didn't have to pay for parking. I got in and out faster. I really felt safe.

Monique Gary, DO, DSc, FACS:

Absolutely. Even the flow of traffic through our offices is directional. We have signs and arrows on the floor, so patients shouldn't even be crossing each other going in and out of the building, or out of the office, as they should be coming in one way and going out the other way. We make sure that there's no one in the waiting room and that in between every single visit everything is cleaned, everything is sterilized, everything is wiped. We really want to do the best thing we can for patients, but we need patients to come in because these numbers are only going to get worse.

If you think about the number of people who are diagnosed annually, and if they don't get that diagnosis in May, if you're due for your screening mammogram and there's a little something [there], how much larger might it be by December? What does that do for your options? What does it do for your longevity? More than ever, we're seeing greater survival. We are seeing greater survival across the board, but it happens when we diagnose early. That is a message for everyone. Now is the time. Get your routine health maintenance done. The one thing that we don't talk enough about, I think, is the impact of stress on the body to cause progression of illness. We got to try to control the things we can control, because there's a lot going on right now that we just can't control.

Jean A. Sachs, MSS, MLSP:

That's a good point. The final question is, we know there are people out there who have felt a lump and they're scared, but they're too afraid to pick up the phone and make an appointment. What do you want to say to them?

Monique Gary, DO, DSc, FACS:

I want to tell them to find a doctor. You can call me if you need to, even if I'm not in your state or your health care system. I will point you in the right direction, because there are doctors all across the country who are just like I am, who are waiting to see you, who want you to come in. They want to see you, to begin this process so that it's not scary. They will partner with you every single step of the way. This is a thing that we need to take control of. It is a thing that can be empowering. What if you find out that it's nothing at all, it's just dense breast tissue? How great, and how wonderful, and how empowering is that? That's a load lifted, right? One less thing to worry about. I want people who are watching to know that much of what we feel is diagnosable. It's manageable, it's treatable. It's not always cancer. But we want to find that as early as we can, and we want to help you to manage, and deal with, and get rid of it so that you can live beyond breast cancer.

Jean A. Sachs, MSS, MLSP:

Given the expectation that there'll be more and more people diagnosed — and we know this virus, even with the vaccine, will be with us for a while — the hospitals are just going to get busier. So in a lot of ways, it would be better if people just started going in now. I imagine there will be a big backlog.

Monique Gary, DO, DSc, FACS:

That's true. The American Society of Breast Surgeons has a campaign called “mask up for mammo.” When my mammogram was due a couple months ago, I put my mask on and I got my mammogram and we taped it. These are the things that patients need to see, is that we have to all go through this, but we will get through this and we will get through this together.

It is so important to do all of the screening that you can, and then take all of the preventive measures that you can, which includes watching your diet. There are articles and studies coming out that show that we are drinking more alcohol than ever. [Consuming] alcohol is a risk factor for breast cancer, excess alcohol, not sleeping well, diet and nutrition, exercise. We can't get to our gym like we used to, we can't get outside like we used to. We have to find some ways to reduce our risk factors. I hope that everybody is thinking creatively about it, because every challenge presents an opportunity. This is a chance for you to spend that time with your family, to work on your exercise routines at home, to try new and great recipes, and to do all of the things you can to reduce your risk for breast cancer.

Jean A. Sachs, MSS, MLSP:

Those are all great things that we could be doing while we're quarantined in the house.

Well, Dr. Gary, thank you so much for always being with us, every time we ask. I do hope you'll be getting the vaccine soon.

Monique Gary, DO, DSc, FACS:

I'm looking forward to it. I think that it just hit Philadelphia. We're going to have about 15,000 or so here in the state of Pennsylvania and if I'm in the first wave, that'd be great, but I think our ER docs, our ICU positions are probably in the first wave and I might be in the second one. But if they're offering it, I'm taking it right.

Jean A. Sachs, MSS, MLSP:

Well, that's great already.

Monique Gary, DO, DSc, FACS:

I'm over it. I want to hug my patients again. I miss that contact and I know they miss it, too.

Jean A. Sachs, MSS, MLSP:

I want to thank Amgen, again, for supporting this important program. We'll continue to cover issues about breast cancer treatment during the pandemic. We know everyone has a lot of questions about the vaccine, so we will be having programming in the new year to help you understand how it's going to roll out, how it works, and what it means for cancer patients.

Remember we have a Helpline. We also have closed Facebook pages. So log on to lbbc.org. We'd be happy to connect you with any of these groups or have you talk directly to a Helpline volunteer. Thank you again, stay safe, and see you soon.