ASO Author Reflections: How COVID-19 Impacted Breast Cancer Presentation and Management.
About: This article is published in Annals of Surgical Oncology.The article was published on 2021-11-30 and is currently open access. It has received 1 citations till now. The article focuses on the topics: Breast cancer & Surgical oncology.
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TL;DR: The COVID-19 pandemic has presented the oncologic community with unique challenges, requiring triage of surgical care, with 64 % to 87 % of cancer patients reporting a delay in surgery during the height of the pandemic in 2020.
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TL;DR: Neoadjuvant AI treatment markedly improved surgical outcomes and Ki67 and PEPI data demonstrated that the three agents tested are biologically equivalent and therefore likely to have similar adjuvant activities.
Abstract: Purpose Preoperative aromatase inhibitor (AI) treatment promotes breast-conserving surgery (BCS) for estrogen receptor (ER) –positive breast cancer. To study this treatment option, responses to three AIs were compared in a randomized phase II neoadjuvant trial designed to select agents for phase III investigations. Patients and Methods Three hundred seventy-seven postmenopausal women with clinical stage II to III ER-positive (Allred score 6-8) breast cancer were randomly assigned to receive neoadjuvant exemestane, letrozole, or anastrozole. The primary end point was clinical response. Secondary end points included BCS, Ki67 proliferation marker changes, the Preoperative Endocrine Prognostic Index (PEPI), and PAM50-based intrinsic subtype analysis. Results On the basis of clinical response rates, letrozole and anastrozole were selected for further investigation; however, no other differences in surgical outcome, PEPI score, or Ki67 suppression were detected. The BCS rate for mastectomy-only patients at pre...
451 citations
Case Western Reserve University1, National Comprehensive Cancer Network2, Yale University3, Harvard University4, Fox Chase Cancer Center5, Carolinas Medical Center6, Yeshiva University7, University of Washington8, University of Pennsylvania9, Scott & White Hospital10, American College of Radiology11, NorthShore University HealthSystem12
TL;DR: This Special Communication uses expert opinion of representatives from multiple cancer care organizations to categorize BC patients into priority levels (A, B, C) for urgency of care across all specialties and provides treatment recommendations for each of these patient scenarios.
Abstract: The COVID-19 pandemic presents clinicians a unique set of challenges in managing breast cancer (BC) patients. As hospital resources and staff become more limited during the COVID-19 pandemic, it becomes critically important to define which BC patients require more urgent care and which patients can wait for treatment until the pandemic is over. In this Special Communication, we use expert opinion of representatives from multiple cancer care organizations to categorize BC patients into priority levels (A, B, C) for urgency of care across all specialties. Additionally, we provide treatment recommendations for each of these patient scenarios. Priority A patients have conditions that are immediately life threatening or symptomatic requiring urgent treatment. Priority B patients have conditions that do not require immediate treatment but should start treatment before the pandemic is over. Priority C patients have conditions that can be safely deferred until the pandemic is over. The implementation of these recommendations for patient triage, which are based on the highest level available evidence, must be adapted to current availability of hospital resources and severity of the COVID-19 pandemic in each region of the country. Additionally, the risk of disease progression and worse outcomes for patients need to be weighed against the risk of patient and staff exposure to SARS CoV-2 (virus associated with the COVID-19 pandemic). Physicians should use these recommendations to prioritize care for their BC patients and adapt treatment recommendations to the local context at their hospital.
286 citations
TL;DR: Within patients receiving chemotherapy for breast cancer, its receipt in the neoadjuvant setting has been increasing among all biologic subgroups, with use in these subgroups being twice as frequent as in HR+/HER2− disease.
Abstract: While breast cancer has historically been treated with surgery followed by adjuvant chemotherapy (AC) and radiation when indicated, neoadjuvant chemotherapy (NAC) use is thought to be increasing; however, the trends of its use in various biological subtypes have not been evaluated. We sought to evaluate the trend of NAC use over time by biological subtype. We identified all patients with invasive breast cancer who underwent curative intent surgery and were treated with chemotherapy from 2010 to 2015 from the National Cancer Database. An unadjusted analysis of trends in proportions over time was performed using Cochran–Armitage trend tests stratified by hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) status. Of 315,264 patients who received chemotherapy, 251,726 (79.8%) received AC and 63,538 (20.2%) received NAC. From 2010 to 2015, significant increases in NAC use were seen in all biologic subtypes (all p < 0.001). The highest proportions and greatest increases in proportions of NAC were seen among triple-negative breast cancers (TNBC; 19.5–33.7%) and HER2+ (HR−/HER2+, 21.5–39.8%; HR+/HER2+, 17.0–33.7%) tumors. HR+/HER2− tumors also had a statistically significant increase in use but this increase was less dramatic (13.0–16.8%) and NAC use in recent years was significantly lower than in other subtypes (p < 0.001). Within patients receiving chemotherapy for breast cancer, its receipt in the neoadjuvant setting has been increasing among all biologic subtypes. The highest use of NAC is in TNBC and HER2+ disease, with use in these subgroups being twice as frequent as in HR+/HER2− disease.
81 citations
TL;DR: It is a pertinent time to revisit the data supporting neoadjuvant endocrine therapy (NET), collect prospective data, and consider whether this imposed deviation will compel a more lasting role for NET in the treatment of ER-positive breast cancer.
Abstract: T he global COVID-19 pandemic has abruptly changed our approach to cancer care. In the face of a potentially deadly virus, surgeons must balance the risks of a delayed surgery for patients with newly diagnosed cancers with the risks of exposure to the virus in this potentially immunocompromised patient population. We must also consider the necessity of conserving limited hospital resources; effectively diverting life-saving medical care to manage a more imminent crisis. Undoubtedly, this is an unprecedented and highly unnerving time. These decisions are very challenging for physicians to make and understandably difficult for patients to accept. Several medical and surgical societies have published expedited consensus guidelines to help triage care for cancer patients. For breast cancer patients with estrogen receptor (ER) positive disease, which account for approximately 75% of all breast cancers, a deviation from the current standard of care is being recommended as a safe alternative to the traditional ‘‘surgery first’’ approach. Estrogen-blocking therapy was the first effective targeted therapy developed for breast cancer and has become the mainstay for the adjuvant treatment of patients with ER-positive disease. The use of endocrine therapy in the neoadjuvant setting, however, has been more limited. In the face of the current pandemic, multidisciplinary experts are recommending this approach as a bridge to surgery for many breast cancer patients. Considering this, it is a pertinent time to revisit the data supporting neoadjuvant endocrine therapy (NET), collect prospective data, and consider whether this imposed deviation will compel a more lasting role for NET in the treatment of ER-positive breast cancer. Traditionally, neoadjuvant chemotherapy (NAC) has been used to downstage breast cancer: to render a nonoperable tumor resectable and to convert surgery from a mastectomy to breast conservation. Several studies demonstrate similar efficacy of chemotherapy whether given in the adjuvant or neoadjuvant setting. However, the ability to evaluate for in vivo biologic treatment response has become a significant driver for the use of NAC, particularly in patients with triple negative or Human epidermal growth factor receptor 2 (HER2) over-expressed subtypes. Treatment
23 citations
TL;DR: In this paper, the authors compared breast cancer stage at diagnosis and rates of neoadjuvant therapy among women presenting to their institution before and during the COVID-19 pandemic forcing clinicians to potentially alter treatment recommendations.
Abstract: INTRODUCTION: The COVID-19 pandemic caused delays in breast cancer management forcing clinicians to potentially alter treatment recommendations. This study compared breast cancer stage at diagnosis and rates of neoadjuvant therapy among women presenting to our institution before and during COVID-19. METHODS: Retrospective chart review of patients with a new breast cancer diagnosis from March 2020-August 2020 (during-COVID-19) were compared with March 2019-August 2019 (pre-COVID-19). We compared stage at diagnosis, clinical/demographic features, and neoadjuvant therapy use between the time periods. RESULTS: A total of 573 patients included: 376 pre-COVID-19, 197 during-COVID-19. Method of cancer detection was by imaging in 66% versus 63% and by physical findings/symptoms in 34% versus 37% of patients comparing pre-COVID-19 to during-COVID-19, p = 0.47. Overall clinical prognostic stage did not differ significantly (p = 0.39) between the time periods, nor did cM1 disease (2% in each period); 23% pre-COVID-19 and 27% during-COVID-19 presented with cN+ disease (p = 0.38). Neoadjuvant therapy use was significantly higher during-COVID-19 (39%) versus pre-COVID-19 (29%, p = 0.02) driven by increased neoadjuvant endocrine therapy (NET) use (7% to 16%, p = 0.002), whereas neoadjuvant chemotherapy use did not change (22% vs. 23%, p = 0.72). In HR+/HER2- disease, NET use increased from 10% pre-COVID-19 to 23% during-COVID-19 (p = 0.001) with a significant increase in stage I patients (7 to 22%, p < 0.001) and nonsignificant increases in stage II (18 to 23%, p = 0.63) and stage III (9 to 29%, p = 0.29). CONCLUSIONS: Breast cancer stage at diagnosis did not differ significantly during-COVID-19 compared with pre-COVID-19. More patients during-COVID-19 were treated with NET, which was significantly increased in stage I HR+/HER2- disease.
19 citations