Prognosis for Early-Stage Breast Cancer Remains Good Despite Pandemic-Related Delays in Surgery

As the COVID-19 pandemic continues to escalate, cancer surgeries in some areas of the country may need to be delayed. Now, a new study is offering reassuring news for women with early-stage breast cancer in this predicament. Researchers are reporting these women can still expect an excellent prognosis that would not be negatively impacted by a short delay.¹

During the pandemic, surgical delays have been common for women with ductal carcinoma in situ (DCIS) and early-stage (cT1-2N0) estrogen receptor-positive (ER+) breast cancer. Researchers examined the association between time to surgery (TTS), pathological staging, and overall survival (OS) prior to the pandemic. In their analysis, they found that surgical delays of more than 60 days were associated with pathological upstaging in patients with DCIS, but not in women with invasive disease. No survival differences were noted in patients with DCIS or early-stage ER+ breast cancer receiving neoadjuvant endocrine therapy (NET) by time to surgery.

“We undertook this study to have some data with which to reassure our patients. Given what we know about DCIS and early-stage hormone receptor-positive breast cancer, we do not anticipate any change in survival outcomes due to COVID-19–related surgical delays, but we didn’t have any studies that directly examined this question,” explained Christina Minami, MD, MS, associate surgeon at Brigham and Women’s Hospital in Boston, Massachusetts, and lead author of this study (email communication, August 2020). “Certainly, our patients were concerned that their cancer was getting ‘worse’ during the delay, but I think our findings should reassure them.”

Endocrine therapy was recommended nationwide as the initial treatment of ER-positive breast cancer during pandemic-related surgical delays by the COVID-19 Pandemic Breast Cancer Consortium. The Consortium included representatives from the American Society of Breast Surgeons, the National Accreditation Program for Breast Centers, the National Comprehensive Cancer Network, the American College of Surgeons Commission on Cancer, and the American College of Radiology.²

In this study, the investigators sought to determine whether longer time to surgical treatment — up to 1 year after diagnosis — had an association with final pathologic staging of the cancer or with 5-year OS. They collected data from the National Cancer Database on 378,839 women who underwent surgery for breast cancer diagnosed between January 1, 2010, and December 31, 2016. Among the 99,749 women with DCIS, 84% (83,754) had ER+ disease and 16% (15,995) had estrogen receptor-negative (ER–) disease. Of the 222,933 women with cT1N0 disease, 1591 (0.7%) received NET; the remaining women underwent primary surgery. Of the 56,157 women with cT2N0 disease, 1880 (3.3%) received NET; the remaining underwent primary surgery. The investigators conducted a multivariable analysis of the women with cT1-2N0 disease, and found that older age, higher comorbidity index lobular disease, and cT2 vs cT1 tumor were significantly associated with receiving NET.

The study showed that 17.6% of women with ER– DCIS were upstaged to invasive disease after postoperative pathologic staging compared with 10.4% of women with ER+ DCIS. The proportion of patients who were upstaged on final pathology increased by TTS among both groups of women with DCIS. Women with ER– DCIS had a higher risk of upstaging only if they underwent primary surgical treatment more than 120 days after diagnosis.

“We were not surprised by our findings. Certainly the fact that surgical delays in DCIS are associated with a slight increase in pathological upstaging has already been documented, but the fundamental take-home point is that these patients still have an excellent prognosis. In the patients undergoing neoadjuvant endocrine therapy, no significant upstaging was seen, which supports our chosen delay strategy during the pandemic,” Dr Minami explained.

However, she stressed that the patient population in their study differs from patients who received NET during the pandemic. Before the pandemic, NET was not in widespread use in the United States for early-stage ER+ breast cancer. Study participants who received NET between 2010 and 2016 did so for specific reasons, such as older age and coexisting illnesses.