Beginning in March, as COVID-19 cases surged in various states in the U.S., the COVID-19 Pandemic Breast Cancer Consortium released recommendations that operations for ductal carcinoma in situ (DCIS) be deferred due to the pandemic. DCIS, which goes by many names including "stage 0" breast cancer, is a non-invasive form of cancer that begins in the milk ducts and is generally surgically excised. In approximately one in five cases, surgeons may find evidence of invasive cancer during surgery. During the pandemic, patients and clinicians expressed concern about what surgical delays might mean for patients' outcomes. A new study led by, investigators from Brigham and Women's Hospital, of more than 378,000 patients who were diagnosed with very early stage breast cancer between 2010 and 2016 offers new data and insights to help address these unknowns. The research team found that while increased time to surgery was associated with a small increase in pathological upstaging in DCIS patients, it did not impact overall survival. Results are published in the Journal of the American College of Surgeons.
"The most pressing question today is what will surgical delays due to the pandemic mean for patient outcomes, and the reality is that we will only have the answers years from now," said lead author Christina Minami, MD, MS, a surgeon in the Division of Breast Surgery at the Brigham. "In the meantime, these data should provide some reassurance and encouragement -- they don't indicate that outcomes will be changed dramatically. But we do encourage patients to follow up with their surgeons on a care plan as COVID-19 surges grow or subside locally."
Minami and colleagues leveraged data from the National Cancer Database for patients, which captures approximately 70 percent of newly diagnosed cancer in the U.S. All patients diagnosed January 1, 2010 to December 31, 2016 who underwent breast cancer surgery were identified. The team focused on patients with DCIS or early-stage (cT1-2N0) ER+ disease, an early form of breast cancer that may be susceptible to hormone therapy drugs.
More than 98 percent of patients with DCIS underwent surgery within three months. Among those who delayed surgery 60 days or longer, there was no significant difference in overall survival but there was a slight increase in upstaging. In patients with cT1-2N0 disease who were placed on neoadjuvant endocrine therapy -- a hormone therapy -- increased time to surgery did not impact stage or overall survival.
The authors note that extrapolating from the historical data to determine what this means for patients whose surgery has been delayed during the pandemic is challenging. Those who delayed surgery during the study period were a highly selective group -- they may not be representative of the wide swath of patients whose surgery was delayed due to the pandemic. In addition, the research team was only able to look at outcomes of three to four years -- understanding the longer-term effects of surgical delays may provide more meaningful insights for patients and clinicians.
"Anxiety for both surgeons and patients alike stems from the unknown -- what does a delay in surgery mean for our patients?" said Minami. "We sought to help address questions about outcomes. Ideally, we'd like to have randomized, controlled studies, but under the circumstances, we needed to take the more unconventional approach by looking at retrospective data."
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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Minami reports research support (to institution) from Conquer Cancer Foundation (Young Investigator Award, 2020-2021) and American College of Surgeons (Faculty Research Fellowship, 2020-2022). Additional disclosures can be found in the paper.
Paper cited: Minami, CA et al. "Association between Time to Surgery and Pathological Stage in Ductal Carcinoma in Situ and Early-Stage Hormone Receptor-Positive Breast Cancers" JACS DOI: 10.1016/j.jamcollsurg.2020.06.021
Journal
Journal of the American College of Surgeons