Posted on December 15, 2021

By Jayla Burton, Program Manager

Screening Disruption Due To COVID-19

Nearly two years ago, a global shelter in place was instituted as just one of the many necessary steps to protect vulnerable members of our communities, including those who are immunocompromised and breast cancer patients, from the coronavirus. Since this landmark implementation of various recommendations from the Center of Disease Control (CDC) to manage the global pandemic, a hot topic for those of us in the breast cancer field has been how COVID-19 has impacted many aspects of breast cancer care, including: regulatory processes, supportive care, clinical trials, and the continuum of care–a topic that will be covered more in depth by our Executive Director, Dr. Krystal Redman (KR).

Almost every day I see a new headline about the impact of declining rates of the breast cancer screening, including and focused on mammography screening, to detect breast cancer since the onset of the pandemic. An overwhelming majority of these articles talk about the negative impact of detecting less cancers, especially in communities of color, however very few mention the limitations of screening and how excess screening can cause harms such as financial burdens and the overtreatment of tumors that will never be life threatening, which can contribute to and exacerbate inequities.

In June of 2020, Drs. Vinay Prasad and H. Gilbert Welch published an op-ed calling out the hyper-medicalized culture where the risks and harms of overtreatment are downplayed, and showed that some would-be patients who skip routine breast cancer screening during COVID-19 may fare better with less medical care.

A study presented at this year’s San Antonio Breast Cancer Symposium (SABCS) looked at the impact of the COVID-19 outbreak on breast cancer in the Netherlands. This was presented by Dr. Anouk H. Eijkelboom, from the Netherlands Comprehensive Cancer Organization. The study compared breast cancer incidence in 2017 to 2019 with incidence in 2020 and 2021. They found the largest decrease in lower stage tumors, which was to be expected because the Netherlands suspended their screening program at the onset of the pandemic. They found that from the beginning of the lock-down, which halted screening (March 2020), to the gradual restart of their breast cancer screening program (June 2021) the incidence of ductal carcinoma in situ (DCIS)and Stage I tumors were lower than they were in 2017-2019. In March and April and May to June, the incidence of Stage II and Stage III tumors were lower than they were in 2017-2019. Conversely, the incidence for Stage IV tumors in 2020-2021 were higher than they were years prior.

These results aren’t alarming, considering the more you screen the more you will find. However, it would be interesting to see long-term how outcomes fare when lower stage breast cancers go untreated. Historically, there have been many conversations about DCIS and how it should be considered and treated. Nearly 20% of new breast cancer diagnoses are DCIS which has a pretty good prognosis with a 20-year breast cancer specific survival rate nearing 97%. But we also know that one-size doesn’t fit all and DCIS can be a precursor for a more invasive tumor, and that younger women (under the age of 25) and Black women experience worse outcomes.

The decline in diagnosis of DCIS and smaller stage I tumors makes me wonder how much collateral damage, including risk of death from secondary cancers that can result from intense treatment of smaller tumors, was avoided due to the decrease in detection caused by paused screening. Breast Cancer Action has always uplifted the reality of overdiagnosis (finding and treating tumors or cells that won’t ever become life threatening) and false positives (finding something suspicious that turns out not to be cancer). Both can result in unnecessary treatment, meaning people who are overtreated and experience the harms of treatment, including lasting physical, financial, sexual, and emotional stress without any of the benefits that would merit the treatment provided, including, improved quality of life of overall survival. As time goes on, there will be more data on the longer-term impacts of tumor progression and overall breast cancer outcomes, and we look forward to that evidence and its implications on screening guidance going forward.

As soon as this data is published, Breast Cancer Action will be ready to assess and translate the science, so people living with and at risk of breast cancer can know what it means for them.