Dr. Anthony Lucci

This October, Breast Cancer Awareness Month was unlike any in recent memory. In this time of uncertainty brought on by the pandemic, it’s important for most women to understand that, while breast cancer screening can be delayed a few months, it should not be skipped altogether.

A few months delay to avoid peak pandemic times is reasonable but skipping screenings altogether may not be the best option. Both early detection, which can identify cancer early when it’s most treatable, and appropriate treatment following a diagnosis are critical in ensuring the best possible outcomes for patients.

When it comes to breast cancer screening, women should maintain regular mammogram appointments with their health care provider, in accordance with national screening guidelines when possible. Women should also know how their breasts normally look and feel and report any breast changes to a health care provider right away. When screening is skipped or delayed for long periods (more than six months), women are at risk of their tumor being detected at a later stage, when it could be more advanced, and possibly harder to treat. We are already seeing this scenario play out this year, with breast cancer screening rates dropping by an astounding 94% in March when the pandemic began.

This steep drop was likely due to the cancellation or postponement of appointments and preventive screenings. Researchers estimate that, because of the pandemic, mammograms were disrupted for 7 million women, resulting in an estimated 36,000 positive breast cancer diagnoses missed or delayed.

The great majority of women should not skip their mammograms because of fear of becoming infected with the virus that causes COVID-19 at a medical facility. Published data has shown that transmission rates of respiratory viruses such as influenza are low when both patients and health care providers wear masks and perform handwashing protocols.

Using genomic testing to personalize a treatment plan, especially during COVID-19

For women newly diagnosed with breast cancer, facing this news amid a pandemic can be especially frightening. Among those whose breast cancer surgery has been delayed, their fear and anxiety may be further heightened. In Texas and in many states across the nation, hospitals had to put some breast cancer operations on temporary hold during the early days of the pandemic, because of concerns that doing elective surgery, even cancer surgery, would use up personal protective equipment (PPE) necessary for health care providers on the front lines, and possibly occupy ICU and hospital beds needed for patients acutely ill with COVID-19. We had to delay the lowest risk cases so that patients considered in more urgent need of surgery were given priority to go to the operating room.

While postponing surgery for removal of a cancerous tumor may sound scary, we have an important tool available to help us determine the best treatment regimen for someone in this situation. That tool is genomic testing, which provides information about the biology of a patient’s tumor and can help us determine which treatment regimen will work best — even prior to surgery. In our practice, we found it useful to use the Oncotype DX Breast Recurrence Score® test, which analyzes each patient’s tumor cells and looks at the expression of cancer-specific genes within the tumor after it has been biopsied or removed. This test reliably identifies those patients whose tumor cells are sensitive to chemotherapy and those whose tumor cells are not. The test results also provide the percent likelihood that a woman’s cancer will return, either in the breast or elsewhere in the body, giving us more confidence about selecting the optimal treatment for each patient.

Recent research has shown that this test can identify women with a low likelihood of their tumor responding to chemotherapy given prior to surgical removal of the tumor. Instead, they may benefit from an alternative approach while awaiting surgery, such as endocrine (hormone) therapy at home. The research findings showed that women with favorable tumor biology, as determined by a low score on their genomic test, did quite well on pre-surgery endocrine therapy, and had very low rates of disease progression until their definitive breast surgery, some as low as 1%.

Several patients whose surgery was delayed due to COVID-19 told me they were reassured when they were found to have a low Recurrence Score® result. The knowledge that they could now be treated safely with endocrine therapy while awaiting surgery, and with a very low chance of disease progression, was reassuring. Also, endocrine therapy does not suppress the immune system, which may be a concern during the pandemic. The emerging data also shows that patients with a low Recurrence Score result have a high chance of their tumor shrinking on endocrine therapy, and an increased likelihood of being able to have breast preservation surgery, based on early study data.

For women who are able to undergo breast cancer surgery without a pandemic-related delay, the genomic test helps us identify whether they are likely to benefit from chemotherapy. This test can reduce the chances of patients with favorable biology being overtreated. We know from an earlier landmark study, called 

, that only a small minority of women with early-stage, node-negative breast cancer substantially benefit from chemotherapy, and the vast majority can now be spared from chemotherapy and its related toxic side effects.

In conclusion, with COVID-19 continuing to be a public health crisis in the United States, women should be mindful of the following and act when it comes to their breast health:

It should now be safe to continue to undergo routine breast cancer screening as recommended by guidelines for your age and risk level.

You should postpone your screening if you are not feeling well or have fever. But do not skip it altogether!

Health care providers are taking all necessary precautions to keep patients safe, and intra-hospital transmission is low. However, if you are worried about transmission of the coronavirus in a health care setting, you might consider asking if a telehealth visit is an option. This is an important tool if you cannot come to a hospital because of travel restrictions.

Patients who are newly diagnosed, but have been told their breast cancer surgery may be delayed, can be reassured that they will be at a low risk of disease progression if they are treated with endocrine therapy after confirming that their genomic test score is low. Patients with a high score need to discuss the options of early surgery, or chemotherapy before surgery, with their oncologist.

If you have been diagnosed recently with breast cancer, you can ask your doctor if you are a candidate for a genomic test to determine the biology of your tumor. The results can often help guide pre-surgery personalized treatment decisions – whether you are undergoing surgery now or later – so you can be treated as optimally as possible.

For more information about genomic testing, visit 

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Dr. Anthony Lucci currently is a professor of surgery with dual appointments in the Departments of Breast Surgical Oncology and Surgical Oncology at The University of Texas MD Anderson Cancer Center

Articles

A breast surgical oncologist at The University of Texas MD Anderson Cancer Center notes that while breast cancer screening can be delayed a few months, it should not be skipped altogether.

Dr. Anthony Lucci

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