Severe Impact of Covid-19 Pandemic on Breast Cancer Care in Italy: A Senonetwork National Survey

Introduction

Italy was the first Western country hit by the Coronavirus disease 2019 (COVID-19) pandemic, with over 246,000 documented cases and more than 35,000 deaths related to the infection as of July 26, 2020. The first documented case in Italy was reported on February 18, 2020, introducing a rapid sequence of events.¹ A few towns near Milan and in Veneto were locked down soon thereafter. Finally, the entire country was locked down on March 9, 2020, with a national quarantine, which has severely limited the movement of the entire population except for documented work and health circumstances. Since then, many hospitals have restrained non-emergency admissions and ambulatory services, particularly for non-oncologic patients. Despite many medical and scientific reports on the current pandemic, little is known on the effect and magnitude of this health emergency on the care of patients with breast cancer.

The Italian National Health System is a public health care provider organized on a regional basis, and 73% of total health costs are delivered through the public system.² Despite many economic restraints in the last 10 to 15 years, with the closure of many small hospitals and the decrease of the total number of health employees, the Italian Ministry of Health issued a directive in December 2014 committing all regional health services to organize Breast Units (BUs) according to a minimum case load of 150 new cases of breast cancer a year. For these reasons, the regionalized system has developed oncologic networks of dedicated units for the multidisciplinary care of women with breast cancer according to the Italian and European requirements.

A national survey was promoted to verify the impact of the COVID-19 emergency on the clinical care of women with breast cancer by Senonetwork Italia, a non-profit organization devoted to support the quality of multidisciplinary breast cancer care. The survey was delivered on April 2, 2020 to the 133 BUs affiliated with Senonetwork. It consisted of 17 questions to be answered by the Clinical Director of each Center along with the responsible physicians of each specialty of the core team. Data collected were anonymized and exported for statistical analysis. For continuous variables, a Wilcoxon rank-sum test was used to check differences between groups. A P value of less than .05 indicated a statistically significant difference.

One-hundred (75%) BUs, treating 37,678 (70%) of the 54,000 women newly diagnosed with breast cancer in Italy in 2019, participated to the survey. Fifty-eight percent of the Centers were located in Northern Italy, 28% in Central Italy, and 14% in Southern Italy, respectively.

According to the relevant findings of our survey:

• •Eighty-eight percent of BUs are currently operating within hospitals involved in the treatment of patients with COVID-19.
• •The weekly multidisciplinary meeting was discontinued or rescheduled to take place less frequently in 23% of BUs and was regularly held through videoconferences in 38%. In 33% of Centers, the decision about treatment was restricted to the responsible physicians of the core team in a large room.
• •A major decrease (more than 50%) in routine activities was reported for radiology, surgery, medical oncology, and radiotherapy in 38%, 22%, 11%, and 5% of BUs, respectively. In 38% of BUs, the number of weekly surgical procedures was reduced by 30% or more. Pathology activity was largely unchanged, and a waiting time of > 30 days was reported in only 3% of cases.
• •A decrease of availability of operating room time was reported by 74% of BUs, and this finding was equally distributed among low- and high-volume BUs (more or less than 300 cases operated annually, respectively), whereas there was a trend towards a more limited access for the BUs located in the north of the country (P = .09).
• •Sixty-six percent of BUs reported major modifications of their organization, including the necessity to temporarily merge in-hospital departments, or to transfer patients or physicians to other facilities.
• •Although 58% of BUs stated that the emergency caused problems that could be addressed, 21% believed that this may impact profoundly on the management of individual patients with breast cancer.
• •In 35% of BUs, personnel were found positive for COVID-19 infection, and in 7% of these cases, more than 3 professionals were involved. In 35% of BUs, 1 or more health care providers were quarantined since the outbreak of the infection.
• •Clinical directors of 79% of surveyed BUs responded that they were very or extremely worried about the impact of the pandemic on the organization of the routine activities of the Centers.
• •Forty-two percent of BUs believed that the emergency impaired the access of patients with cancer to the most appropriate treatment.
• •Despite all this, the vast majority of women were reported to show an accommodating and understanding attitude towards the difficulties experienced by the Centers.

Discussion

The results of our survey highlight a decrease in the overall performance of the Italian BUs owing to the COVID-19 pandemic. At the same time, they stress the need to protect both health facilities and specialized personnel to return quickly to deliver optimal support.

The COVID-19 pandemic is having a dramatic impact on the health care systems worldwide. In this context, the optimization of clinical care of patients with cancer and reallocation of human resources and medical supplies represent major issues. At the same time, the benefits of cancer care should be balanced against the risk of patients’ exposure to severe acute respiratory syndrome coronavirus 2 infection.

A number of recently published reports suggest strategies to accomplish these goals, both in the outpatient and in the in-hospital care setting.3, 4, 5 Specific protocols and guidelines for diagnosis, treatment, and follow-up have been proposed for patients with breast cancer,^{6 , 7} and several recommendations have been issued by many scientific societies urging clinicians to consider treatment delay or prioritizing the health care of women affected by breast cancer.

Most recommendations encourage maintaining weekly multidisciplinary team or tumor board meetings, preferably via videoconferencing or telephone, and delaying treatments of low-grade tumors or commencing neoadjuvant therapies instead of primary surgery when indicated. However, several reports suggest that delaying surgery or time to adjuvant/neoadjuvant therapies may have a negative impact on survival,^{8 , 9} or, in the case of ductal carcinoma in situ, on the development of an invasive disease.¹⁰

Conclusions

To the best of our knowledge, this is the first national report on the real-world impact of the COVID-19 pandemic on the management of women with breast cancer. Data indicate a major health issue regarding an adequate and prompt access to treatment, and policy makers should take this into account. If not reversed by appropriate actions, we might face an increased number of women with advanced breast cancer at diagnosis in the future, with the consequence of a decreased possibility of cure.

Disclosure

The authors have stated that they have no conflicts of interest.