Routine mammograms are an important weapon in the fight against breast cancer, and are key to diagnosing the disease at its earliest stages and begin treatment. The arrival of the coronavirus pandemic, however, made keeping appointments for mammograms (and other important screening tests) difficult, if not impossible, for a period of time.
A new study published in The American Surgeon finds that the number of women who canceled their mammogram appointments indeed went up during the early days of the coronavirus pandemic, but steadily returned to pre-COVID levels (2021; https://doi.org/10.1177/00031348211051695).
Researchers at Loma Linda University Health (LLUH) conducted the study, which they hope will help breast cancer surgeons and breast cancer care teams prepare for what could be a significant uptick in patients presenting with advanced stages of breast cancer as we emerge from the pandemic. The American Society of Breast Surgeons (ASBrS) and American College of Radiology (ACR) recommended that all breast screening studies be postponed, effective March 26 of last year.
"These are unprecedented times and call for extraordinary measures," the ASBrS and ACR boards of directors wrote in March 2020, also recommending that routine breast visits and consultations for non-urgent breast abnormalities also be delayed. "These actions during this pandemic are for the utmost protection of our patients and staff. There is no evidence that delaying screening mammography for the proposed short time period will affect mortality, but there is plenty of evidence that being exposed to the coronavirus can impact mortality."
To examine the trends and explanations for mammogram cancellations during the early stages of the pandemic, the researchers performed a retrospective review of all canceled mammograms at a single tertiary care institution between January 1, 2020, and August 31, 2020. The study authors quantified both the number and reason for mammogram cancellations before and after March 26, and noted utilization of the electronic patient portal for appointment cancellation as a surrogate for telehealth uptake.
During the study period, the study authors found that 5,430 mammogram appointments were kept. In that same timeframe, 2,784 mammogram appointments were canceled. From a baseline of 30 canceled mammograms in January 2020 (close to 11% of all appointments), the number of cancellations peaked in March, reaching 576, representing 20.6 percent of all appointments.
Reasons for women calling off mammogram appointments varied greatly by month, and included COVID-19 concerns (236 canceled appointments, or 8.5%), unspecified patient reasons (1,210, or 7%), administrative issues (147, or 5.3%), provider requests (46, or 1.7%), or sooner appointments were available (31 appointments, or 1.1%). Close to 18 percent (486 patients) declined to offer reasons for their cancellations. The number of patients who withdrew their mammogram appointments because of COVID-related issues hit a high in April, with the number of cancellations slowly coming back down by August 2020, when restrictions began to be lifted.
In addition, electronic patient portal access peaked in August (67, 34%), the authors noted. Increasing use of electronic patient access figures to be sustained, according to the researchers, who found screening mammogram cancellations have steadily recovered as early COVID-19 constraints have been lessened.
Sharon Lum, MD, Chair of the Loma Linda University Hospital Department of Surgery and the study's principal investigator, expects to see telehealth adoption continue to proliferate once the pandemic eventually recedes.
"One interesting observation from our study was that the use of the electronic patient portal (MyChart) to notify of cancellations increased at the onset of the pandemic and continued to be used throughout the recovery period," said Lum. "I think telehealth will continue to be used in expanded ways for breast cancer care in the future."
She saw a handful of COVID-related factors driving the increased number of mammogram cancellations early in the pandemic.
"The increase in cancellations in April 2020 was due to COVID-19 related reasons, such as patients having COVID-19 or caring for someone with COVID-19, or having to watch kids at home in compliance with pandemic safety precautions," noted Lum. "The other category of reasons were unspecified patient-related reasons, which may have included the above, but were not specifically mentioned by the patient when they canceled their screening appointment."
The study's authors have pointed out that the broader medical community has seen similar decreases in cancer screenings throughout the pandemic, and they call for additional research to help fully understand just how missed cancer screenings are affecting cancer outcomes and potential upstaging.
Ultimately, these findings stand to help breast cancer surgeons and the rest of the oncology and cancer care teams prepare to provide the best care for the potential surge of patients presenting with more advanced stages of breast cancer.
"We have a fear that, because so many patients missed their cancer screenings during the pandemic, they will eventually return with higher stages of disease at diagnosis," said Lum. "Cancer care teams can prepare to deliver multidisciplinary care, and we should continue to encourage people to come back in for screening."
Mark McGraw is a contributing writer.