Survival Consistent for Women With Early-Stage Breast Cancer Despite Surgery Delays

Overall delays in surgical procedures to treat early-stage breast cancer, particularly estrogen-sensitive early-stage disease, as well as receiving neoadjuvant endocrine therapy (NET) because of such a delay, did not decrease odds of 5-year survival or increase odds of pathologic upstaging among a cohort of female patients, authors report in the Journal of the American College of Surgeons.

The authors hope these results provide reassurance to women in similar situations whose surgeries were delayed because of the coronavirus disease 2019 (COVID-19) pandemic, especially those who received NET because the anti-estrogen therapy “was recommended nationwide as the initial treatment of [estrogen receptor (ER)-positive] breast cancer during pandemic-related surgical delays,” said lead study author Christina Minami, MD, MS, an associate surgeon at Brigham and Women's Hospital, in a statement announcing the findings.

This study investigated survival outcomes among 2 groups of female patients (N = 378,839): those who had ductal carcinoma in situ (stage 0/noninvasive disease, n = 99,749) and those with ER-positive stage I/limited stage II disease (cT1N0, n = 222,933; cT2N0, n = 56,157), which happen to mirror a majority of patients with breast cancer whose surgeries were considered nonurgent and postponed early in the pandemic, Minami noted. The women in the study had their cancer diagnosed between January 1, 2010, and December 31, 2016, and their data were extracted from the National Cancer Database.

Study results show that the average time to surgery was within 120 days for 98% of all the women studied, as well as for 59.6% of the ER-positive group with cT1N0 disease and 30.9% with cT2N0 disease.

Additional results show slightly greater odds of clinical upstaging the longer surgery was delayed among women with ER-positive or -negative disease, but only if these delays were longer than 60 and 120 days after diagnosis, respectively, compared with a reference point of no more than a 60-day delay:

• ER-positive disease:
  • 60 to 120 days: odds ratio (OR), 1.15 (95% CI, 1.08-1.22)
  • More than 120 days: OR, 1.44 (95% CI, 1.24-1.68)
• ER-negative disease:
  • 60 to 120 days: not significant
  • More than 120 days: OR, 1.36 (95% CI, 1.01-1.82)

There was no associated increase for patients with invasive disease, “irrespective of initial treatment strategy,” the authors noted.

For patients in the estrogen receptor group, older age, higher comorbidity index, lobular disease, and cT2 vs cT1 tumor status meant a greater likelihood of NET.

“Our study found that on adjusted analyses, surgical delays of >120 days were associated with pathological upstaging in patients with DCIS but not in those with invasive disease,” the authors concluded. “[And while] there were too few DCIS patients on NET to render an adequate analysis in the current study, taken together, these data suggest that initiation of NET in patients with ER+ DCIS is a reasonable delay strategy.” However, they add that NET has not yet entered widespread use in the United States.

To truly understand how similar delays from the COVID-19 pandemic have and could affect women with early-stage disease, the authors note that studies must be carried out of how these women actually were treated during the pandemic. Still, they believe their findings can provide preliminary reassurance, because the patients groups affected are so similar.

Reference

Minami CA, Kantor O, Weiss A, Nakhlis F, King TA, Mittendorf EA. Association between time to operation and pathological stage in ductal carcinoma in situ and early-stage hormone receptor-positive breast cancer. J Am Coll Surg. Published online August 6, 2020. doi:10.1016/j.jamcollsurg.2020.06.021