The present study, conducted among Senonetwork Italian Breast Centers, focused on the management of BC care during 2020 COVID-19 pandemic. Comparing patients’ clinic-pathological characteristics, diagnosis, surgical and medical treatment variables between 2019 and 2020 time-frames, we sought to investigate if, in this selected, high-volume network of Breast Centers, any change in standard practice occurred due to the onset of the pandemic. To do so, we took advantage of data collected in Senonet, the Senonetwok data warehouse, and used a set of QIs, configured to monitor quality and commitment of Breast Centers in BC care, to describe changes in specific BC treatment areas.
Our analysis did not show any statistically significant difference in terms of diagnosis, surgical, oncological and radiation therapy procedures when comparing the two trimesters of the years considered. Nevertheless, we observed statistically significant differences, favoring the 2020 pandemic year, when analyzing time-to surgery and time-to radiotherapy (when indicated). This could be explained by an improvement in treatment strategies and even more strict collaboration between different Breast Centers. Indeed, since the first onset of the pandemic, Italian Breast Centers’ activities have been promptly reorganized, in response to the need of balancing the emergency of COVID-19 patients with the urgency of continuum of care for oncological patients, bearing in mind the potential exposure to SARS-CoV-2 infection of these frail patients. As cited before, many international guidelines recommended postponing surgery in low to medium risk BC patients, favoring neoadjuvant approaches, with many studies reporting a five-fold increment in the choice for neoadjuvant endocrine therapy in HR positive, HER2 negative tumors (9, 10). In our dataset, we observed a significant reduction in the use of neoadjuvant chemotherapy and we did not recollect any data on a major use of neoadjuvant endocrine therapy. This might be due to the fact that our high-volume, highly selected, Breast Centers were restructured to serve as BC care hubs for other low volume Hospitals and were organized to be able to perform upfront surgery (mainly BCS, as encouraged by International Guidelines) to the majority of ≤ 3 cm, HR positive, HER2 negative patients.
Moreover, a major implement of SLNB, without axillary lymph node dissection (ALND), was observed in our case series in 2020 compared to 2019. This might be explained by the elevated number of small, cN0 tumors selected for upfront surgery, as previously explained, but it might also reflect the gradual paradigm switch that the surgical management of the axilla have been encompassing through the last years, due to the wide acceptance of Z0011 trial findings on the possibility of omitting ALND in selected low-risk tumors (11).
Regarding radiation therapy, moderate-hypofractionated schedules were strongly recommended during the COVID-19 pandemic, reducing treatment duration and patients’ risk exposure (12), and in case of clinical indication for a boost, a further dose to the tumor bed, was preferably a simultaneous integrated one (13). These management indications, together with the possibility of addressing BC patients to dedicated Breast Centers hubs for adjuvant radiotherapy and the lowering of indications for palliative radiation treatments, might explain the shorter time-to radiotherapy observed in our case series in 2020 compared to 2019.
In conclusion, even if we globally observed a decrease in the performance of the Italian Breast Centers due to the COVID-19 pandemic, with major issues regarding an adequate and prompt access to treatment (6), in our study, providing data from a highly selected network of high-volume Breast Centers, we could not notice any treatment delay or radical change in standard clinical practice. These findings probably reflect the Senonetwork selection of Breast Centers fulfilling high-standard requirements of multidisciplinary organization and the capability of this network of Brest Centers to cooperate, joining forces also to serve as surgical and radiation therapy hubs for the nearest territorial area.
Due to the persistence of pandemic waves after 2020 and the unceasing need for COVID-19 inpatient care which might lead to an increased number of women with advanced BC at diagnosis in the future, we still need to accurately monitor the performance of Italian Breast Centers through the years and take in place appropriate actions to prevent disfunction in the health care of oncologic patients.