In this cohort of women with and without breast cancer, participants reporting a delay in breast health care had worse psychosocial outcomes compared to those not reporting a delay. Among recently diagnosed breast cancer patients, we found that longer time to treatment was experienced by participants with high anxiety, depression, perceived stress, loneliness, and low emotional support.
In our study, 58% of participants reported a delay in their breast health care over the COVID-19 pandemic including delays in surgery, radiation, chemotherapy, medical oncology treatments, clinical appointments, breast imaging and/or biopsies, survivorship follow-up, support groups, and screening. While the impact of these delays on oncologic outcomes is unknown, delays in treatment for breast cancer have been found to increase mortality [16–17]. Our study is similar to previous studies that have identified a large proportion of breast cancer patients reporting treatment delays due to the COVID-19 pandemic [18–22].
In an effort to mitigate delays in oncology treatment, our institution and several others adopted more widespread use of telehealth services to expedite consultations and arrange for medical therapy [23]. In our study, we found that among breast cancer patients 88% of our patients utilized telehealth, 89% in the delay group and 86% in the no delay group; however, among those without delays, there was a greater median number of telehealth encounters. This data suggests that while telehealth increases access to medical care, it may also expedite the process of obtaining treatment, thereby mitigating delays.
Our study adds to the growing body of work that has demonstrated how COVID-19-related treatment delays among breast cancer patients lead to increased anxiety and depression [18–19, 24–27]. For example, one Korean study of 154 breast cancer patients found that COVID-19-related treatment changes significantly correlated with depression [19]. Another Canadian qualitative study by Fortin and colleagues also found that women who began breast cancer treatment prior to the start of the pandemic reported less psychological distress than those that started treatment during the pandemic [25]. Additionally, Rodriguez and colleagues surveyed 312 United States cancer patients and found that 60% felt very or extremely concerned that COVID-19 would affect their care, and 52% reported an impact on at least one of their social determinants of health [26].
In our time to treatment analysis, we identified three participants who had greater than 120 days between their diagnosis and initiation of treatment. Importantly, 2 of these 3 participants also screened positive on the PHQ-9 including the participant with the longest time to treatment (314 days). Review of this participant’s record revealed that she was diagnosed with ductal carcinoma in situ in February 2020, offered surgery at that time, but declined until Fall 2020. It was not until early 2021 that the patient ultimately had the recommended surgical therapy. In clinical practice, patients do sometimes refuse recommended treatment. In these instances, it is the essential role of the healthcare provider to counsel and assess for co-existing stressors that may prevent a patient from proceeding with care. During the height of the COVID-19 pandemic as telehealth visits became the norm, we speculate that perhaps this patient was unable to be offered the usual supportive resources amenable to in-person visits. While the use of telehealth helps expedite medical care, it is possible that it may make it more difficult to engage with complex patients [23].
Clinical Implications
Our finding that 2 out of 3 patients with the longest time to treatment had clinically significant depression underscores the need to screen for mental health issues among breast cancer patients. This finding coupled with the finding that longer time to treatment was experienced by the high anxiety, depression, perceived stress, loneliness, and low emotional support participants suggest that there is a need for breast cancer providers to better identify patients who may be struggling with concurrent psychological stress and provide the necessary additional support. Proposed strategies to mitigate the adverse psychological impact of pandemic-related treatment delays include improving communication among patients and their healthcare team and allowing family members and caregivers to take part in consultation for provider visits including initial diagnosis and first treatment [26].
Study Limitations
Our study is limited by the relatively small sample size of our survey respondents; however, this allowed for a more granular analysis of patients within our cohort. Additionally, due to the nature of this cross-sectional study, we did not have access to data regarding pre-existing psychological comorbidities, and the psychosocial measures were self-reported. Our results must be interpreted cautiously as we assessed self-reported psychosocial outcomes and patient-reported delays simultaneously, so we cannot report on temporality and whether adverse psychosocial measures may have impacted the delay of care. As part of a prospective longitudinal study, we also cannot yet report on oncologic outcomes such as recurrence and survival.