[Skip to Content]
Outline
Claim CME
PDF
Oncology

Comparison of Use of Neoadjuvant Systemic Treatment for Breast Cancer and Short-term Outcomes Before vs During the COVID-19 Era in Ontario, Canada

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
JAMA Network Open
Published Online: August 2, 2022
Original Investigation
Steven Habbous, PhD1;
Xiaochen Tai, MSc1;
Jaclyn M Beca, MSc1,2;
Jessica Arias, MACP1;
Michael J. Raphael, MD2,3;
Ambica Parmar, MD, MSc3;
Andrea Crespo, BScPhm, RPh1;
Matthew C Cheung, MD4;
Andrea Eisen, MD1,3;
Antoine Eskander, MD, ScM5,6;
Simron Singh, MD, MPH3,6;
Maureen Trudeau, MD, MA3;
Scott Gavura, BScPhm, RPh1;
Wei Fang Dai, MPH1;
Jonathan Irish, MD, MSc1,5;
Monika Krzyzanowska, MD, MPH1,6,7;
Lauren Lapointe-Shaw, MD, PhD6,8;
Rohini Naipaul, BScPhm, RPh1;
Stuart Peacock, DPhil9;
Lyndee Yeung, BScPhm, MBA1;
Leta Forbes, MD1,10;
Kelvin K. W. Chan, MD, PhD1,2,3,6
Author Affiliations
  • 1Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
  • 2Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
  • 3Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  • 4Hematology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  • 5Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
  • 6Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
  • 7Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
  • 8Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 9Cancer Control Research, BC Cancer, Vancouver, British Columbia, Canada
  • 10Division of Medical Oncology, RS McLaughlin Durham Regional Cancer Centre Lakeridge Health, Oshawa, Ontario, Canada
Read article on JAMA Network

MOC/CME Information

editorial comment icon
Editorial
Comment
 related articles icon
Related
Articles
 author interview icon
Interviews
 multimedia icon
Multimedia
Read Article Claim CME
Key Points

Question  Did the use of neoadjuvant-intent systemic therapy for patients with breast cancer change after the emergence of COVID-19 in Ontario, Canada?

Findings  In this cohort study including 10 920 patients, the use of neoadjuvant-intent chemotherapy and hormonal treatment increased during the COVID-19 era, but there was substantial regional variability. Bridging hormonal therapy was a more common adaptation to cancer treatment in the COVID-19 era than neoadjuvant chemotherapy; neoadjuvant-intent systemic treatment was not associated with short-term outcomes in the COVID-19 era.

Meaning  These findings suggest that patients with breast cancer were more likely to receive neoadjuvant-intent systemic treatment in the COVID-19 era to offset delays in surgical capacity.

Abstract

Importance  In response to an increase in COVID-19 infection rates in Ontario, several systemic treatment (ST) regimens delivered in the adjuvant setting for breast cancer were temporarily permitted for neoadjuvant-intent to defer nonurgent breast cancer surgical procedures.

Objective  To examine the use and compare short-term outcomes of neoadjuvant-intent vs adjuvant ST in the COVID-19 era compared with the pre–COVID-19 era.

Design, Setting, and Participants  This was a retrospective population-based cohort study in Ontario, Canada. Patients with cancer starting selected ST regimens in the COVID-19 era (March 11, 2020, to September 30, 2020) were compared to those in the pre–COVID-19 era (March 11, 2019, to March 10, 2020). Patients were diagnosed with breast cancer within 6 months of starting systemic therapy.

Main Outcomes and Measures  Estimates were calculated for the use of neoadjuvant vs adjuvant ST, the likelihood of receiving a surgical procedure, the rate of emergency department visits, hospital admissions, COVID-19 infections, and all-cause mortality between treatment groups over time.

Results  Among a total of 10 920 patients included, 7990 (73.2%) started treatment in the pre–COVID-19 era and 7344 (67.3%) received adjuvant ST; the mean (SD) age was 61.6 (13.1) years. Neoadjuvant-intent ST was more common in the COVID-19 era (1404 of 2930 patients [47.9%]) than the pre–COVID–19 era (2172 of 7990 patients [27.2%]), with an odds ratio of 2.46 (95% CI, 2.26-2.69; P < .001). This trend was consistent across a range of ST regimens, but differed according to patient age and geography. The likelihood of receiving surgery following neoadjuvant-intent chemotherapy was similar in the COVID-19 era compared with the pre–COVID-19 era (log-rank P = .06). However, patients with breast cancer receiving neoadjuvant-intent hormonal therapy were significantly more likely to receive surgery in the COVID-19 era (log-rank P < .001). After adjustment, there were no significant changes in the rate of emergency department visits over time between patients receiving neoadjuvant ST, adjuvant ST, or ST only during the ST treatment period or postoperative period. Hospital admissions decreased in the COVID-19 era for patients who received neoadjuvant ST compared with adjuvant ST or ST alone (P for interaction = .01 for both) in either setting.

Conclusions and Relevance  In this cohort study, patients were more likely to start neoadjuvant ST in the COVID-19 era, which varied across the province and by indication. There was limited evidence to suggest any substantial impact on short-term outcomes.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

See More About

Breast Cancer Oncology Surgery Surgical Oncology Women's Health Coronavirus (COVID-19)
Article Information

Accepted for Publication: June 13, 2022.

Published: August 2, 2022. doi:10.1001/jamanetworkopen.2022.25118

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Habbous S et al. JAMA Network Open.

Corresponding Author: Steven Habbous, PhD, Ontario Health (Cancer Care Ontario), 525 University Ave, Toronto, Ontario M5G 2L3, Canada (Steven.Habbous@ontariohealth.ca).

Author Contributions: Ms Tai and Dr Habbous had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Habbous, Beca, Raphael, Crespo, Eskander, Singh, Gavura, Dai, Irish, Krzyzanowska, Naipaul, Peacock, Forbes, Chan.

Acquisition, analysis, or interpretation of data: Habbous, Tai, Beca, Arias, Raphael, Parmar, Crespo, Cheung, Eisen, Eskander, Singh, Trudeau, Krzyzanowska, Lapointe-Shaw, Peacock, Yeung, Forbes, Chan.

Drafting of the manuscript: Habbous, Raphael, Eskander, Singh, Irish.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Habbous, Tai, Eskander, Singh, Peacock.

Obtained funding: Beca, Eskander, Chan.

Administrative, technical, or material support: Habbous, Beca, Arias, Eskander, Singh, Gavura, Irish, Naipaul, Yeung.

Supervision: Habbous, Crespo, Cheung, Eskander, Singh, Irish, Peacock, Forbes.

Conflict of Interest Disclosures: Dr Krzyzanowska reported grants from EISAI, Exelixis, and Lilly; and personal fees from Ipsen Advisory Board and Lilly Advisory Board outside the submitted work. No other disclosures were reported.

Funding/Support: This work was funded by the COVID-19 Research Initiative grant from the Sunnybrook Foundation and Sunnybrook Research Institute.

Role of the Funder/Sponsor: The funder did not influence the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Disclaimer: Parts of this material are based on data and information compiled and provided by the Canadian Institute of Health Information (CIHI). However, the analyses, conclusions, opinions, and statements expressed herein are those of the author, and not necessarily those of CIHI. All views expressed are those of the authors of this report and do not necessarily reflect those of Ontario or the Ministry.

Additional Contributions: We acknowledge support of the Ministry of Health and Long-Term Care in this report.

References
1.
Douin  DJ , Ward  MJ , Lindsell  CJ ,  et al.  ICU bed utilization during the coronavirus disease 2019 pandemic in a multistate analysis-March to June 2020.   Crit Care Explor. 2021;3(3):e0361. doi:10.1097/CCE.0000000000000361PubMedGoogle ScholarCrossref
2.
Liang  W , Guan  W , Chen  R ,  et al.  Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China.   Lancet Oncol. 2020;21(3):335-337. doi:10.1016/S1470-2045(20)30096-6PubMedGoogle ScholarCrossref
3.
Zhang  L , Zhu  F , Xie  L ,  et al.  Clinical characteristics of COVID-19-infected cancer patients: a retrospective case study in three hospitals within Wuhan, China.   Ann Oncol. 2020;31(7):894-901. doi:10.1016/j.annonc.2020.03.296PubMedGoogle ScholarCrossref
4.
Wang  J , Vahid  S , Eberg  M ,  et al.  Clearing the surgical backlog caused by COVID-19 in Ontario: a time series modelling study.   CMAJ. 2020;192(44):E1347-E1356. doi:10.1503/cmaj.201521PubMedGoogle ScholarCrossref
5.
Finley  C , Prashad  A , Camuso  N ,  et al.  Guidance for management of cancer surgery during the COVID-19 pandemic.   Can J Surg. 2020;63(22):S2-S4. doi:10.1503/cjs.005620PubMedGoogle ScholarCrossref
6.
Walker  MJ , Wang  J , Mazuryk  J ,  et al; Cancer Care Ontario COVID-19 Impact Working Group.  Delivery of cancer care in Ontario, Canada, during the first year of the COVID-19 pandemic.   JAMA Netw Open. 2022;5(4):e228855. doi:10.1001/jamanetworkopen.2022.8855PubMedGoogle ScholarCrossref
7.
Keech  J , Beca  J , Eisen  A ,  et al.  Impact of a novel prioritization framework on clinician-led oncology drug submissions.   Curr Oncol. 2019;26(2):e155-e161. doi:10.3747/co.26.4501PubMedGoogle ScholarCrossref
8.
Naipaul  RD , Mercer  RE , Chan  KKW , Yeung  L , Forbes  L , Gavura  S .  Clinician perspectives of COVID-19-related cancer drug funding measures in ontario.   Curr Oncol. 2021;28(2):1056-1066. doi:10.3390/curroncol28020103PubMedGoogle ScholarCrossref
9.
Al-Quteimat  OM , Am  AM .  The Impact of the COVID-19 Pandemic on Cancer Patients. Am J Clin Oncol Cancer Clin Trials; 2020. doi:10.1097/COC.0000000000000712
10.
Campbell  M , Vu  K , Pardhan  A ,  et al.  Toward a common goal: improving safety of oral chemotherapy prescribing practices at a jurisdictional level.   JCO Oncol Pract. 2020;16(9):e1036-e1044. doi:10.1200/JOP.19.00797PubMedGoogle ScholarCrossref
11.
Welcome - Ontario Data Catalogue. Accessed November 3, 2021. https://data.ontario.ca/
12.
Census Profile. 2016. Accessed June 8, 2021. https://www150.statcan.gc.ca/n1/en/catalogue/98-316-X2016001
13.
Sheng  JY , Santa-Maria  CA , Mangini  N ,  et al.  Management of breast cancer during the COVID-19 pandemic: a stage- and subtype-specific approach.   JCO Oncol Pract. 2020;16(10):665-674. doi:10.1200/OP.20.00364PubMedGoogle ScholarCrossref
14.
Cavalcante  FP , Novita  GG , Millen  EC ,  et al.  Breast cancer and COVID-19 pandemic in Brazil.   J Surg Oncol. 2020;122(6):1260-1261. doi:10.1002/jso.26143PubMedGoogle ScholarCrossref
15.
Koca  B , Yildirim  M .  Delay in breast cancer diagnosis and its clinical consequences during the coronavirus disease pandemic.   J Surg Oncol. 2021;124(3):261-267. doi:10.1002/jso.26581PubMedGoogle ScholarCrossref
16.
Rocco  N , Montagna  G , Di Micco  R ,  et al.  The impact of the COVID-19 pandemic on surgical management of breast cancer: global trends and future perspectives.   Oncologist. 2021;26(1):e66-e77. doi:10.1002/onco.13560PubMedGoogle ScholarCrossref
17.
Tang  M , Daniels  B , Aslam  M , Schaffer  A , Pearson  S-A .  Changes in systemic cancer therapy in Australia during the COVID-19 pandemic: a population-based study.   Lancet Reg Health West Pac. 2021;14:100226. doi:10.1016/j.lanwpc.2021.100226PubMedGoogle ScholarCrossref
18.
Clark  JJ , Dwyer  D , Pinwill  N , Clark  P , Johnson  P , Hackshaw  A .  The effect of clinical decision making for initiation of systemic anticancer treatments in response to the COVID-19 pandemic in England: a retrospective analysis.   Lancet Oncol. 2021;22(1):66-73. doi:10.1016/S1470-2045(20)30619-7PubMedGoogle ScholarCrossref
19.
Vanni  G , Pellicciaro  M , Combi  F ,  et al.  Impact of COVID-19 pandemic on surgical breast cancer patients undergoing neoadjuvant therapy: a multicentric study.   Anticancer Res. 2021;41(9):4535-4542. doi:10.21873/anticanres.15265PubMedGoogle ScholarCrossref
20.
Dave  RV , Kim  B , Courtney  A ,  et al; B-MaP-C study collaborative.  Breast cancer management pathways during the COVID-19 pandemic: outcomes from the UK ‘Alert Level 4’ phase of the B-MaP-C study.   Br J Cancer. 2021;124(11):1785-1794. doi:10.1038/s41416-020-01234-4PubMedGoogle ScholarCrossref
21.
Park  KU , Gregory  M , Bazan  J ,  et al.  Neoadjuvant endocrine therapy use in early stage breast cancer during the covid-19 pandemic.   Breast Cancer Res Treat. 2021;188(1):249-258. doi:10.1007/s10549-021-06153-3PubMedGoogle ScholarCrossref
22.
Forner  D , Noel  CW , Wu  V ,  et al.  Nonsurgical management of resectable oral cavity cancer in the wake of COVID-19: a rapid review and meta-analysis.   Oral Oncol. 2020;109:104849. doi:10.1016/j.oraloncology.2020.104849PubMedGoogle ScholarCrossref
23.
Fligor  SC , Wang  S , Allar  BG ,  et al.  Gastrointestinal malignancies and the COVID-19 pandemic: evidence-based triage to surgery.   J Gastrointest Surg. 2020;24(10):2357-2373. doi:10.1007/s11605-020-04712-5PubMedGoogle ScholarCrossref
24.
Dietz  JR , Moran  MS , Isakoff  SJ ,  et al.  Recommendations for prioritization, treatment, and triage of breast cancer patients during the COVID-19 pandemic. the COVID-19 pandemic breast cancer consortium.   Breast Cancer Res Treat. 2020;181(3):487-497. doi:10.1007/s10549-020-05644-zPubMedGoogle ScholarCrossref
25.
Gandhi  S , Brackstone  M , Hong  NJL ,  et al; Canadian National Neoadjuvant Breast Cancer Consortium.  A Canadian national guideline on the neoadjuvant treatment of invasive breast cancer, including patient assessment, systemic therapy, and local management principles.   Breast Cancer Res Treat. 2022;193(1):1-20. doi:10.1007/s10549-022-06522-6PubMedGoogle ScholarCrossref
26.
Ürün  Y , Hussain  SA , Bakouny  Z ,  et al.  Survey of the impact of COVID-19 on oncologists’ decision making in cancer.   JCO Glob Oncol. 2020;6(6):1248-1257. doi:10.1200/GO.20.00300PubMedGoogle ScholarCrossref
27.
Karacin  C , Bilgetekin  I , B Basal  F , Oksuzoglu  OB .  How does COVID-19 fear and anxiety affect chemotherapy adherence in patients with cancer.   Future Oncol. 2020;16(29):2283-2293. doi:10.2217/fon-2020-0592PubMedGoogle ScholarCrossref
28.
Kasymjanova  G , Anwar  A , Cohen  V ,  et al.  The impact of COVID-19 on the diagnosis and treatment of lung cancer at a Canadian academic center: a retrospective chart review.   Curr Oncol. 2021;28(6):4247-4255. doi:10.3390/curroncol28060360PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Close
Want full access to the AMA Ed Hub?
Become an AMA member now
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
Become an AMA member now
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close
Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue