Sustaining Breast Reconstruction during a Pandemic: Institutional Review from the United States COVID-19 Epicenter

PURPOSE: Screening, detection, and treatment for cancer faced numerous challenges and delays across the United States and world during the coronavirus disease-19 (COVID-19) pandemic. The effects of this are presumed to extend far beyond the initial peaks of the pandemic, as predictive modeling has suggested that delays in breast cancer screening, diagnosis, and treatment will lead to increases in subsequent breast cancer mortality over the ensuing decade. In our state, there was a strict month-long moratorium on elective consultations, imaging, procedures, and surgeries to preserve healthcare resources and divert personnel and attention to caring for patients with COVID-19 in April 2020. It is important to understand how screening delays created by the COVID-19 pandemic may affect both short-term and long-term oncologic outcomes for patients with breast cancer. Furthermore, it is important to characterize how these delays affected breast reconstruction in these patients. The objective of this study was to quantify the effect of the COVID-19 pandemic on breast cancer screening, primary oncologic breast operations, and subsequent breast reconstruction practices at a single institution situated within the epicenter of the pandemic. METHOD: A retrospective review of a single academic institution was performed to identify all mammograms, lumpectomies, mastectomies, and breast reconstruction operations performed from January 2019 through June 2021. Data was extracted from a combination of institutional databases in conjunction with direct electronic health record review. Only index breast reconstructions were included, and by such, revisions or secondary procedures were not included. Wilcoxon signed-rank tests were used to compare the number of total number of mammograms, oncologic, and reconstruction cases between calendar quarters using SPSS Version 25 (IBM Corp., Armonk, N.Y.). Predetermined level of significance was p<0.05. RESULTS: Mammography volume declined by 11% in March-May of 2020. Oncologic breast surgeries and reconstructive surgeries similarly declined by 6.8% and 11%, respectively, in 2020 compared to 2019, reaching their lowest levels in April 2020. The volume of all procedures increased during the summer of 2020. Mammography volume in June and July 2020 were found to be at pre-COVID-19 levels, and in October-December 2020 were 15% higher than in 2019. Oncologic breast surgeries saw a similar rebound in May 2020, with 24.6% more cases performed compared to May 2019. Breast reconstruction volumes increased, though changes in the types of reconstruction were noted. Oncoplastic closures were more common during the pandemic, while two-stage implant reconstruction and immediate autologous reconstruction decreased by 27% and 43%, respectively. Volume in 2021 will supersede 2020 levels in all categories. CONCLUSION: The COVID-19 pandemic acutely reduced the volume of breast cancer surveillance, surgical treatment and reconstruction procedures. Despite mask mandates and required COVID-19 preoperative testing, diligent efforts were made to mitigate the decline in volume related to the COVID-19 pandemic. Volume increased beyond baseline levels to make up for the backlog created by the COVID-19 pandemic. The plastic surgery community can learn from these experiences in order to mitigate the impact of future disrupting events.