Postpandemic Breast Cancer Screening Rates Explained: Adam Brufsky, MD, PhD

In this interview from a Pittsburgh Institute for Value-Based Medicine® event, “Driving the Future of Cancer Care,” held on November 13, Adam Brufsky, MD, PhD, addresses how the COVID-19 pandemic affected breast cancer screening rates across Pittsburgh, as well as that the overall impact was less severe than many had anticipated on a national level. He also highlights certain patient populations facing the greatest risk of delayed or inconsistent screening for breast cancer and that they also face a higher risk of more advanced-stage diagnosis.

Brufsky is a professor of medicine at the University of Pittsburgh and moderated the discussion “Gaps and Unmet Needs in the Journey of Patients With Breast Cancer.”

This transcript has been lightly edited for clarity; captions were auto-generated.

Transcript

How have breast cancer screening rates evolved since the COVID-19 pandemic, and what populations remain at greatest risk for delayed or inconsistent screening?

I think, at least in the Pittsburgh area, we did a really good job. I think there may have been a small drop in the number of people who were screened. They didn't want to come in or they delayed their screening during the pandemic because they were afraid, or, more often, I think that the facility itself was a little bit concerned about the spread of coronavirus, so they kind of really closed things down a bit. So, people delayed their screening. I think some people actually even canceled; a couple did. And for a while, probably over the last 3 to 5 years, we've seen a few people come in with a little bit more advanced disease than we thought they would have. It hasn't been as much as I think everybody thought it was, but it was still something that you could see.

I think the populations now that really remain most at risk are really low-income populations. I think low socioeconomic status—people who are working several jobs to make ends meet. They don't have time to get a mammogram, to get screened. Those are probably the biggest ones, I would say. There are some cultural ones, too. I mean, there are certain cultural ethnic groups that may be more distrustful of the medical establishment and don't really want to get a mammogram, I think, or any other kind of cancer screening. Those are probably the ones, at least to me, that are the ones that are at most risk, I think, for more advanced disease because they’re not getting screened.

Where do the biggest gaps exist in genomic testing access and utilization?

By genomic testing you probably mean the assays, like MammaPrint and Oncotype, things like that. I think some of it is they are fairly widespread among medical oncologists. I think they're becoming more and more widespread among surgeons. In fact, what's happening is that surgeons are ordering them earlier and earlier in the disease course, and it's not necessarily what the medical oncologist wants. In other words, for example, a surgeon may want a MammaPrint and order it because MammaPrint can let you know what the rate of pathologic complete response is to neoadjuvant chemotherapy. Oncotype really can't. So, they'll order it, but then the medical oncologist really wants an Oncotype because they’re just more familiar with it, so they're going to want that.

There's always this kind of like… I've gone to many areas of the country to try to defuse some of these arguments between the medical oncologist and surgeon, and that, in itself, can be somewhat of a barrier to someone wanting to order the test.

I think another one is actually insurance reimbursement. I think sometimes insurers are very siloed, and I think that you have the testing department of an insurance company or a payer, and then you have the treatment part that pays for all of the chemotherapy and hormone therapy and whatnot, and then you have just the cancer part, which is some other division, and they all have certain financial goals. I think it sometimes is more difficult for a system to globally look at something and realize that if you get a genomic test, half of the people who get it are probably not going to get chemotherapy. That’s going to save an enormous amount of money, plus it’s going to save any potential hospitalization and whatnot from that. That's probably a big barrier, just getting the payers to understand the value of these tests, and I think they do.

Another thing is information also at the level of the payers and the providers, to be honest with you. There's a lot more things now with early-stage genomic testing that are coming out that are going to be pretty radical, and I think really, really change the way we treat breast cancer. For example, I think we're learning that MammaPrint likely will predict benefit from anthracyclines or lack of benefit. Anthracyclines can be pretty toxic, especially to the heart, and if we could figure out who doesn't need anthracyclines, it's great. Another thing, as an example, that MammaPrint can do, it can tell you who doesn't need any therapy whatsoever. There's something called ultra-low, and ultra-low patients need absolutely nothing.

In speaking around the country on this topic, it's really surprising how few medical oncologists really know that. I think it's an educational issue. There's also a lot of tests that can determine whether you need 10 years of endocrine therapy vs 5. There's MammaPrint, there's Biotheranostics' Breast Cancer Index. There’s a whole other group of tests like that, and there’s just not a lot of education among a lot of oncologists. It's not their fault. I'm a breast oncologist. I treat only breast cancer, where other oncologists have to treat all 13 to 15 cancers plus hematology a lot of times, and they just don't have time to stay up complete with the literature.

Things like this, continuing education, just more educational products that are available to them in ways that they can digest quickly in their spare time, which is very little, would really be helpful. It's a combination of education and I just think understanding on the part of payers and providers about what these tests can really offer, is probably the biggest barrier, at least in the early-stage setting.