In the current study, we found a strong decline of newly diagnosed gynecological and breast cancer cases in 2020 as compared to 2019. This decrease was mainly due to a lower cancer detection rate at our department during the two lockdown periods (16 March 2020–30 April 2020 and 3 November 2020–31 December 2020) as compared to the same period in 2019.
To guarantee adequate patient care, considerable efforts have been made during the first lockdown to facilitate gynecological screening examinations with a minimized risk of a hospital acquired infection: COVID-19 symptom screening by questionnaires, temperature measurements, mandatory facemasks and optimized patients waiting time. By 14th of June, these actions were expanded by COVID-19 screening of every admitted patient. Therefore, although rising infection rates were experienced during fall and winter, screening examinations and outpatient care were guaranteed. However, as our study shows, even with optimized pandemic management, a strong decline in newly diagnosed cancers was still observed throughout the year 2020 as compared to 2019.
In the group of breast cancer, a strong decline of cancer detection rate was observed during both lockdown periods. In between the lockdowns, cases of newly diagnosed breast cancer increased and even reached a higher number as compared to 2019. We suppose that patients who missed screening examinations during the first lockdown, tended to catch up their appointment as soon as the pandemic situation looked stabilized. Significantly more patients with tumor-specific symptoms presented directly at our department or were referred by their gynecologist due to these symptoms. This observation indicates that tumor-specific symptoms forced patients to consult a doctor, while non-symptomatic cancer cases in patients who missed the routine mammography remained undetected. The observed tumor stage shift towards higher stage at diagnosis might also be explained by postponed mammography during the first lockdown. However, further studies on larger population are needed to prove this assumption. Moreover, there was an increasing trend towards neoadjuvant chemotherapy and a reduction in primary surgical cases during the lockdown periods. This might be explained by advanced tumor stage and the attempt to increase the overall hospitals’ bed capacity.
A decrease of 45% of newly diagnosed gynecological cancers was observed as compared to 2019. In particular, non-symptomatic tumors such as cervical cancer was underdetected in 2020, as annual PAP test was postponed during the first lockdown period. In the same time, tumor patients with tumor-specific symptoms such as postmenopausal bleeding or abdominal pain, less frequently consulted their specialist and presented themselves directly at our department.
Looking at percentages we have a similar loss in newly diagnosed tumors during the lockdown period in the breast cancer (−52%) as in the gynecological cancer group (−45%). In the breast cancer group, we have seen a strong decline in tumor diagnoses during the both lockdown periods and an increase in between the lockdowns. Whereas in gynecological cancer, we can just see a decline in percentage of cancer diagnoses throughout the year. The reason could be, that in gynecological cancer, we summarized different tumor entities and have a smaller sample size.
In accordance with our results, analyses of the national cancer screening patterns in the USA noticed a drop in breast and cervical cancer screening of 94% [4]. Among calculations, the COVID-19 pandemic could lead to 36 000 delayed or missed breast cancer diagnoses and 2 500 missed cases of cervical cancer in the three months from March to June 2020 [5]. Moreover, strong decline in newly diagnosed cancers was observed in breast, colorectal, lung and prostate cancer in the USA and across Europe [6,7,8,9]. Kaufman et al. have shown a decrease in mean weekly numbers of newly diagnosed patients with colorectal cancer, lung cancer, pancreatic cancer, gastric cancer, esophageal cancer and breast cancer of 46.4% for the timespan of 1 March to 18 April of 2020 when compared to the weekly numbers between 6 January 2019 and 29 February 2020. For breast cancer alone, they describe a decrease of 51.8% in the same period [10]. Also, Morais et al. were able to show a decrease of nearly 40% in new cases of 12 different types of cancer including breast cancer and cervical cancer. In their study, cervical cancer has shown the highest decrease with 74.3% when compared to the year 2019. For breast cancer, a decrease of 38.6% was found [11].
In contrast to most other published literature, this study includes data of the whole year 2020, compared to 2019. By investigating the whole year, we were able to find an inverse correlation of the number of positively tested COVID-19 patients in Austria and newly diagnosed cancers at our department. Thus, we analysed not only the differences in cancer diagnoses during the lockdown, but also investigated potential short term increases in between the lockdowns, as shown in our sub-analysis for breast cancer patients.
Efforts have been taken to organize cancer screening and management during the pandemic including the implementation of telemedicine for the outpatient treatment of cancer survivors to minimize face-to-face appointments [12]. It is recommended to continue oncological surgery, chemotherapy and radiotherapy based on priorities, while surgeries due to benign diseases should be postponed [13].
Treatment delays in potentially curable disease could lead to inferior outcomes and have impact on the overall survival of our patients, with the risk of missing the optimal treatment window. As the COVID-19 pandemic will be a challenge for some time to come, new strategies in patient care are needed to minimize the risk of infection. New strategies may include telemedicine or self-sampling HPV test, which detects viral nucleic acid rather than morphological changes and thus does not rely on healthcare practitioners visualizing the cervix [14], and thereby provide early diagnosis and improved treatment options for our patients. Most importantly, awareness must be raised for the importance of screening examinations to avoid any further shift in tumor stages at the time of diagnosis.
The major limitations of the current study are its relatively small sample size of only 889 patients and its single-center observational character. Despite these limitations, we were able to demonstrate that the COVID-19 pandemic led to a strong decline in the detection rate of newly diagnosed gynecological and breast cancers, which is in accordance with the findings of other subspecialities.