The Impact of the COVID-19 Pandemic on Practice Patterns in Breast Radiation Oncology: A Case-Based Survey Study in the United States

PURPOSE/OBJECTIVE(S): The COVID-19 pandemic posed challenges in resource allocation and breast cancer (BC) treatment decisions. Our study aims to understand changes in practice patterns of United States radiation oncologists (RO) treating BC during the COVID-19 pandemic. MATERIALS/METHODS: An IRB-approved 58-question survey with 6 clinical scenarios was distributed between July 17 and November 8, 2020 to ASTRO directory members. The cases included 1) Low-grade ductal carcinoma in situ (DCIS), 2) Low-risk BC treated with lumpectomy, 3) Low-risk BC treated with mastectomy with reconstruction 4) BC treated with neoadjuvant chemotherapy and mastectomy with reconstruction 5) BC treated with mastectomy and adjuvant chemotherapy but without reconstruction 6) Metastatic BC with enlarging breast mass. RO were surveyed about treatment recommendations if cases were seen pre-pandemic (PP) and hypothetically during the peak of pandemic (DTPP). Chi-square and McNemar-Bowker tests were used to examine the significance of changes. RESULTS: A total of 285 respondents from 48 states completed the survey and reported treating at least one patient with BC in the past 12 months. 45% primarily practice in university affiliated hospitals and 43% in private practice. 22% reported treating ≥ 1 COVID-positive BC patients. Moderate hypofractionation (2.31 - 3 Gy per fraction) in the PMRT and immediate reconstruction setting was recommended by 0.7% PP compared to 10.5% DTPP. In the low-risk PMRT setting, recommendation of no further treatment increased from 13% PP to 20% DTPP. Further, 56% changed their DCIS recommendations if the patient was seen DTPP. For low-risk BC, whole breast RT was preferred by 83.5% PP compared to 46.7% DTPP, and 35.1% recommended delay of RT DTPP compared to 0.4% PP (P < 0.05). Increase in ultra-hypofractionation (> 5 Gy per fraction) was significant for low-risk BC after lumpectomy as 0.4% reported its use PP compared to 3.8% DTPP. In addition, utilization of brachytherapy as PBI modality decreased from 23.9% to 17% among respondents PP and DTPP respectively. The Florence fractionation schedule for PBI was recommended by 46.2% for early-stage BC and by 51.7% for DCIS DTPP compared to 20% and 34.4% PP. Finally, 68.1% reported the use of 10-25 fractions PP for the palliative scenario. However, of those who would change their recommendation (48.8%), 62.8% reported recommendation of ≤ 5 fractions DTPP. Additional subset analysis by geographic region and practice type were notable for variable changes in treatment recommendations, and will be presented. CONCLUSION: This large survey of Breast RO clinical decision making demonstrates significant differences in recommendations and rapid adoption of unique fractionation. While likely reflective of intent to optimize resource allocations during the pandemic, maintenance of new practice patterns remains subject to future investigation.