To date, the COVID-19 pandemic has resulted in over 44.8 million cases and 722,000 deaths in the US alone [1]. Breast cancer patients faced many delays in care at the beginning of the pandemic. Patients with cancer, especially those currently receiving chemotherapy, are at significantly higher risk of morbidity and mortality if infected with COVID-19, but delay in cancer treatment is also known to be associated with worse overall survival [2-9]. The stress of managing and navigating this delicate balance has proven to be challenging to physician well-being [10].

In the CROWN Study, we reported that breast cancer treatment delays during the initial surge of the COVID-19 pandemic were associated with a negative impact on breast cancer physician emotional wellness [11]. Of survey respondents, 79.4% of physicians reported delays in some component of patient care. The number one physician concern about treatment delays was “patients will become anxious” [11]. An interview-based survey of patients with early-stage breast cancer who experienced surgical postponement due to COVID-19 corroborated this concern. Patients described worry both about their cancer diagnosis and the COVID-19 pandemic [12]. However, the perceived quality of physician communication was associated with greater patient acceptance and better coping strategies. Trust was built through simple acts, like direct physician to patient communication to report the delay in surgery and discuss risks due to the deviation from standard protocol. Some patients also reported being comforted by alternative treatment strategies, i.e., Neoadjuvant endocrine therapy (NET).

Treatment delays were common during the initial surge of the COVID-19 pandemic with physicians reporting that surgical delays were most common. Furthermore, nearly 40% of physicians worried that treatment delays would impact overall survival or lead to progression of disease. Most respondents (43.3%) reported an average delay of one month, but up to 4% reported a delay of 4 months or longer [11]. In a survey of US medical oncologists, radiation oncologists, and surgical oncologists regarding use of NET in early-stage ER positive breast cancers, nearly half (46%) of respondents were willing to delay surgery for up to 2 months and nearly another quarter (21%) of respondents were willing to delay surgery for up to three months without use of NET due to the pandemic [13]. Review of the COVID-19 registry established within the American Society of Breast Surgeons (ASBrS) Mastery of Breast Surgery database (“ASBrS COVID-19 registry”) corresponded with the physician reported survey data [14]. In an analysis of patients entered into the ASBrS COVID-19 Registry from March 1, 2020 and March 15, 2021, the mean time to primary surgery was 44.5 days, and a change in surgical approach due to COVID-19 was reported in 5.4% of patients. This is concerning given that increased time from diagnosis to initiation of treatment has been associated with decreased patient survival [6-8]. While the optimal time from diagnosis to surgery was thought to be <90 days, at which point overall survival decreases by 3.1-4.6% [9], one study showed decreased survival for every 30-day delay in surgery (HR 1.1 [95% CI 1.08–1.13, p<0.001]) [15]. Additionally, patients taking longer than 38 weeks to complete surgery, chemotherapy, and radiation also have a decrease in overall survival, so upfront delays in surgery could have a meaningful and compounded impact on patient survival [5].

Over half (51.6%) of physicians reported delays in breast imaging in the CROWN study, and nearly 95% of surgeons reported that mammographic screening even was completely suspended at their institution at some point during the pandemic [11,14]. Even though mammographic screening did not stop indefinitely, there was also a 94% decrease in mammographic screening observed during 2020 [16]. Correspondingly, there was a 51.8% drop in new breast cancer diagnoses during the pandemic [17,18]. Of the cancers that were diagnosed, more presented at later stages than in the time period prior to the pandemic [19-22].

We found that 44.1% of respondents to the CROWN survey were outside normal limits for anxiety and 60.8% were outside normal limits for sleep disturbance [11]. Physicians whose patients experienced delays in either surgery, adjuvant therapy, breast imaging, radiation therapy, or specialty consultation reported significantly higher anxiety and COVID-19 related burnout. Nine percent of our survey respondents were radiologists, but a survey distributed specifically to members of the Society of Breast Imaging and National Consortium of Breast Centers had similar findings [23]. In this study, over two-thirds (68%) of respondents had anxiety. Others expressed feelings of sadness (41%), problems sleeping (36%), anger (25%), and depression (23%). Higher psychological distress stores were correlated with female gender, younger age, increased childcare needs, and higher financial loss. Likewise, the European Society for Medical Oncology (ESMO) conducted two online surveys of medical oncologists, one in April-May 2020 and the second in July- August 2020, and evaluated responses of the same participants at the two different timepoints [24]. In this study, the risk of burnout and distress was also higher in young physicians and female physicians, with an increased risk of distress/lower well-being and higher levels of burnout in the second survey as compared to the first [24]. These findings are similar to ours in the CROWN study in which female physicians and shorter time in practice were both independent risk factors for higher levels of anxiety and COVID-19 related burnout emotions [11].

The American Society of Clinical Oncology (ASCO) clinician well-being task force also interviewed 25 oncologists from various fields regarding the impact of the COVID-19 pandemic on their well-being, and later published strategies for the implementation of institutional well-being programs [10,25]. On an individual level, the ASCO task force recommended that oncologists assess their personal needs for sleep, nutrition, exercise, patient coverage, work logistics, and support systems [25]. They also encouraged peer support, communication with work colleagues, and mindfulnessbased stress reduction in addition to advocating for organizational cohesion and communication [25]. Additional recommendations proposed by the medical oncologists interviewed by ESMO included thinking of positives, change in physical activity, talking to colleagues, and using humor or laughing [24]. On an institutional level, the ASCO task force recommended instilling trust, having clear communication especially regarding efforts to prevent clinician exposure to COVID-19, creating clear management plans for patients being treated for cancer during the pandemic, respecting physician values, and forming peer support groups [25]. Oncologists also recommended that employers provide access to mental health and schedule flexibility [10]. Professional societies can also play a role in supporting physician well-being by helping to facilitate peer support typically provided at conferences by professional societies and providing access to mental health support [10].

In conclusion, breast cancer treatment delays during the COVID-19 pandemic were associated with a negative impact on breast cancer physician emotional wellness [11]. Young female physicians seem to be at highest risk for burnout [11,23,24].

There are multiple interventions that can be taken by individuals, institutions, and national societies to support oncologists during the COVID-19 pandemic [10,24,25]. As the COVID-19 pandemic continues, it is paramount that institutions and national societies make oncologist wellness a priority going forward so that physician burnout does not compound the current labor shortages and further limit access to care.