Early in the pandemic, breast screening stopped altogether, and even after centers started back up, new protocols for distancing and sanitizing rooms reduced the number of patients that could be screened. Patients also stopped coming in for screenings in large numbers during the first two years of the pandemic. This led to what many physicians thought would happen when the screening programs became disrupted––more advanced cancers now being found. Missed screenings resulted in the loss of opportunity to treat these cancers when they were much smaller and easier to treat.

"We were all asked to stop screening mammography, and we saw an incredible drop in rates of women being screened for breast cancer, not only in the U.S., but worldwide," she said. "We also saw an increase in more advanced breast cancer, which of course was predictable."

She said people at all centers worked very hard to try and make up for nearly two years of reduced breast screenings and get as many women into the imaging centers as possible to clear the backlog of missed exams. 

How MGH fixed its health inequities in post-COVID breast screenings

Lehman said Mass General's breast imaging program looked at their numbers to better understand where they are in the recovery mode. The findings were published in AJR earlier this year.[1]

"While we were back close to our pre-pandemic volumes, we weren't positive it was an equitable rebound. It was possible that our numbers rebounded, but that access to the diversity of patients we serve was out of balance, and that is exactly what we found. We found the recovery was much quicker for our patients who identified as white or caucasian and much slower for our patients of color and Hispanics," Lehman explained.

MGH put together programs to try and address this imbalance, including Saturday and evening screenings, and emphasis on getting a screen at the same time as an annual checkup with their doctor. On the technical side, MGH initiated same-day biopsies and immediate mammogram reads.[2] Lehman said this has caused a rebound in screenings for Black, Asian and Hispanic patients. 

"They are now exceeding the volumes that we saw before the pandemic," she explained. "These things can be addressed and fixed, but you have to measure them, because you can't change what you don't measure."

How COVID vaccine lymphadenopathy was addressed in breast imaging

When the COVID-19 vaccines were first rolled out in the last weeks of 2020 and start of 2021, within weeks there was a sudden, large uptick in enlarged lymph nodes detected on mammograms. Swollen lymph nodes are generally cause for alarm because they can be associated with a cancer. The axillary lymphadenopathy detected on mammograms after the vaccines were released generally occurred on one side of the patient depending on which are they received their vaccine or boosters. It was quickly determined to be a benign reaction to the vaccine and a sign that the body's immune system was reacting to the vaccine to identify and fight off the COVID virus later. This reaction required a revision of how breast imaging centers evaluated mammograms, questions asked of patients about vaccination status and when they received shots, and when to biopsy patients. 

Lehman said researchers poured through data from breast imaging centers around the country to come up with new protocols to address the increased rates of axillary lymphadenopathy due to the vaccine and to head off unnecessary biopsies and patient call backs for additional testing. She was involved with two publications on this issue.[3,4]

"We discovered the adenopathy was on the side where they had their recent vaccine. The Society of Breast Imaging (SBI), Mass General and others shared our large databases, and we came up with recommendations as quickly as we could based on that science," she said. 

This included waiting 4-6 weeks after a vaccination before getting a mammogram. Later studies found the vaccine-related adenapathy could last 10 weeks or more in some patients. So, in the past year, many centers have started to screen patients again without waiting periods.

While it seemed like an emergency in early 2021 on how to best manage these patients, it quickly became a normal finding by radiologists reading these exams. 

"We have become very comfortable and see this very often after vaccines and boosters that there may be asymmetric lymph nodes that are plump compared to the other side of the patient. We are very comfortable now in noting it and having a clinical followup. If it resolves and there are no clinical symptoms or concerns, the patient just continues on," Lehman said. 

She said this is what is now done in patients with swollen lymph nodes who do not have any other signs of breast cancer. For those that do have suspicious areas on mammograms showing possible cancer, she said the standard-of-care followup and testing is used.  

"The pandemic has challenged us, but has also taught us so much," Lehman said. "It showed us we can be faster than we thought, more innovative and it pushed us all to find solutions much faster than before the pandemic."

References:

1. Lehman CD, Mercaldo SF, Wang GX, Dontchos BN, Specht MC, Lamb LR. Screening Mammography Recovery After COVID-19 Pandemic Facility Closures: Associations of Facility Access and Racial and Ethnic Screening Disparities. AJR Am J Roentgenol 2022.

2. Dontchos BN, Achibiri J, Mercaldo SF, Wang GX, Lamb LR, Miles RC, Narayan AK, Lehman CD. Disparities in Same-Day Diagnostic Imaging in Breast Cancer Screening: Impact of an Immediate-Read Screening Mammography Program Implemented During the COVID-19 Pandemic. AJR Am J Roentgenol 2021.

3. Lehman CD, D'Alessandro HA, Mendoza DP, Succi MD, Kambadakone A, Lamb LR. Unilateral Lymphadenopathy After COVID-19 Vaccination: A Practical Management Plan for Radiologists Across Specialties. J Am Coll Radiol 2021.

4. Lehman CD, Lamb LR, D'Alessandro HA. Mitigating the Impact of Coronavirus Disease (COVID-19) Vaccinations on Patients Undergoing Breast Imaging Examinations: A Pragmatic Approach. AJR Am J Roentgenol 2021.