Like the rest of the world, Tanja Krupa had no idea what was about to happen. It was January 2020 and Krupa, a 41-year-old mother living outside of Detroit, was full of hope. She had a happy marriage and a thriving business running wellness workshops. A series of surgeries after a near-fatal car accident were behind her. She was living the healthiest life she had ever known, practicing yoga five days a week. She meditated. She avoided gluten, sugar, dairy, and caffeine. “I was finally at this place where it was like, ‘Oh my gosh, I’m full-on,’” Krupa says.
But that January, Krupa noticed something odd: a hard spot under her left areola. It’s probably a blocked milk duct, she thought. Seven years of nursing her children had taught her not to panic about such things. But in February, the hard spot was still there. So Krupa called her doctor, who referred her for a March mammogram at a local hospital. And then came COVID-19. Krupa closed down her business. Her husband, a school principal, suddenly had to manage a staff and student body in chaos. The couple’s children, then 4, 10, and 12, were at home full-time.
The hospital that was supposed to schedule Krupa’s mammogram never called. Weeks of waiting to schedule her scan turned into months. When Krupa finally had the mammogram in June and a biopsy in July, doctors discovered she had invasive breast cancer that had been growing long enough to spread to a nearby lymph node. As the pandemic stretched on, Krupa underwent chemotherapy, surgery, and radiation. And because her breast cancer was a type fueled by estrogen, she also had hormone treatment that will continue for the next 5 to 10 years.
Last year, many women found themselves in similar circumstances as breast cancer diagnosis and treatment was delayed across the country. As these women return to the fold, oncologists are wondering if COVID-19 might provide lessons on how to improve early detection and treatment in the future. Rena Callahan, MD, an oncologist at the University of California, Los Angeles, says one of her patients had an abnormal mammogram before the pandemic and was advised to undergo another round of imaging three to six months later. “During COVID, that three to six months became a year,” Callahan says. Like Krupa, the patient was eventually diagnosed with breast cancer that had spread to her lymph nodes, and she was prescribed chemotherapy, a treatment she might have avoided with an earlier diagnosis. “I’m confident she will do fine, but this is probably not something that would have happened otherwise,” Callahan adds.
Although COVID-19 ravaged the country, killing more than 600,000 Americans, it also “presented a sort of natural experiment,” says Barnett Kramer, MD, a special adviser to the National Cancer Institute (NCI) and retired director of the NCI’s Division of Cancer Prevention: What exactly happens when cancer screening stops for several months and cancer care is disrupted? Dorraya El-Ashry, MD, chief scientific officer for the Breast Cancer Research Foundation, says doctors are projecting a surge of late-stage breast cancer diagnoses in the years ahead, as a result of delayed screenings during the pandemic.
Screenings slowed during the early months of the pandemic, as health care facilities tried to preserve resources for COVID patients and reduce exposure to the virus. In June 2020, NCI Director Norman Sharpless, MD, published an editorial in Science warning there could be nearly 10,000 extra deaths from breast and colorectal cancer by 2030 due to disruptions in screening and treatment. A study published in The Lancet Oncology the following month predicted breast cancer deaths in the UK could increase up to 10 percent in the next five years.
Undoubtedly, there will be some cancer deaths caused not by COVID-19, but because of it. Callahan says one of her patients with metastatic breast cancer contracted COVID last year. The patient was hospitalized and successfully treated for the virus, but while she was in the hospital, her cancer treatment had to be paused, and her disease progressed so much that she eventually died. Cases like these, along with those of women like Krupa, who had a palpable breast lump that was not investigated quickly, are what surgeon and oncologist Laura Esserman, MD, worries about most. “If you do have a bad cancer that’s growing quickly, waiting four or five months can be a problem,” says Esserman, director of the University of California, San Francisco Carol Franc Buck Breast Care Center.
She is less concerned about women who missed routine mammograms during the pandemic. Screening rates that plummeted in mid-2020 largely recovered by the end of the year. In addition, as Esserman points out, screening is not always the panacea many women believe it to be. She is a critic of the country’s breast cancer screening paradigm—a mammogram every year, beginning at age 40 for women of average risk—because, she says, it ignores the fact that the risk of developing breast cancer varies from woman to woman.
Esserman advocates a more personalized, risk-based approach and is investigating whether this strategy could save more lives by determining whether some women should be screened more often—using other tools like MRIs and ultrasound—while others could be safely screened less often, or not at all. “We have consistently made screening one-size-fits-all, which is just not very sensible,” Esserman says. “We can definitely do better than that.”
As for the pandemic’s impact on breast cancer in the years to come, Kramer says, “We don’t really know yet what the long-term consequences, if any, will be.” By spring 2021, Krupa’s black hair, which she lost during chemotherapy, had grown back. She had received a COVID-19 vaccine and returned to her role as a fast-pitch girls’ softball assistant coach. Her business was operating again. She was reclaiming her life. “Everyone is crawling back to the light again, flowing back into this changed world,” Krupa says. “But for some of us—breastless, numb, aching, bald, infertile, prematurely aged, weary, burned, poked, and now cancer-stamped—it’s a tougher return.”
Krupa’s treatments worked well and she is likely to survive her ordeal. But she can’t help thinking how things might have gone differently if she had been diagnosed sooner. Would the cancer have been caught before it spread? Would her tumor have been smaller when her treatment began? Her odds of surviving higher? She will always wonder.