_{Published October 25, 2021}

Rameysh Danovani

Consultant Breast Radiologist Specialist
Women’s Imaging Clinic

By now, we are well aware of the challenges that coronavirus disease (COVID-19) has brought along to clinical practice, universally affecting all of us—from changing regulations and workflow limitations, to alterations in clinical coverage and reallocation of resources. The impact on breast imaging practice is an example, particularly concerning the screening population. At the heights of the pandemic in various locations, these seemingly well groups of patients were classified as non-critical, while resources were, justifiably so, reallocated to critical care. However, as the situation gradually settles, or cruising along between waves of infections in some places, there are increasing concerns regarding whether this group of patients is being neglected, or unduly delayed, thereby risking a delayed cancer diagnosis. This is not just by way of delayed screening mammography in itself, but given increasing vaccination rates, questions have been raised concerning its associated ipsilateral axillary lymphadenopathy.

At the beginning of the vaccination drives, this was unchartered territory. Not only were patients’ screening mammograms delayed by the pandemic itself, some patients potentially faced further delays once they were vaccinated. Concerns for delayed cancer diagnoses became increasingly significant.

We were not alone in this struggle here in Singapore, with conflicting schools of thought, which were all individually valid. There were proponents of delaying asymptomatic cases to minimize unnecessary workups, due to false positivities. In addition, this policy assists in reducing hospital admittance rates and the risks of COVID-19 community spread. On the other hand, there were those who strongly recommended business as usual to avoid any delayed cancer diagnoses. Although little known at the time, much work has now been published that affirms the latter tactic. Various cancer models and analyses have been performed in several countries, mostly confirming what we feared could happen: an increase in projected breast cancer deaths in the coming years due to pandemic-related delays. Indeed, there is anecdotal evidence from assorted practitioners who have encountered cases of COVID-19-related delayed cancer diagnoses in their clinical practice.

It is clear how serious the impact to individual patients remains. Therefore, the simple advice of delaying screening may not be entirely justifiable without clearer and more directed guidelines. Much to our relief, both AJR and the Society of Breast Imaging (SBI) have published recommendations for the management of axillary lymphadenopathy in patients with recent COVID-19 vaccinations. According to SBI, specifically, screening-detected unilateral axillary lymphadenopathy should be ascribed BI-RADS 0 category to allow further radiological assessment, coupled with documentation of any recent COVID-19 vaccination in the clinical history [4–6]. This could be surveilled with short-term (4–12 weeks) follow-up after completion of the second vaccination dose, considering nodal sampling in the event of non-resolution at follow-up.

As we anecdotally observed in Singapore, not all patients with recent vaccinations demonstrate evidence of axillary lymphadenopathy in their screening mammograms. This has been corroborated in a published study from Israel, which reported only 49% of cases developed mammographic evidence. Nevertheless, in the remaining patients and in those institutions offering multimodality screening approaches, the axillary lymphadenopathy is bound to be detected with growing frequency as vaccines continue to be administered worldwide. As a result, many breast imaging centers in Singapore have adopted this pragmatic approach clearly documenting recent COVID-19 vaccination in the ipsilateral arm, along with imaging follow-up to resolution of the lymphadenopathy (Fig. 1).

As the pandemic progresses, we will continue to learn from the ever-evolving COVID-19 infection. What is now current may soon prove to be outdated. Regardless, concerns about delayed diagnosis should continue to be addressed, and mitigating steps should be taken, so that the benefit of early detection continues to outweigh the risks—whatever the situation.