Discussion
This case highlights the factors due to which the COVID-19 pandemic may
impact the breast cancer patients disproportionately. These include
residing in a remote area (or travelling a long distance to their
physicians) and the presence of progressive disease. In general,
postoperative surveillance for early-stage breast cancer patients
includes annual mammography and other adjunctive investigations, such as
ultrasonography and CT.3 On the other hand, for
metastatic breast cancer patients or those experiencing disease
recurrence, investigation of serum tumor marker levels and other imaging
examinations performed every few months are recommended, depending on
the patients’ conditions.4 Regular follow-up was
particularly difficult for our patient because of the long-distance
travel required for each follow-up visit and the fear of potentially
contracting and spreading the infection. Indeed, travelling across
prefectures was discouraged during the COVID-19 pandemic in Japan.
In our case, considering the patient’s condition, her primary physician
understood the importance of performing a CT scan immediately, and the
patient also made an effort to find a nearby hospital. However, it
eventually took seven months until she could visit our hospital,
probably due to the increased burden on medical institutions brought on
by the pandemic and their subsequent reluctance to accept new patients.
Another reason could be a scarcity of specialist physicians and
hospitals specializing in providing care to cancer patients in rural
areas such as Fukushima. While the collaboration between medical
institutions is well established, both in medical communities and
society at large, its importance has been reiterated during the COVID-19
pandemic. It has become increasingly difficult to find a hospital to
refer patients to now that many hospitals are overburdened due to the
pandemic and restricting the acceptance of new patients as a
countermeasure. If our patient or her primary physician could have found
a medical institution earlier, metastasis might have been detected in
time.
This case also demonstrates the limitations of remote video
consultations for cancer during the COVID-19 pandemic. In fact, there
has been a rapid increase in remote video consultations for patients
with various diseases, including cancer.5 Similar to
our case, some hospitals have started to practice telemedicine and
providing drug prescriptions virtually to patients who cannot visit
hospitals for various reasons during the COVID-19, which was not widely
practiced in Japan prior to the pandemic.6 However,
without finding a nearby collaborating hospital, where the necessary
examinations can be performed and treatments can be received when
required, telemedicine should not be thoughtlessly implemented as a
major strategy for provision of care, especially for patients with
metastatic cancer or progressive disease.7
Considering that the COVID-19 pandemic is occurring as successive waves
in Japan, it is necessary to not only rely on the introduction of novel
telemedicine technology but also to reform and adjust the traditional
referral system for medical institutions, especially between urban and
rural areas, so that it is suitable for the post-pandemic era.
Telemedicine can be a useful option; however, patients who have been
receiving treatment at hospitals in urban areas should be able to
continue their treatment in rural areas even when it becomes difficult
for them to visit hospitals in urban areas.8
Therefore, it is important for medical institutions to take this
opportunity to recognize the advantages and disadvantages of
telemedicine. In general, remote video consultation is an effective
method for patients with skin diseases that can be detected visually, or
for follow-up of patients with stable chronic conditions, such as
hypertension.9 However, in cases like ours, the
indication of telemedicine for patients requiring specialized diagnostic
imaging on a regular basis is currently limited, and it is important to
understand its limitations before selecting suitable patients.