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A nuanced approach is needed to weigh the risk of vaccination-associated axillary lymphadenopathy against the risk of delaying breast cancer screening.
The COVID-19 pandemic has complicated breast cancer screening, from the early days of the pandemic when tests were stopped to preserve medical resources and reduce the risk of infection, to more recent delays due to reactive lymphadenopathy associated with recent COVID-19 vaccination.
Navigating these challenges requires an individualized and informed approach, Kimberly Garver, M.D., clinical assistant professor of radiology at Michigan Medicine suggested in a recent editorial in Academic Radiology.
“Instead of applying a ‘one size fits all’ algorithm to these patients, we need to take a more nuanced and informative approach to better help these patients and their physicians manage these competing risks,” Garver wrote.
Garver noted that lymphadenopathy related to vaccination should be weighed in relation to the risks associated with disruptions to breast cancer screenings. She pointed to a recent study in Academic Radiology by Renata Faermann, M.D., and colleagues in Israel, who found that the number of detected lymphadenopathies increased by 394% in 2021 compared with 2019 and 2020. The study found that 77.8% of lymphadenopaties were associated with vaccination in 2021.
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The National Comprehensive Cancer Network and the Society of Breast Imaging (SBI) have recommended delaying breast cancer screening 4 to 6 weeks after the second dose of the COVID-19 vaccine when possible, with follow-up after 3 months if abnormal lymph nodes are detected. SBI noted that adenopathies can occur in 11.6% of patients after the first dose of the Moderna or Pfizer-BioNTech vaccine and in 16% of patients after the second dose.
Disruptions in breast cancer screenings disproportionately affect underrepresented minority populations. A recent study found that older age, Medicare insurance coverage and racial and ethnic minority status were associated with missed breast cancer screening.
Women ages 40-79 have a 0.4% probability of being diagnosed with breast cancer from a single asymptomatic screening examination. That risk varies up or down depending on factors such as genetic mutations and family history.
A 10% overall probability exists for being called back for any abnormality detected during screening. That number increases with vaccination. The Israeli study found ipsilateral lymphadenopathies among 26.7% of patients in 2021, up from 6.4% and 5.7% in the previous two years.
Understanding each person’s risk profile and personal preferences are important considerations.
“For one woman, undergoing a call back examination for evaluation of possible abnormal lymph nodes would be a small event, but for another woman, it may cause extreme anxiety, made worse by the prospect of waiting 3 months until a follow-up ultrasound confirms the resolution of the lymphadenopathy,” Garver wrote. “Breast radiologists and breast imaging practices should understand individual patient preferences and practice culture to best determine the appropriate follow-up imaging strategy.”
Delaying vaccination also carries risks that vary with age and health status. The current mRNA vaccines approved for COVID-19 are over 90% effective at preventing serious illness.
“Women and their health care providers need to be educated with the most recent information available to best manage these competing risks,” Garver wrote.
Previous research has suggested that focusing breast cancer screening on those with the highest likelihood of developing breast cancer could be beneficial. In March, a team of investigators led by Diana L. Miglioretti, Ph.D., chief of biostatistics at the University of California-Davis School of Medicine, determined roughly 12% of mammograms account for more than half of breast cancers identified.
The American Society of Breast Surgeons published recommendations last year to help providers determine which patients and situations warrant breast imaging during the pandemic.