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.