\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{Possible Association of Typhoon Hagibis and the COVID-19 Pandemic on
Patient Delay in Breast Cancer Patients: a case report}



\author[1]{Yudai Kaneda}%
\author[2]{Akihiko Ozaki}%
\author[3]{Masahiro Wada}%
\author[3]{Tomohiro Kurokawa}%
\author[2]{Toyoaki Sawano}%
\author[4]{Masaharu Tsubokura}%
\author[5]{Tetsuya Tanimoto}%
\author[3]{Yoshiaki Kanemoto}%
\author[3]{Tomozo Ejiri}%
\author[3]{Norio Kanzaki}%
\affil[1]{Hokkaido University}%
\affil[2]{Minamisoma Municipal General Hospital}%
\affil[3]{Jyoban Hospital of Tokiwa Foundation}%
\affil[4]{Fukushima Medical University School of Medicine}%
\affil[5]{Navitas Clinic}%


\vspace{-1em}



  
  \date{May 27, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Little is known on how disasters interact in their impacts on patient
care. We experienced a breast cancer patient whose initial presentation
was delayed for two years due to the COVID-19 pandemic and Typhoon
Hagibis. Increasing awareness is needed on the combined impacts of
disasters on breast cancer management.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Breast cancer is the most common cancer for women, with an estimated 2.3
million cases worldwide in 2020.\textsuperscript{1} Any delay in initial
medical consultation and subsequent breast cancer treatment increases
the risk of relapse, recurrence, and
mortality.\textsuperscript{2-4}Therefore, it is important for the
general public to be more aware of the symptoms and signs of breast
cancer, and to visit medical institutions if they experience any
symptoms that may lead them to suspect breast
cancer.\textsuperscript{5,6}

More than 75\% of breast cancer patients are detected after a
recognition of their symptoms,\textsuperscript{3} and 20-30\% of
symptomatic patients experience a delay of more than three months
between the initial perception of symptoms and the first visit to
medical institutions.\textsuperscript{4} From a previous study, even a
three month delay in diagnosis has been shown to reduce the five year
survival rate by about 7\%.\textsuperscript{3} For these delays, various
factors related to the patients and their environment, such as young age
and living alone, have been suggested.\textsuperscript{7}

Recently, the impact of disasters on cancer care has been attracting
global attention, as seen in past events such as the Triple Disaster of
2011 (earthquake, tsunami, and nuclear power plant accident), Hurricane
Katrina, Gorsica earthquake, and Typhoon Hagibis. Especially with the
COVID-19 pandemic that has been spreading worldwide since November 2019,
various aspects of breast cancer care have been affected
negatively.\textsuperscript{8,9}

We previously reported on how complex disasters can jeopardize cancer
treatment in the context of the 2011 Triple
Disaster.\textsuperscript{10, 11} However, the effects of this disaster
were mainly due to the accident at the Fukushima Daiichi Nuclear Power
Plant, which forced local residents to evacuate on a large scale for
fear of the radiation. There is not enough information on how cancer
treatment would be compromised in the event of such a combination of
completely different disasters. It is clinically important to consider
this issue because we are currently living under the COVID-19 pandemic
and we do not know when other disasters will occur.\textsuperscript{12,
13}

Here, we report on a breast cancer patient in Fukushima, whose initial
visit to medical institutions was delayed by two years due to Typhoon
Hagibis and the COVID-19 pandemic.

\textbf{Case presentation}

A woman in her 50s living at home with her mother in her 80s needing
nursing care visited our hospital in Iwaki City, Fukushima Prefecture
for the first time in April 2021 due to a lump in her right breast that
she had been aware since April 2019. She made her first visit to our
hospital when she started to feel pain around February 2021. As a result
of various examinations including mammography, ultrasonography, CT and
PET scans, she was diagnosed with Clinical T2N1M1 (bone) Stage IV breast
cancer.

Detailed interview with the patient revealed her complicated situation
behind the two-year delay in initial medical consultation. This delay
was due to a combination of various factors at work and at home, in
addition to the 2019 Typhoon Hagibis and the COVID-19 pandemic, which
have significantly lowered the priority of receiving medical
consultation. When she first became aware of her symptoms in April 2019,
she did not recognize the seriousness of her condition and used
ointments to relieve them. While her symptoms did not disappear, she was
not worried about it so much for a few months.

Then, she experienced the Typhoon Hagibis in October 2019. She was
living near the Natsui River, which flooded during the
typhoon,\textsuperscript{14}and the first floor of her house was
completely flooded that day. She climbed up the stairs carrying her
mother on her back and escaped from the flooding. A few months after the
typhoon, she became aware that the lump was gradually getting larger and
considered an initial consultation about her condition, as hospital fees
were exempted until March 2020 due to the typhoon. However, she was
living on the second floor of her house at that period and was busy
cleaning the first floor, so she could not visit the doctor after all.
Then, from around March 2020, the effects of the COVID-19 pandemic began
to appear also in Iwaki City.\textsuperscript{14}

In April 2020, a nationwide state of emergency against the COVID-19
pandemic was declared for the first time in
Japan.\textsuperscript{15}Subsequently, as the pandemic had not been
completely controlled in Japan, people refrained from going out as much
as possible and continued to do so even after the state of emergency was
ended. In addition, vaccination against the COVID-19 was not available
until the early summer of 2021. During this period, she was afraid to
see even her relatives or friends and could not talk to them about her
symptoms. Moreover, the patient usually went out for work during the day
and had to go home to take care of her mother as soon as she finished
her work. Due to these reasons, her initial medical consultation was
delayed for two years.

Since there was only one bone metastasis at the time of diagnosis, we
discussed the advantages and disadvantages of each treatment strategy
with the patient and performed chemotherapy followed by mastectomy and
axillary dissection in September 2021. She is treated with the hormonal
therapy with fulvestrant and abemaciclib as of October 26, 2021.

\textbf{Discussion}

We reported a case of advanced breast cancer patient whose initial
diagnosis was delayed by 2 years in Fukushima, Japan, mainly due to the
combined effects of Typhoon Hagibis and the COVID-19 pandemic. If she
had been consulted earlier, she might have been able to receive
treatment for her breast cancer before she developed bone metastasis.

This case shows that undiagnosed breast cancer patients tend to postpone
their first medical consultation in the event of a disaster, and this
effect may be strengthened especially for patients who tend to delay
seeking help. A notable finding of this case is that living with other
family members partly prevented her from making initial medical
consultation. Although social support from family or friends is
extremely important for the treatment and recovery process of breast
cancer patients,\textsuperscript{16} it may also have a negative impact
as shown in this case. Therefore, it is important to understand the
characteristics of each patients and treat them individually.

At the same time, it is important to recognize that delays in medical
consultation may occur before healthcare professionals and others have
contact with those patients, which may limit the actual measures taken.
In order to deal with this problem, it is essential to cooperate with
media such as newspapers and television to further raise people's
awareness of breast cancer symptoms and encourage patients to accurately
recognize the severity of their symptoms so that they can seek initial
advice from their family or friends. Also, especially in this case, it
would have been necessary to intervene to her work place or home to
ensure that the patient could receive appropriate medical care, for
example, by establishing an environment where the patient could easily
take time off work, or by sending someone who could take care of her
mother instead of her.

In addition, in the event of a disasters during the COVID-19 pandemic,
it is necessary to handle the situation with precautions to prevent the
spread of infection. Generally, those affected by disasters are
vulnerable to infectious diseases due to overcrowded shelters,
environmental changes and poor personal
hygiene.\textsuperscript{17}Furthermore, since many people have
refrained from social interactions for fear of infection, various
support activities that have been carried out in the past disasters,
such as child care, transportation of supplies, and soup
kitchens,\textsuperscript{18} may be reduced. In order to ensure access
to medical services even in such a situation, it is also important to
share information on hospitals and evacuation centers where medical
treatment is available, and to expand telemedicine services.

In conclusion, we experienced a breast cancer patient whose medical
consultation was delayed for a long time due to the combined effects of
the COVID-19 pandemic and the typhoon. Especially in the current
situation of the COVID-19 pandemic, it is important to communicate the
risks of breast cancer and the benefits of screening by effectively
utilizing the media to encourage patients to seek timely medical care.
In addition, it is important to approach patients individually by
providing consultation services for patients and their families, or
reminding patients to visit the hospital.

References

\textbf{1.} Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics
2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36
Cancers in 185 Countries. CA Cancer J Clin\textbf{.} 2021;71(3):209-249.

\textbf{2.} Shin DW, Cho J, Kim SY, et al. Delay to curative surgery
greater than 12 weeks is associated with increased mortality in patients
with colorectal and breast cancer but not lung or thyroid cancer. Ann
Surg Oncol\textbf{.} 2013;20(8):2468-2476.

\textbf{3.} Richards MA, Westcombe AM, Love SB, Littlejohns P, Ramirez
AJ. Influence of delay on survival in patients with breast cancer: a
systematic review. Lancet\textbf{.} 1999;353(9159):1119-1126.

\textbf{4.} Bish A, Ramirez A, Burgess C, Hunter M. Understanding why
women delay in seeking help for breast cancer symptoms. J Psychosom
Res\textbf{.} 2005;58(4):321-326.

\textbf{5.} Coleman C. Early Detection and Screening for Breast Cancer.
Semin Oncol Nurs\textbf{.} 2017;33(2):141-155.

\textbf{6.} Gotzsche PC, Jorgensen KJ. Screening for breast cancer with
mammography. Cochrane Database Syst Rev\textbf{.} 2013(6):CD001877.

\textbf{7.} Stuver SO, Zhu J, Simchowitz B, Hassett MJ, Shulman LN,
Weingart SN. Identifying women at risk of delayed breast cancer
diagnosis. Jt Comm J Qual Patient Saf\textbf{.} 2011;37(12):568-575.

\textbf{8.} Papautsky EL, Hamlish T. Patient-reported treatment delays
in breast cancer care during the COVID-19 pandemic. Breast Cancer Res
Treat\textbf{.} 2020;184(1):249-254.

\textbf{9.} Freer PE. The Impact of the COVID-19 Pandemic on Breast
Imaging. Radiol Clin North Am\textbf{.} 2021;59(1):1-11.

\textbf{10.} Ozaki A, Leppold C, Tsubokura M, et al. Social isolation
and cancer management after the 2011 triple disaster in Fukushima,
Japan: A case report of breast cancer with patient and provider delay.
Medicine (Baltimore)\textbf{.} 2016;95(26):e4027.

\textbf{11.} Ozaki A, Leppold C, Sawano T, et al. Social isolation and
cancer management - advanced rectal cancer with patient delay following
the 2011 triple disaster in Fukushima, Japan: a case report. J Med Case
Rep\textbf{.} 2017;11(1):138.

\textbf{12.} Ishiwatari M, Koike T, Hiroki K, Toda T, Katsube T.
Managing disasters amid COVID-19 pandemic: Approaches of response to
flood disasters. Prog Disaster Sci\textbf{.} 2020;6:100096.

\textbf{13.} Sohrabizadeh S, Yousefian S, Bahramzadeh A, Vaziri MH. A
systematic review of health sector responses to the coincidence of
disasters and COVID-19. BMC Public Health\textbf{.} 2021;21(1):709.

\textbf{14.} Ozaki A, Kanemoto Y, Wada M, et al. A call for
individualized evacuation strategies for floods: A case report of
secondary surgical site infection in a postsurgery breast cancer patient
in Fukushima, Japan, following Typhoon Hagibis in 2019. Clin Case
Rep\textbf{.} 2021;9(3):1212-1214.

\textbf{15.} Looi MK. Covid-19: Japan declares state of emergency as
Tokyo cases soar. BMJ\textbf{.} 2020;369:m1447.

\textbf{16.} Walsh F. Family resilience: a framework for clinical
practice. Fam Process\textbf{.} 2003;42(1):1-18.

\textbf{17.} Kouadio IK, Aljunid S, Kamigaki T, Hammad K, Oshitani H.
Infectious diseases following natural disasters: prevention and control
measures. Expert Rev Anti Infect Ther\textbf{.} 2012;10(1):95-104.

\textbf{18.} Kondo H, Koido Y, Kawashima Y, et al. Consideration of
Medical and Public Health Coordination - Experience from the 2016
Kumamoto, Japan Earthquake. Prehosp Disaster
Med\textbf{.}2019;34(2):149-154.

\selectlanguage{english}
\FloatBarrier
\end{document}

