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,14and 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.14
In April 2020, a nationwide state of emergency against the COVID-19 pandemic was declared for the first time in Japan.15Subsequently, 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.