Regional spread of an atypical ESBL-producing Escherichia coli ST131H89 clone among different human and environmental reservoirs in Western Switzerland.

We describe the inter-regional spread of a novel ESBL-producing Escherichia coli subclone (ST131H89) in long-term care facility residents, general population, and environmental water sources in Western Switzerland between 2017 and 2020. The study highlights the importance of molecular surveillance for tracking emerging antibiotic-resistant pathogens in healthcare and community settings.

Genomic signature to guide adjuvant chemotherapy treatment decisions for early breast cancer patients in France: a cost-effectiveness analysis.

Introduction: Chemotherapy (CT) is commonly used as an adjuvant treatment for women with early breast cancer (BC). However, not all patients benefit from CT, while all are exposed to its short- and long-term toxicity. The Oncotype DX® test assesses cancer-related gene expression to estimate the risk of BC recurrence and predict the benefit of chemotherapy. The aim of this study was to estimate, from the French National Health Insurance (NHI) perspective, the cost-effectiveness of the Oncotype DX® test compared to standard of care (SoC; involving clinicopathological risk assessment only) among women with early, hormone receptor-positive, human epidermal growth factor receptor 2-negative BC considered at high clinicopathological risk of recurrence. Methods: Clinical outcomes and costs were estimated over a lifetime horizon based on a two-component model that comprised a short-term decision tree representing the adjuvant treatment choice guided by the therapeutic decision support strategy (Oncotype DX® test or SoC) and a Markov model to capture long-term outcomes. Results: In the base case, the Oncotype DX® test reduced CT use by 55.2% and resulted in 0.337 incremental quality-adjusted life-years gained and cost savings of €3,412 per patient, compared with SoC. Being more effective and less costly than SoC, Oncotype DX® testing was the dominant strategy. Discussion: Widespread implementation of Oncotype DX® testing would improve patient care, provide equitable access to more personalized medicine, and bring cost savings to the health system.

Prevalence of sexual dysfunction after breast cancer compared to controls, a study from CONSTANCES cohort.

PURPOSE: Sexuality, a substantial factor in quality of life, may be altered after breast cancer (BC) treatments as they intimately afflict femininity. This study aimed to assess the prevalence of sexual dysfunction in women with a history of BC and to compare it with women without a BC history. METHODS: The French general epidemiological cohort CONSTANCES includes more than 200,000 adults. All inclusion questionnaires from CONSTANCES non-virgin adult female participants were analyzed. Women reporting a history of BC were compared to controls in univariate analysis. Multivariate analysis was performed to highlight any demographic risk factor for sexual dysfunction. RESULTS: Among the 2,680 participants who had a history of BC, 34% did not engage in sexual intercourse (SI) in the month preceding the completion of the questionnaire (n = 911), 34% had pain during SI (n = 901) and 30% were not satisfied with their sex life (n = 803). Sexual dysfunction was significantly more frequent in women who had a history of BC: they had less sexual interest (OR 1.79 [1.65;1.94], p < 0.001), experienced more pain during SI (OR 1.10 [1.02;1.19], p < 0.001) and were more dissatisfied with their sex life (OR 1.58 [1.47;1.71], p < 0.001). This stayed true after adjustment on multiple demographic factors such as age, menopausal status, body mass index and depression. CONCLUSIONS: Overall, in this real-life study in a large national cohort, history of BC appeared to be a risk factor for sexual disorders. IMPLICATIONS FOR CANCER SURVIVORS: Efforts to detect sexual disorders in BC survivors and offer quality support must be pursued.

COVID-19 burden and influencing factors in Swiss long-term-care facilities: a cross-sectional analysis of a multicentre observational cohort.

OBJECTIVES: To describe the burden of COVID-19 in Swiss long-term care facilities in 2020, to identify its influencing factors, and to assess vaccination rates among residents and healthcare workers at the end of the vaccine campaign in Switzerland in May 2021. DESIGN: Cross-sectional survey. SETTING AND PARTICIPANTS: Long-term care facilities from two Swiss cantons (St. Gallen / Eastern Switzerland and Vaud / Western Switzerland). METHODS: We collected numbers of COVID-19 cases and related deaths and all-cause mortality for 2020, potential risk factors at the institutional level (e.g. size, infection prevention and control measures, and resident characteristics), and vaccination rates among residents and healthcare workers. Univariate and multivariate analyses were used to identify factors associated with resident mortality in 2020. RESULTS: We enrolled 59 long-term care facilities with a median of 46 (interquartile range [IQR]: 33-69) occupied beds. In 2020, the median COVID-19 incidence was 40.2 (IQR: 0-108.6) per 100 occupied beds, with higher rates in VD (49.9%) than in SG (32.5%; p = 0.037). Overall, 22.7% of COVID-19 cases died, of which 24.8% were COVID-19-related deaths. In the univariate analysis, higher resident mortality was associated with COVID-19 rates among residents (p < 0.001) and healthcare workers (p = 0.002) and age (p = 0.013). Lower resident mortality was associated with the proportion of single rooms (p = 0.012), isolation of residents with COVID-19 in single rooms (p = 0.003), symptom screening of healthcare workers (p = 0.031), limiting the number of visits per day (p = 0.004), and pre-scheduling visits (p = 0.037). In the multivariate analysis, higher resident mortality was only associated with age (p = 0.03) and the COVID-19 rate among residents (p = 0.013). Among 2936 residents, 2042 (69.9%) received ≥1 dose of the COVID-19 vaccine before 31 May 2021. Vaccine uptake among healthcare workers was 33.8%. CONCLUSION AND IMPLICATIONS: COVID-19 burden was high but also highly variable in Swiss long-term care facilities. severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among healthcare workers was a modifiable factor associated with increased resident mortality. Symptom screening of healthcare workers appeared to be an effective preventive strategy and should be included in routine infection prevention and control measures. Promoting COVID-19 vaccine uptake among healthcare workers should be a priority in Swiss long-term care facilities.

Sexuality after breast cancer, how to provide a global and contemporary approach.

Patients' sexuality is one of the major and most neglected impact of breast cancer (BC) and its treatment. Even though research is ongoing on the subject, sexuality issues are rarely taken into account and efficiently dealt with in clinical practice. The objective is to review the impact of BC and its treatment on modern women sexuality. In the literature, a heterogeneous level of advancement is notable in the different publishing countries depending on the cultural background; some countries simply do not publish on the matter, others mainly discuss the male partners and practicians experience, and lastly, the most progressive countries have moved up to studying niches of patients such as sexual and gender minorities. A multidisciplinary approach, including pharmacologic and nonpharmacologic management, appears most efficient. There is a need for greater inclusion of partners and for providing a specific training to first-line health care providers. This review provides a general contemporary worldwide overview of the state of the art in sexuality issues in BC patients and survivors.

[Impact of the COVID-19 pandemic on breast cancer management: Experience of a French Comprehensive Cancer Center]. / Impact de la pandémie de COVID-19 sur la prise en charge du cancer du sein : retour d'expérience d'un centre de lutte contre le cancer.

INTRODUCTION: The COVID-19 pandemic had a profound impact on health-care systems and reduced access to care. This study assays the mid-term effects of the COVID-19 pandemic on breast cancer management over a 2-year-period in a single French Comprehensive Cancer Center. METHODS: We performed, in a French comprehensive cancer center, an observational study including all patients with newly diagnosed breast cancer between 2019 and 2021. We collected the number of first consultations for breast cancer, the number of breast and axillary surgeries, pTNM and ypTNM cancer staging, the therapeutic sequence (surgery or neoadjuvant chemotherapy as a primary treatment), patients' age and their place of residence. RESULTS: In total, 14,772 patients had a first consultation for breast cancer. Among these 9058 breast and axillary surgeries were performed, 1798 patients had neoadjuvant chemotherapy as a primary treatment. During the first COVID-19 lockdown ( March17, 2020-May 10, 2020), we observed a reduction in the number of first consultations for breast cancer and breast cancer surgeries giving respectively a 42.3% and 27% rate of change. Subsequently, we observed a resumption of consultations and surgeries with a slight increase in early 2021 compared to 2019. In addition, we did not find any difference in terms of therapeutic sequence, pTNM and ypTNM stages, age at diagnosis or place of residence between the reference year 2019 and the years 2020 and 2021. CONCLUSION: Our study shows a decrease in activity during the first lockdown of 2020, then a resumption of activity. These reassuring results only concern patients with breast cancer, and are specific to our institution, whose oncology activity was preserved during the COVID-19 pandemic.

Variation over time of the factors influencing return to work and work capacities after a diagnosis of breast cancer: a study on the behalf of the Seintinelles research network.

PURPOSE: To evaluate the dynamics of the determinants of returning to work (RTW) in a population of patients treated for breast cancer (BC) in a real-world setting. METHOD: We conducted a retrospective study including 1278 BC patients working or looking for work at the time of diagnosis. We performed a focused principal component analysis to highlight the dimensions of a persistent decline in work capacity. Logistic regression analyses were performed to identify correlates of non-RTW 1 and 2 years after treatment. RESULTS: One-third (31%, n = 389) of patients continued working during treatment. At study inclusion, 1100 patients had returned to work (89%). Three-quarters (n = 508, 75%) of the women reported a decline in work capacity 1 year after RTW and 22% (n = 148) presented a persistent decline in work capacity 2 years after the diagnosis. The odds ratio for non-RTW at 1 year was significantly higher for patients treated with a combination of chemotherapy and trastuzumab (OR = 1.72, 95% CI [1.07-2.76]), manual workers (OR = 3.99, 95% CI [1.54-10.81]), patients with lower incomes (OR = 2.33, 95% CI [1.29-4.19]), and patients experiencing fatigue (OR = 1.81, 95% CI [1.34-2.48]). The odds ratio for non-RTW at 2 years was higher for various occupational categories (OR = 3.49, 95% CI [1.89-6.74] for clerks, OR = 4.58, 95% CI [1.48-12.82] for self-employed workers, OR = 8.98, 95% CI [2.69-27.89] for manual workers), patients with comorbidities (OR = 2.80, 95% CI [1.61-4.93]), and patients experiencing anxiety symptoms (OR = 2.54, 95% CI [1.18-5.76]), while the impact of the type of treatment was no longer significantly associated with RTW. CONCLUSION: The determinants of RTW change over time. Patients should be offered supportive interventions tailored to risk factors and time from diagnosis.

Impact of catch-up human papillomavirus vaccination on cervical conization rate in a real-life population in France.

OBJECTIVE: To evaluate the impact of catch-up human papillomavirus (HPV) vaccination on conization rates in France in a large population-based study. METHODS: We conducted a retrospective real-life cohort study on data collected prospectively by French National Health Insurance. Echantillon généralistes des bénéficiaires (EGB) is a database composed of demographic and health care utilization data for a 1/97th sample of the French population. We extracted data about all women born between 1983 and 1991, corresponding to the catch-up population (vaccination after 14 years old) at the time of implementation of HPV vaccination. The primary outcome was the occurrence of conization (all types of procedures) compared between vaccinated and non-vaccinated women. RESULTS: The cohort consisted of 42,452 women. Vaccination coverage (at least one dose) was low (9.8%, n = 4,129), but increased with time from vaccine implementation, from 0% in the 1983 cohort to 31% in the 1991 cohort. The conization rate was 1% for the overall population. The risk of conization for women between the ages of 19 and 30 years was reduced in the vaccinated group with a Hazard Ratio (HR) of 0.59 (95% CI[0.39-0.90]; p = 0.043). CONCLUSIONS: With a 10-year follow-up, catch-up HPV vaccination is associated with risk reduction of conization between the ages of 19 and 30.

Molecular Epidemiology and Risk Factors for Extended-Spectrum ß-Lactamase-Producing Enterobacterales in Long-Term Care Residents.

OBJECTIVES: We aimed to assess the burden of extended-spectrum ß-lactamase (ESBL)-producing Enterobacterales in Swiss long-term care facilities (LTCFs) to describe the molecular epidemiology, describe the intrainstitutional and regional clusters of resistant pathogens, and identify independent institution- and resident-level factors associated with colonization. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: From August to October 2019, we performed a point prevalence study among residents from 16 LTCFs in Western and Eastern Switzerland (8 per region). METHODS: Residents underwent screening for ESBL-producing Enterobacterales (ESBL-E); whole-genome sequencing (WGS) was performed. We gathered institution-level (eg, number of beds, staff-resident ratio, alcoholic hand rub consumption) and resident-level [eg, anthropometric data, time in facility, dependency, health care exposure, antibiotic treatment, proton-pump inhibitor (PPI) use] characteristics. Factors associated with colonization were identified using a generalized linear model. RESULTS: Among 1185 eligible residents, 606 (51%) consented to the study. ESBL-E prevalence was 11.6% (70/606), ranging from 1.9% to 33.3% between institutions, with a median of 12.5% in the West and 6.9% in the East (P = .03). Among 59 Escherichia coli (from 58 residents), multilocus sequence type (ST) 131 was most common (n = 43/59, 73%), predominantly its subclone H30R1 (n = 37/43, 86%). WGS data identified multiple intrainstitutional and regional clusters. Independent risk factors for ESBL carriage were previous ESBL colonization [adjusted odds ratio (aOR) 23.5, 95% confidence interval (CI) 6.6-83.8, P < .001), male gender (aOR 2.6, 95% CI 1.5-4.6, P = .002), and use of PPIs (aOR 2.2, 95% CI 1.2-3.8, P = .01). CONCLUSIONS AND IMPLICATIONS: Overall ESBL-E prevalence in Swiss LTCF residents is low. Yet, we identified several clusters of residents with identical pathogens within the same institution. This implies that particularly affected institutions might benefit from targeted infection control interventions. PPI use was the only modifiable factor associated with carriage of ESBL producers. This study adds to the growing list of adverse outcomes associated with PPIs, calling for action to restrict their use in the long-term care setting.

[Episode-based bundled payment model: evaluation of medical costs for early operable breast cancer]. / Financement à l'épisode de soins : évaluation du coût d'une chirurgie première pour cancer du sein précoce.

INTRODUCTION: Episode-based bundled payment model is actually opposing to fee-for-service model, intending to incentivize coordinated care. The aims of these study were to determine episode-based costs for surgery in early breast cancer patients and to propose a payment model. METHODS: OPTISOINS01 was a multicenter prospective study including early breast cancer patients from diagnosis to one-year follow up. Direct medical costs, quality and patient reported outcomes were collected. RESULTS: Data from 604 patients were analyzed. Episode-based costs for surgery were higher in case of: planned radical surgery (OR=9,47 ; IC95 % [3,49-28,01]; P<0,001), hospitalization during more than one night (OR=6,73; IC95% [2,59-17,46]; P<0,001), home hospitalization (OR=11,07 ; IC95 % [3,01-173][3,01-54][3,01-543][3,01-54,33]; P<0,001) and re-hospitalization (OR=25,71 ; IC95 % [9,24-89,17; P<0,001). The average cost was 5 268 € [2 947-18 461] when a lumpectomy was planned and 7408 € [4 222-22 565] in case of radical mastectomy. Bootstrap method was applied for internal validation of the cost model showing the reliability of the model with an area under the curve of 0,83 (95 % CI [0,80-0,86]). Care quality and patient reported outcomes were not related to the costs. DISCUSSION: This is the first report of episode-based costs for breast cancer surgery. An external validation will be necessary to validate our payment model.

[Therapeutic de-escalation in breast cancer surgery]. / Désescalade thérapeutique dans le cancer du sein en chirurgie oncologique.

The surgical management of breast cancer has been marked by a therapeutic de-escalation from radical surgery to breast conservation and from axillary curage to sentinel lymph node sampling. With regard to breast surgery, the de-escalation of treatment has been largely due to organized screening, which has made it possible to diagnose tumors of smaller volume or at an earlier stage. The indications for conservative surgery have been broadened by the addition of radiotherapy on one hand, and the introduction of adjuvant and neo-adjuvant treatments on the other hand. In an effort to de-escalate surgery, totally non-invasive techniques such as radiofrequency, HIFU (High Intensity Focused Ultrasound) or cryotherapy have been tested. Currently, three trials are underway to evaluate active surveillance, without surgery, in the management of certain low-risk ductal carcinomas in situ (DCIS). Regarding axillary procedures, the sentinel node technique has allowed axillary staging in patients with early breast cancer without clinical or radiological lymph node involvement. Currently, international recommendations (ASCO, NCCN) and the consensus of experts in St Gallen do not recommend additional curage in cases of macro or micrometastatic invasion of the sentinel lymph nodes if the criteria of ACOSOG Z0011 are met. The question now arises as to the relevance of a biopsy of suspected axillary nodes during the initial workup and the usefulness of the sentinel node technique in the case of a negative initial workup.

Has tumor doubling time in breast cancer changed over the past 80 years? A systematic review.

Over the past century, epidemiologic changes and implementation of screening may have had an impact on tumor doubling time in breast cancer. Our study was designed to evaluate changes in tumor doubling time in breast cancer over the past 80 years. A systematic review of published literature and meta-regression analysis was performed. An online electronic database search was undertaken using the PubMed platform from inception until June 2020. All studies that measured tumor doubling time in breast cancer were included. A total of 151 publications were retrieved. Among them, 16 full-text articles were included in the qualitative analysis. An exponential growth model was used for quantitative characterization of tumor growth rate. Tumor doubling time has remained stable over the past 80 years. Recent studies have not only identified "fast growing tumor" (grade 3, human epidermal growth factor receptor 2-positive, triple-negative, or tumor with an elevated Ki-67) but also "inactive breast cancer" feeding the ongoing debate of overdiagnosis due to screening programs. The stability of tumor doubling time over the past 80 years, despite increasing and changing risk factors, supports the validity for our screening guidelines. Prospective studies based on more precise measurement of tumor size and adjustment for tumor characteristics are necessary to more clearly characterize the prognostic and predictive impact of tumor doubling time in breast cancer.

Absenteeism and indirect costs during the year following the diagnosis of an operable breast cancer: A prospective multicentric cohort study.

BACKGROUND: Diseases consequence on individual work as much as consequences of being absent from work are matters of interest for decision makers. METHODS: We analyzed lengths of absenteeism and related indirect costs for patients with a paid activity in the year following the diagnosis of early stage breast cancer, in the prospective OPTISOINS01 cohort. Both human capital and friction costs approach were considered for the valuation of lost working days (LWD). For the analysis, the friction period was estimated from recent French data. The statistical analysis included simple and multiple linear regression to search for the determinants of absenteeism and indirect costs. RESULTS: 93 % of the patients had at least one period of sick leave, with on average 2 period and 186 days of sick leave. 24 % of the patients had a part-time resumption after their sick leave periods, during 114 days on average (i.e. 41 LWD). Estimated indirect costs were 22,722.00 € and 7,724.00 € per patient, respectively for the human capital and the friction cost approach. In the multiple linear regression model, factors associated with absenteeism were: the invasive nature of the tumor (p = .043), a mastectomy (p = .038), a surgery revision (p = .002), a chemotherapy (p = .027), being a manager (p = .025) or a craftsman (p = .005). CONCLUSION: Breast cancer lead to important lengths of absenteeism in the year following the diagnosis, but almost all patients were able to return to work. Using the friction cost or the human capital approach in the analysis led to an important gap in the results, highlighting the importance of considering both for such studies.

[Hot flushes and breast cancer with positive hormone receptors: Mechanisms and management]. / Bouffées de chaleur et cancer du sein avec récepteurs hormonaux positifs : mécanismes et prise en charge.

Breast cancer is the most frequently diagnosed cancer in women and the first cause of cancer death in France. Among the different subtypes of breast cancer, the predominant form is characterized by positive hormone receptors (more than 70% of breast cancers). Hormone therapy thus plays a key role in the strategy of management of these cancers both in adjuvant and metastatic situations. The two types of adjuvant hormone therapy used are selective estrogen receptor modulators and aromatase inhibitors. Fulvestrant, an anti-estrogen, is used alone or in combination with other molecules in metastatic situations. Hot flashes are one of the symptoms most frequently reported by patients under hormone therapy. Hormone replacement therapy, which is currently the most effective treatment for hot flashes, is contraindicated in patients with a personal history of breast cancer. Various therapeutic classes of drugs have been tested in this indication but without real efficacy in the various studies carried out to date, and moreover associated with non-negligible side effects. The recent discovery of the implication of the kisspeptin system located at the hypothalamic level in the mechanism of genesis of hot flashes opens the way to possible new symptomatic treatments for hot flashes. Neurokinin 3 receptor antagonists have shown encouraging preliminary results in postmenopausal cancer-free patients and could be considered in patients in hormonal therapy for breast cancer. Broader additional studies are needed to confirm these initial results.

A subset of activated fibroblasts is associated with distant relapse in early luminal breast cancer.

BACKGROUND: Early luminal breast cancer (BC) represents 70% of newly diagnosed BC cases. Among them, small (under 2 cm) BC without lymph node metastasis (classified as T1N0) have been rarely studied, as their prognosis is generally favorable. Nevertheless, up to 5% of luminal T1N0 BC patients relapse with distant metastases that ultimately prove fatal. The aim of our work was to identify the mechanisms involved in metastatic recurrence in these patients. METHODS: Our study addresses the role that autonomous and non-autonomous tumor cell features play with regard to distant recurrence in early luminal BC patients. We created a cohort of T1N0 luminal BC patients (tumors between 0.5-2 cm without lymph node metastasis) with metastatic recurrence ("cases") and corresponding "controls" (without relapse) matched 1:1 on main prognostic factors: age, grade, and proliferation. We deciphered different characteristics of cancer cells and their tumor micro-environment (TME) by deep analyses using immunohistochemistry. We performed in vitro functional assays and highlighted a new mechanism of cooperation between cancer cells and one particular subset of cancer-associated fibroblasts (CAF). RESULTS: We found that specific TME features are indicative of relapse in early luminal BC. Indeed, quantitative histological analyses reveal that "cases" are characterized by significant accumulation of a particular CAF subset (CAF-S1) and decrease in CD4+ T lymphocytes, without any other association with immune cells. In multivariate analysis, TME features, in particular CAF-S1 enrichment, remain significantly associated with recurrence, thereby demonstrating their clinical relevance. Finally, by performing functional analyses, we demonstrated that CAF-S1 pro-metastatic activity is mediated by the CDH11/osteoblast cadherin, consistent with bones being a major site of metastases in luminal BC patients. CONCLUSIONS: This study shows that distant recurrence in T1N0 BC is strongly associated with the presence of CAF-S1 fibroblasts. Moreover, we identify CDH11 as a key player in CAF-S1-mediated pro-metastatic activity. This is independent of tumor cells and represents a new prognostic factor. These results could assist clinicians in identifying luminal BC patients with high risk of relapse. Targeted therapies against CAF-S1 using anti-FAP antibody or CDH11-targeting compounds might help in preventing relapse for such patients with activated stroma.

COVID-19 in breast cancer patients: a cohort at the Institut Curie hospitals in the Paris area.

BACKGROUND: Cancer patients have been reported to be at higher risk of COVID-19 complications and deaths. We report the characteristics and outcome of patients diagnosed with COVID-19 during breast cancer treatment at Institut Curie hospitals (ICH, Paris area, France). METHODS: An IRB-approved prospective registry was set up at ICH on March 13, 2020, for all breast cancer patients with COVID-19 symptoms or radiologic signs. Registered data included patient history, tumor characteristics and treatments, COVID-19 symptoms, radiological features, and outcome. Data extraction was done on April 25, 2020. COVID-19 patients were defined as those with either a positive RNA test or typical, newly appeared lung CT scan abnormalities. RESULTS: Among 15,600 patients actively treated for early or metastatic breast cancer during the last 4 months at ICH, 76 patients with suspected COVID-19 infection were included in the registry and followed. Fifty-nine of these patients were diagnosed with COVID-19 based on viral RNA testing (N = 41) or typical radiologic signs: 37/59 (63%) COVID-19 patients were treated for metastatic breast cancer, and 13/59 (22%) of them were taking corticosteroids daily. Common clinical features mostly consisted of fever and/or cough, while ground-glass opacities were the most common radiologic sign at diagnosis. We found no association between prior radiation therapy fields or extent of radiation therapy sequelae and extent of COVID-19 lung lesions. Twenty-eight of these 59 patients (47%) were hospitalized, and 6 (10%) were transferred to an intensive care unit. At the time of analysis, 45/59 (76%) patients were recovering or had been cured, 10/59 (17%) were still followed, and 4/59 (7%) had died from COVID-19. All 4 patients who died had significant non-cancer comorbidities. In univariate analysis, hypertension and age (> 70) were the two factors associated with a higher risk of intensive care unit admission and/or death. CONCLUSIONS: This prospective registry analysis suggests that the COVID-19 mortality rate in breast cancer patients depends more on comorbidities than prior radiation therapy or current anti-cancer treatment. Special attention must be paid to comorbidities when estimating the risk of severe COVID-19 in breast cancer patients.