March 23, 2021

Cancer screenings plummeted last year. Now the 'missed' cancers are showing up—and they’re serious.

Daily Briefing

    Editor's note: This story was updated on May 10, 2021.

    As the Covid-19 pandemic surged over the past year, cancer screening rates plummeted. But now that screening rates are inching up again, cancer specialists say they are seeing patients come in with far more severe disease, Reed Abelson writes for the New York Times.

    Cancer screening rates plummet

    According to the Times, several studies indicate that the number of patients screened for or diagnosed with cancer declined during the pandemic's early months.

    For instance, one analysis from the Epic Health Research Network found that by June 2020, the screening rates for breast, colon, and cervical cancer were still between 29% and 36% lower than they were before the pandemic hit. Overall, according to the analysis, "[h]undreds of thousands fewer screenings were performed last year than in 2019," the Times reports.

    Similarly, a study conducted by Avalere Health for the Community Oncology Alliance looked at Medicare data and found that cancer testing rates dipped when Covid-19 cases spiked in 2020. For example, according to the study, cancer testing levels in November of last year were roughly 25% lower than they were in 2019, while the number of biopsies declined by about 33%.

    An increase in advanced cancer diagnoses, providers say

    Cancer specialists say it's too early to determine the full effect of these postponed and skipped screenings, but they confirm that at least anecdotally, patients appear to be coming in with more severe cancers, the Times reports.

    "There's no question in practice that we are seeing patients with more advanced breast cancer and colorectal cancer," said Lucio N. Gordan, president of the Florida Cancer Specialists & Research Institute.

    According to the Times, one such patient, Yvette Lowery, had her annual mammogram in March 2020 canceled amid the pandemic. And even after she discovered a lump under her arm in August, she wasn't able to get an appointment until October—at which point she was diagnosed with Stage 2 breast cancer. She began chemotherapy in November of last year and recently underwent a double mastectomy.

    "I've been seeing a lot of patients at an advanced stage," Kashyap Patel, one of Lowery's providers and CEO at Carolina Blood and Cancer Care Associates. According to Patel, if Lowery's cancer had been spotted in May or June of last year, they could have likely caught it before it spread.

    And even among patients who might have otherwise been able to keep their screening appointments, other challenges got in the way, the Times reports. Some, for instance, skipped their routine screenings or ignored symptoms because they were worried about contracting Covid-19 at their providers' facilities or because—if they lost their jobs amid the pandemic—they simply couldn't afford the tests. 

    For instance, Sandy Prieto, a librarian in California, didn't go to the doctor in March of last year, when she started getting stomach pains, because she worried she would contract Covid-19. Finally, in May, she went to the ED with severe symptoms, only to learn she had Stage 4 pancreatic cancer. She passed away in September.

    "If it wasn't for Covid and we could have gotten her some place earlier, she would still be with us today," Prieto's sister, Carolann Meme, said.

    Barbara McAneny, CEO of New Mexico Oncology Hematology Consultants, said that many of her patients are not coming in—even if they have insurance—because they cannot afford the co-payments or deductibles. "We're seeing that, particularly with our…folks who are living on the edge…living paycheck to paycheck," she said.

    According to the Times, some of the patients who had to skip or delay testing included people at high risk for cancer because of genetics or because of a previous cancer diagnosis.

    For example, Ritu Salani, director of gynecologic oncology at the UCLA Health Jonsson Comprehensive Cancer Center, said one of her patients who had a high risk of colon cancer skipped her usual screening amid the pandemic, only to learn when she did go to her provider later that she had advanced stage cancer. "It's just a devastating story," Salani said. "Screening tests are really designed when patients aren't feeling bad."

    But some health systems were able to counteract at least some of the effects of the pandemic on screening rates, the Times reports. For instance, during the initial stay-at-home orders issued last year, providers at Kaiser Permanente noticed a decline in testing. They "immediately got together" to reach out to patients, according to Tatjana Kolevska, medical director for the Kaiser Permanente National Cancer Excellence Program.

    Kaiser Permanente also uses its EHRs to schedule overdue mammography appointments for patients when they schedule other visits, such as scheduling a primary care visit or eye exam. And while Kolevska said she's still waiting on data for the system as a whole, she said she's been encouraged to see her patients get up to date with their mammograms. "All of those things put in place have helped tremendously," she said (Abelson, New York Times, 3/17).

     

    Advisory Board's take

    3 steps to take in advance of a wave of 'missed' cancers

    By Emily Heuser and Deirdre Saulet

    These emerging stories are devastating, but not surprising. The oncology world has been bracing for a silent wave of advanced cancer diagnoses since the impact of the pandemic on screening and diagnostic testing became evident.

    Last summer, the NCI forecasted 10,000 excess deaths just from breast and colorectal cancers over the next ten years due to upstaging. While no one fully knows the long-term impact of delayed screenings yet, there are still steps you can take to mitigate the impacts on your patients and cancer programs.

    First, overcorrect your screening rates. It's not enough to get rates back up to pre-pandemic levels—programs need to be reaching both patients who are overdue for screenings and those who should be screened right now. These kinds of unprecedented volumes set programs up for screening bottlenecks, so review our strategies for managing patient communication and optimizing efficiency to keep your programs running smoothly. And while you're at it, use this opportunity to reinvent your screening program to address racial disparities in cancer screenings and mobilize your lung screening to reach communities in need.

    Second, prepare for more complex, late-stage cancer patients and their diverse biopsychosocial needs. Key to meeting those needs is integrating palliative care into oncology practice, which requires resource investment and thoughtful strategies to overcome longstanding cultural barriers. As the Daily Briefing previously reported, Providence St. Joseph is one organization approaching this challenge in a thoughtful way.

    Third, make sure eligible patients are benefiting from advances in treatment. Stay on top of the latest innovations, and provide clinical decision support. These advances also underscore the importance of preparing for patient questions and managing their expectations.

    While there's no lemonade to be made from this crisis, let it be a learning opportunity, both on an individual program and industry-wide scale. The NCI has announced it will fund research to use this "natural experiment" to study overdiagnosis and overtreatment—complicated issues in oncology that are unethical to study prospectively.

    While reactions to that research question are mixed, the NCI's aim to learn from the pandemic and its impact on outcomes is valid. Take stock of what your organization and cancer program have experienced and overcome the past year, and use those learnings to elevate your program— from improving screening disparities and access to palliative care to codifying telehealth in your workflows and caring for your staff. 

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