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September 12, 2022

What we know (and still don't) about the pandemic's impact on cancer

Daily Briefing

    During the peak of the pandemic, an estimated 9.4 million cancer screenings were missed—which we know led to delayed cancer diagnoses.

    Radio Advisory's Rachel Woods sat down with oncology experts Ashley Riley and Lauren Woodrow to discuss both the human and system-wide impacts of delayed cancer screenings and what health leaders can do to rebound.

    Read a lightly edited excerpt from the interview below, and download the episode for the full conversation.

    Rachel Woods: I want to start this conversation by backing up to the beginning of the pandemic, so I'm trying to remember how it felt in spring, early summer of 2020. I'm remembering, basically, being afraid of everything, right? We were washing our groceries. We weren't getting together in-person for, basically, any reason. Everything went virtual, including weddings, birthday parties, and the like, and that meant a lot of folks weren't actually going to the doctor. But tell me, what did that actually mean in terms of cancer care?

    Lauren Woodrow: Health systems all but shut down their cancer screening services. They were worried about exposing patients to Covid. They were worried about exposing their own staff, and they had to see fewer patients because of new social distancing, cleaning protocols, things we hadn't had to do in the past. Many clinical leaders had to make real trade-offs about staffing. They had to redeploy resources to fight the Covid-19 surge, which contributed to millions of patients missing their cancer screenings.

    Woods: And that caused kind of its own set of fears, not just about what the Covid pandemic would mean for health care, but what these missed screenings would mean for the state of everyone's health.

    Woodrow: I mean, there was, and there still is, a lot of concern that missed screenings would lead to delayed diagnoses, which would lead to more patients being diagnosed with late-stage cancers, which would ultimately lead to more cancer deaths.

    Woods: I don't want to minimize the very human impact that you just shared, Lauren, but we are in the business of studying health care. This is a health care business podcast. What kinds of larger consequences could the industry see here?

    Ashley Riley: I'm not sure honestly how much most health care leaders were thinking beyond that human impact, really to those business implications, but I think two big ones stood out to me. One being changes to treatment patterns, and then the second being higher costs.

    So advanced cancers typically require more complex and more extensive treatment than early-stage cancers, which can lead to increased cancer costs, which probably isn't super surprising. So for example, one analysis that we looked at found that Medicare spends almost $80,000 more for a stage IV colorectal cancer patient, compared to a stage I colorectal cancer patient, right?

    This is bad news for payers, it's bad news for patients, and even providers who are participating in value-based payment models, right? So pretty much bad news across the board. This could also mean, though, that certain stakeholders are going to have to make more investments in things like more subspecialized physicians, for example, to manage those additionally complex patients and treatments. More and more support services and support staff, maybe, to manage the additional side effects that are associated with the more complex and extensive treatments, or even just infrastructure necessary to provide those more complex treatments.

    Woods: When I have conversations with health leaders, they bring up these exact implications. You're right that they weren't doing it in, necessarily, let's say May of 2020, but as time has gone on, they're thinking more and more about these larger business implications. And by the way, I'm not talking to oncology leaders like the two of you are. I'm talking about any C-suite leader in the payer landscape, provider, life sciences. They will bring this up.

    And they brought it up because at the time, at the start of the pandemic, we had this hypothesis about how the missed cancer screenings would affect the whole industry. Two and a half years later, was our hypothesis actually correct?

    Woodrow: Yes and no, so let me break that down. We predicted delayed diagnoses and we have seen data showing that there were fewer new cancer diagnoses during the peak of the pandemic than expected, so meaning there definitely was a delay in some patients getting diagnosed. I saw a study that between March and May of 2020, so peak toilet paper shortage, there was a 36% decline in monthly average of new breast cancer diagnoses in the US.

    Woods: I don't want to be crass here, but did those delays actually, ultimately impact mortality?

    Woodrow: Yeah. I want to be careful with my words here because, obviously, cancer is incredibly scary and painful diagnosis, but in most cases, cancer is a long battle, meaning that there is sometimes a long time between diagnosis and death.

    I say that because even though it's been more than two years, we're still making predictions. The National Cancer Institute predicts that all those missed screenings will lead to 2,500 additional breast cancer deaths and 5,000 additional colorectal cancer deaths in the US. But that's still a hypothesis, and those predictions are over the next decade.

    Woods: So you can't actually give me a definitive answer.

    Woodrow: I can. It's still too early to say whether missed screenings and delayed diagnoses have actually resulted in an increase in the number of cancer deaths.

    Woods: What about late-stage cancer diagnosis? That's another big concern that I've heard.

    Riley: I think that's, honestly, the one I've heard most about. I've been talking to cancer program leaders. We can't say for sure with the impact on late-stage cancer diagnoses has been either, but we do have a little bit more to go off here.

    So anecdotally, we've heard from several providers that they've started to see more advanced stage cancer diagnoses among their individual patient cohorts. More recently, we've also seen a few quantitative data points to support this. So for example, data from a sample of 400 oncologists across the US showed that there was a 1% to 2% increase in patients diagnosed with metastatic or advanced breast, lungs, cervical, and colorectal cancers in 2020 compared to pre-pandemic.

    But on the flip side, in that same study, they found that patients diagnosed with metastatic prostate cancer declined by 1% during 2020, so not totally consistent across the board. Another study from 21st Century Oncology—and they have 300 locations across the U.S., so pretty a big practice network—they showed a 50% increase in breast cancer patients that were diagnosed with advanced cancer during the peak of the pandemic, compared to pre-pandemic.

    Woods: Wait a minute, 50% increase and 1% to 2% increase are not even remotely close to each other.

    Riley: Yeah, it is all over the board, right? And the third one I saw was someplace in the middle around 16 to 20, or something like that. So the estimates are really all over the place, which honestly gives me some concerns about the reliability of the data and how much stock we should actually put in it right now.

    So not only is it all over the place, these data points aren't nationally representative, and it's data from a relatively short time period, right? So they're not long term studies, which tend to be the gold standards within cancer.

    So like Lauren, I can't give a definitive answer, but I know I'm not ready to say, for sure, that missed screenings have caused an uptick in late stage cancer diagnoses overall. I think we really need to see more data, and I'm looking at you, health care leaders, to collect and publish that data.

    Woods: I am not surprised that as researchers, you have come to this conversation with a lot of data to back up our hypotheses, and the fact that we're still not ready to put a line in the sand about what this means. But I have to believe that our listeners are probably thinking about individual stories that they've heard, whether it's from their organization, or from their friends, or from their family that say that these missed screenings have had a real impact on people.

    Riley: Yeah. We've definitely heard a lot of those stories as well, and they are heartbreaking for sure. And it's one of the reasons that oncology leaders have spent their careers pushing for more cancer screenings and more efforts to reduce disparities in screening as well, even before the pandemic.

    We know that screening can save lives, so it is really critical, still. Even though if we don't know the true impact of the missed screenings, it's still important to get patients back in to receive their recommended screenings, right? That should be a top priority for all oncology stakeholders.

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