Data Reveal Sharp Drops in Preventive Care

Dr Kaufman’s cross-sectional study looked at all US patients who underwent testing by Quest Diagnostics and subsequently received a new ICD-10 diagnosis of breast, colorectal, lung, pancreatic, gastric, or esophageal cancer between January 1, 2018, to April 18, 2020.3 The researchers calculated average weekly diagnoses for each cancer from January 2019 to February 2020 to establish a baseline mean incidence.  Then they compared that baseline with weekly mean incidence in the first 7 weeks of the pandemic.

Among the 278,778 patients included in the study, 92.8% were during the baseline period, and the remaining 7.2% during COVID-19. The weekly number of diagnoses dropped 46.4% from baseline to the pandemic period for all 6 cancers combined.

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“The bottom line is still that people didn’t go to get routine visits and routine screens, so a lot of cancers were progressing and not diagnosed,” Dr Kaufman noted.

The biggest decrease was in breast cancer cases, which fell by 51.8% (P <.001). Even the cancer with the smallest percentage decline, pancreatic cancer, saw a 24.7% drop (P =.01). Similar findings were reported in the Netherlands, where weekly incidence fell by 40%, and in the United Kingdom, which saw a 75% fall in referrals for suspected cancer following COVID-19 restrictions.

Other private company data revealed similar patterns. The San Francisco-based health care analyst firm Komodo Health reviewed 320 million patients’ billing records and found the following:4

•   Colonoscopies and biopsies fell close to 90% in mid-April compared with numbers in 2019.

  • New colorectal cancer diagnoses were 32% lower in mid-April compared with 2019.
  • Colorectal surgeries were down by 53% compared with the previous year.

Initially, the Centers for Disease Control (CDC) and other public health agencies and medical organizations discouraged routine care until the nation had time to prepare for what the pandemic might bring. The decline in visits in March/April, therefore, wasn’t surprising or necessarily concerning, as long as people were only delaying preventive care a month or two.

“It made sense at first to say, ‘Don’t come here unless you have to,’” said Folasade P. May, MD, PhD, MPhil, director of the Melvin and Bren Simon Gastroenterology Quality Improvement Program at UCLA’s David Geffen School of Medicine, California. “Now that we have in play very safe procedures, we need the patients to come back,” Dr May said. She told Cancer Therapy Advisor that UCLA health saw a 90% drop in colonoscopies. “This is a life-saving screening procedure that identifies [cancer] early. That’s potentially devastating.”

The concern about missing screenings entirely, rather than simply having screenings delayed, points to a broader need to get patients into routine screening programs, said Dr Brawley.

“The recommendation for colonoscopies is every 10 years. So what if you miss it by 3 to 4 months? Everybody talks about ‘get a mammogram’; they should be saying ‘get into a mammogram program where you get the thing every 2 years.’ If you’re in it for every 2 years and miss it by 4 months once, that doesn’t really matter.”

The problem, again, is when patients aren’t in a routine program, and the delay becomes a miss. Indeed, if the current trends persist, the NCI estimates that the pandemic’s impact could threaten the trend of annually decreasing cancer mortality seen in the US since 1990. If screenings of breast and colon cancers average 75% lower over 6 months, for example, the delays in care could translate into a 1% increase in excess deaths from breast and colon cancer over the next decade, according to Dr Sharpless.1 That’s about 10,000 additional deaths over 10 years — or 1000 people a year — for just breast and colon cancers.

A June 2020 preprint estimated that 33,890 excess cancer deaths would occur in the United States as a result of Covid-19.5 A recent systematic review and meta-analysis published November 2020 in The BMJ looked at mortality resulting from delays in cancer treatment.5

“Even a 4-week delay of cancer treatment is associated with increased mortality across surgical, systemic treatment, and radiotherapy indications for 7 cancers,” reported Timothy P. Hanna, MD, PhD, of Queen’s University in Kingston, Ontario, Canada, and his colleagues.

“What we’re going to see down the line if we continue with this trajectory is increased cases of cancer and late-state presentation, which predicts survival and is directly related to the number of treatment options you have,” Dr May said. “If I diagnose a patient with colon cancer at stage I, there is a 90% survival for that patient, but if I don’t diagnose that patient until stage IV, that survival drops to 11%. This is why stage at time of diagnosis really matters and why we’re impressing on patients that you can’t just delay your cancer screening — because those cancers continue to grow and spread. You need to come in when you’re due.”

Patient advocates are paying attention, too. Julia Maués, a patient advocate with metastatic breast cancer whose Twitter bio lists her as being in Washington, DC, tweeted in late September 2020 that she hopes researchers “are using this terrible pandemic as natural experiments to see how some changes affect cancer outcomes and [quality of life],” including delayed scans, extended infusion intervals, and replacing infusion chemotherapy with oral chemotherapy.