Disproportionate Effects of Delayed Treatment
Given the past controversies over balancing the risks and benefits of some cancer screenings — particularly the prostate-specific antigen (PSA) test for prostate cancer and recommended ages for routine mammography — it’s worth asking if the lower screening numbers might also indicate a drop in harms from screenings, such as fewer false-positives that lead to biopsies and other invasive procedures. But it depends on the screening, and the drops occurring right now likely obscure increasing health disparities when it comes to who is and isn’t getting caught up, according to Tomasz Beer, MD, deputy director of the Oregon Health and Science University’s Knight Cancer Institute, Portland.
With PSA screening, for example, “clearly there’s a balance between harms and benefits, and forgoing that test on a net basis may not have a large adverse impact,” he said, while acknowledging that overdiagnosis and overtreatment are legitimate concerns. But he also worries about the preexisting inequities that this pandemic has amplified.
“You might consider that the pandemic has affected people greatly unequally, and there’s growing evidence that, certainly with regard to economic status, there’s an enormous difference between what’s happening between high- and middle-income individuals who got their jobs back and low-income individuals who have not,” Dr Beer said. “There are also large differences in how underrepresented minority groups have been affected with cancer and mortality. These are the same groups that have traditionally had less access to cancer screenings.”
Dr Brawley agreed, and said that the 10,000 excess deaths in the NCI estimate are “more likely to be poor folks.”
“As we get longer and longer into the coronavirus mess, the people who are losing their health insurance are not going to get adequate treatment because of financial toxicities,” he pointed out; this was also a concern of Dr Beer’s.
“There’s also the issue of a backlog, even if everyone magically showed up on the first day elective procedures resumed,” Dr Beer said. “Colonoscopies take a while to catch up on. So some of these screenings never happen or won’t happen for a long time.”
Worse, the numbers continue to waver, Dr Kaufman says. At the end of August 2020, Quest began to see another gradual drop-off in cancer diagnoses, which corresponded to a similar decline he heard about from a cancer registry. He expressed worry that it suggests “a renewed sense of dread of going to the doctor and getting routine screenings. It’s a bit disconcerting that we’re now trending back into another gap.”
Getting the Message to Patients
Back in June 2020, ASCO recommended that cancer screening procedures requiring clinic visits, such as mammograms and colonoscopies, be postponed “for the time being.”6 The webpage with that recommendation has not been updated since June 22, 2020 — but COVID-19 is still here.
“There is not an end in sight for this pandemic,” Dr Bunnell said. “Given that, people should not put off recommended screening tests.”
To accommodate that need, clinics and hospitals have developed and implemented procedures and interventions to reduce the risk of Covid-19 to patients coming in for routine screenings and other preventive or non-urgent care. But not all patients appear to understand that it’s now safe to get the screenings they need.
“At the patient level, all of our advocacy [for screening] has halted,” Dr May said. “COVID has derailed all of the conversation to this virus. We need to get back out there and tell people about the importance of screening.”
That starts at the health system level, she said.
“At UCLA Health, we made a coordinated effort to campaign among our primary care and other providers and specialists that need to be sure they discuss this with all their patients whether those visits are in person or via telehealth,” Dr May said.
She also emphasized the importance of implementing interventions to do procedures safely at this time and protecting patients and providers, such as COVID-19 testing protocols and safe use of physical space.
“There need to be concerted efforts at the health level system to get things up and running again,” she added. To get their endoscopy back online, Dr May said, her team went through “exhausting” efforts in April and May of this year.
The message to physicians and other health care workers is clear, Dr Kaufman said. “Providers need to reach out to patients to get them back into the health care system in terms of routine visits and screening. Telemedicine is part of the answer, but it’s also —as it relates to cancer — mammography, colonoscopies, lab testing, physical exams, histories; all of that plays into early identification,” he said. “Part of that is to reassure patients that it is safe to travel and get to a doctor’s office or clinic or hospital, but that’s the answer. We got to get patients back in.”
- Lai A, Pasea L, Banerjee A, et al. Estimating excess mortality in people with cancer and multimorbidity in the COVID-19 emergency. April 2020. doi:10.13140/RG.2.2.34254.82242.
- Cavallo J. How delays in screening and early cancer diagnosis amid the COVID-19 pandemic may result in increased cancer mortality: A conversation with NCI director Norman E. ‘Ned’ Sharpless, MD. The ASCO Post. Published September 10, 2020. Accessed December 1, 2020.
- Kaufman HW, Chen Z, Niles J, Fesko Y. Changes in the number of US patients with newly identified cancer before and during the coronavirus disease 2019 (COVID-19) pandemic. JAMA Netw Open. 2020;3(8):e2017267. doi:10.1001/jamanetworkopen.2020.17267
- Komodo Health. New colorectal cancer diagnoses fall by one-third as colonoscopy screenings and biopsies grind to a halt during height of COVID-19. Research brief. Published May 2020. Accessed December 1, 2020.
- Hanna TP, King WD, Thibodeau S, et al. Mortality due to cancer treatment delay: systematic review and meta-analysis. BMJ. 2020;371:m4087. doi:10.1136/bmj.m4087
- American Society of Clinical Oncology (ASCO). Cancer screening, diagnosis, staging & surveillance. Updated June 22, 2020. Accessed December 1, 2020.