Last March, when the COVID-19 outbreak was declared a pandemic, many medical facilities shuttered themselves to everyone but those suffering from the virus or in need of necessary medical care.
The thinking: Spare medical facilities for the unfolding emergency and avoid exposing people seeking nonemergency medical care to the virus. Preventive care could wait.
But as the pandemic raged on, concern grew among cancer experts around one issue in particular: screening.
Cancer screening provides one of the best ways to find cancer early, at a time when it's most treatable. With few exceptions, multiple cancer screening tests are recommended for early cancer detection across any adult’s lifetime.
What will happen now, as the statistics accumulate and it’s clear that millions of people skipped recommended cancer screenings during the pandemic?
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COVID-19 and Cancer Screening: A Staggering Decline
The American Cancer Society (ACS) and National Comprehensive Cancer Network report that an estimated 22 million cancer screenings were missed or canceled between March and June of last year, resulting in declines in screening rates for breast, colon, and cervical cancers by as much as 94 percent overall (compared with historical averages) according to Epic Health Research Network.
What’s more, recent data show a roughly 46 percent combined decrease in weekly new diagnoses across six different cancers, according to a study published in August 2020 in JAMA Network Open. That decline is unlikely due to an organic decrease in occurrence of those cancers, say experts, but rather to cancers that would normally have been diagnosed going undetected due to missed screenings.
While these cancers may eventually be caught, they are likely to be caught at a later stage, which is always bad for prognosis.
“A delay in screening can cause a delay in diagnosis and in turn cause poor outcomes,” says Carolyn Muller, MD, the chief of gynecologic oncology at the University of New Mexico in Albuquerque, “making it likelier that the cancer will be more advanced by the time it is diagnosed.”
This notion has certainly been borne out in the case of delayed breast cancer screening. Data presented at the 2020 San Antonio Breast Cancer Symposium showed an uptick in advanced breast cancer cases, and that's also proved true with lung cancer, according to a study published in April 2021 in the Journal of the American College of Surgeons, with screening delays leading to a significant increase in patients presenting with suspicious nodules.
While the true impact of the pandemic on cancer outcomes may not be known for years to come, Norman E. Sharpless, MD, the director of the National Cancer Institute, warned as early as June of last year that the steep drop in early cancer diagnoses and treatment would ultimately result in almost 10,000 excess deaths from breast and colon cancer over the next decade.
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Signs of a Rebound, a Backlog, and New Solutions
Aside from the first half of 2019, there is an indication of continuing recovery, driven in part by increased vaccination rates. “Screening rates started to rebound late last summer,” says Jennifer Haas, MD, an internist at Massachusetts General Hospital in Boston.
Jovanna McKinney, the operations manager at Seattle Cancer Care Alliance’s imaging and procedure access and prevention and screening program says that at her center, breast cancer screening volumes rebounded to levels 4 percent higher than previous levels between June and October, and that lung cancer screenings (which had experienced a 62 percent decline) have resumed normally.
Yet, the rebound in screening has not occurred without challenges. The system is now coping with tens of thousands of people trying to reschedule their appointments.
Dr. Haas explains that restarting certain screening modalities (such as breast imaging) has been easier than others (colonoscopy), mostly because of the numbers of missed and delayed exams. “About a month or so ago, we had a backlog of at least 10,000 patients who still needed to reschedule their colon cancer screening,” she says.
Fortunately, most health systems have restructured appointment times, reconfigured waiting rooms, and created strategies to ensure that in-person screening can safely resume without unnecessary risk of COVID-19 transmission or acquisition. Many are also devising novel outreach methods that target high-risk, underserved, vulnerable communities to remind them of the need for cancer screening.
And there have been unforeseen positives. Haas points to a silver lining, noting that at Mass General (which historically has been colonoscopy-focused), the backlog forced them to take a broader look at screening strategies to better accommodate patients, a move that ultimately resulted in a shift to offering noninvasive, stool-based testing for colon cancer.
Home screening tests are also on the horizon for cervical cancer, although none have yet received FDA approval.
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Cancer Screening: Are You Overdue?
How should patients handle a return to routine cancer screening?
If patients have access to their electronic health portal, they can check there to learn if they are overdue for specific screenings. Haas also emphasizes that it is important that patients contact their provider to help create a plan based on medical history, prior testing and results, and overall risk.
“This is even more important for someone with baseline risks or a history of abnormal Pap findings, for example,” says Dr. Muller.
Muller also points out that earlier in the pandemic, many facilities transitioned to telemedicine for virtual visits, noting that while patients cannot effectively have most screening done virtually, telemedicine is another avenue for getting back in touch with one’s primary provider.
Finally, although guidelines vary depending on the organization issuing them, the ACS underscores the need to consider resuming the following:
- Breast cancer Yearly mammography recommended for women ages 45–54
- Colon cancer For average risk, initiate screening at age 45 and continue through age 75
- Colonoscopy Every 5–10 years
- Most stool-based tests Every 3 years
- Cervical cancer Start age, 25; through age 65, every 3–5 years for Pap test depending on use of HPV testing
- Lung cancer Risk driven, starting at age 45
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