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November 5, 2020

COVID-19 May Rollback Decades of Progress Against Cancer

COVID-19 May Rollback Decades of Progress Against Cancer

Updated on October 19, 2020 at 4:00pm EDT.

As the COVID-19 pandemic persists, doctors and public health experts are growing concerned about another crisis that may be brewing.

In the early months of the pandemic—particularly during lockdown—essential cancer screenings were delayed along with doctor visits for mild or early warning signs of cancer. In many cities, these issues took a back seat to slowing the spread of COVID-19 and freeing up healthcare resources for people with severe cases of the disease.

Clinics have since re-opened with stringent precautions, but the drop in screenings may have long-lasting repercussions on cancer care in the United States.

Perfect storm for cancer care
“Three effects of COVID-19 combine to make a perfect storm for delayed diagnosis of cancer which will persist well beyond when the pandemic ends,” says William Cance, MD, chief medical and scientific officer of the American Cancer Society (ACS).

First, the shutdown of clinics during the early months of the pandemic created a patient backlog. Even now, screening centers are seeing fewer patients and functioning more slowly because of the requirements for containing the pandemic, Dr. Cance explains.  

Second, the financial fallout of the pandemic has triggered mass unemployment. Up to 12 million people may have lost employer-sponsored health insurance, according to estimates by the Economy Policy Institute. As a result, health concerns—including cancer prevention or even treatment—may seem like less of a priority than paying the mortgage or putting food on the table.

Third, fear of catching COVID-19 may still keep people away from doctor’s offices. Outpatient doctor visits dropped nationwide by almost 60 percent in early April 2020, and were still 10 percent below normal in late July, according to analyses by the healthcare technology company Phreesia, Harvard University and the Commonwealth Fund. And while visits to adult primary care doctors may be rebounding, pediatric visits are still far below pre-pandemic levels.  

Cancer screenings have declined
While the news may be sobering, knowledge is power. Knowing the statistics may be a first step in tackling the problem.

One May 2020 study published by the Epic Health Research Network showed that during January through April 2020, weekly screenings for colon cancer dropped by 86 percent compared to average rates for those time periods in 2017 to 2019. The study, which included 2.7 million people across 23 states,  also revealed that weekly screenings for breast and cervical cancer dropped by 94 percent.

That’s important, because breast and colon cancer cause about one-sixth of all U.S. cancer deaths.

A July 17 update to this study showed that the number of screenings started to rebound, but not completely. The update included even more people—9.8 million patients across 28 states—and showed that weekly cancer screenings were still 29 percent lower for breast cancer, 35 percent lower for cervical cancer and 36 percent lower for colon cancer, compared to pre-pandemic averages. This may translate into 285,000 missed breast cancer screenings, 95,000 missed colon cancer screenings and 40,000 missed cervical cancer screenings between March and June 2020.

Certain groups at higher risk
The impact of the drop in cancer screenings could be strongest among racial and ethnic minorities, who have been hardest hit both by COVID-19 and by job losses.

Black and Hispanic people are historically underserved by healthcare and may be at increased risk for certain cancers. For example, Black people have a higher overall rate of death from cancers compared to whites. This is largely due to higher rates of death from breast, colorectal, prostate and lung cancer.

“There’s a disproportionate impact particularly on Black and Hispanic people who have lost health insurance,” Cance says. “If you look at the federally qualified health centers, fewer people are being screened but more people are using the family qualified health centers because they’ve lost their insurance.”

New cancer diagnoses down
Research suggests that rates of new cancer diagnoses have also dropped steeply since the COVID-19 pandemic began. This could result in more cases being diagnosed at more advanced stages, when they’re harder to treat.

One August 2020 study published in JAMA Network Open showed that weekly numbers of new cancer diagnoses fell by 46.4 percent for seven weeks between March and April 2020, compared to pre-COVID levels. The research included 278,778 patients from across the U.S. and looked at six types of cancer: breast, colorectal, lung, pancreatic, gastric and esophageal.

The steepest drop was for breast cancer at 51.8 percent.

Another July 2020 study published in the Journal of Clinical Oncology conducted by the COVID and Cancer Research Network found that new diagnoses of malignant tumors dropped by 65.2 percent in April 2020, compared to April 2019. The study was the largest of its kind so far with more than 28 million patients from 20 different institutions across the U.S.

Why this trend is worrisome
The decline in cancer screenings and early detection could have far-reaching implications.  

In a June editorial published in Science, Norman Sharpless, MD, director of the National Cancer Institute, warned that delayed cancer diagnoses could extend into 2030. Over the next ten years, that could lead to as many as 10,000 additional deaths from breast and colorectal cancer alone.

But that may underestimate the damage, because it doesn’t include other types of cancer. It also doesn’t account for medical problems tied to more advanced stages of cancer or prolonged disruption of care.   

“We have a lot of solid data that shows we are identifying fewer cancer diagnoses compared to a year ago, but the ramifications of that will take years to play out,” Cance says. “The key point is that the impact of COVID-19 on cancer will last a good 10 years. We’ll keep seeing this because of the long-term ramifications of not diagnosing people.”

Each year, the ACS puts out a cancer report with statistics on trends in cancer in the U.S. for the previous three years. Before the pandemic hit, the group reported the largest single drop in history in cancer deaths for the period 2016 to 2017, mostly due to decreases in lung cancer deaths.

COVID-19-related delays in cancer care could undermine decades of progress in the fight against cancer, and trade one public health crisis for another.

The good news: You’re not powerless
Clinics have become adept at curbing the spread of COVID-19, and they’re encouraging patients to catch up on their healthcare.

Rigorous precautions include increased disinfecting, strict social distancing, temperature and COVID-19 screenings, use of masks and other personal protective equipment, and prioritizing patients who need to be seen in clinic.

“The message we should get out is that everybody should get screened,” Cance says.

Anyone due for a screening should reach out to their healthcare provider to have it scheduled. There may be a slight wait due to COVID-19 protocols and the fact that more people may be scheduling screenings they have put off.

Those having any worrisome symptoms or at higher risk for cancer due to smoking or a family history of cancer should be sure to let their healthcare provider know. Doctors may need to be more selective about who gets screened first.

“The recommendations would be based on your risk of cancer and when you had your last screen,” Cance says. “The risks that both patients and doctors should really stress are family history of cancer and presence of symptoms. Those people should make sure to get screened.”

What about people who are at high risk for severe COVID-19, and who may also be at increased risk for certain cancers?

“For people who are at very high risk for COVID-19 and are fearful of going to the doctor’s for screening, clearly you have to decide what is the worse risk,” Cance says. “If you’re high risk for COVID-19 and are having symptoms of colorectal cancer—such as blood in the stool—you’re at a higher risk for colon cancer than COVID-19.”

Even if you’re young, it doesn’t mean you’re risk-free. Recent years have shown a shift toward earlier age at cancer diagnosis for people born after 1950. So, a young person who is having persistent symptoms—especially if they have a family history of cancer—should get screened, Cance advises.

If you have concerns about COVID-19 and are at high risk for cancer, talk to your doctor. There may be alternative screening methods that are less invasive than standard testing. For example, at-home stool-based tests and expanded hours for mammography may be an option.

“The message is that it is now safe to go to your healthcare provider,” Cance says. “I think we need to be very proactive. If everybody paid more attention to family history and symptoms, we would save a lot of lives by identifying cancer earlier.”

Medically reviewed in October 2020.

Sources:
AARP. “Why You May Regret Letting Virus Fears Keep You Away From the Doctor.” Jul 9, 2020.
Economic Policy Institute. “Health insurance and the COVID-19 shock.” Aug 26, 2020.
The Commonwealth Fund. “The Impact of the COVID-19 Pandemic on Outpatient Visits: Changing Patterns of Care in the Newest COVID-19 Hot Spots.” Aug 13, 2020.
Epic Health Research Network. “Delayed Cancer Screenings.” May 4, 2020.
Epic Health Research Network. “Delayed Cancer Screenings-A Second Look.” Jul 17, 2020.
Norman E. Sharpless. “COVID-19 and cancer.” Science. Jun 19, 2020. Vol. 368, Issue 6497, pp. 1290.
Economic Policy Institute. “Black workers face two of the most lethal preexisting conditions for coronavirus—racism and economic inequality.” Jun 1, 2020.
Pew Research Center. “Coronavirus Economic Downturn Has Hit Latinos Especially Hard.” Aug 4, 2020.
American Cancer Society. “Cancer Facts & Figures for African Americans.”
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.
Jack W. London, PhD; Elnara Fazio-Eynullayeva, MA; Matvey B. Palchuk, MD, MS, et al. “Effects of the COVID-19 Pandemic on Cancer-Related Patient Encounters.” JCO Clinical Cancer Informatics no. 4 (2020) 657-665. Published online July 27, 2020.
American Cancer Society. “Facts & Figures 2020 Reports Largest One-year Drop in Cancer Mortality.” Jan 8, 2020.
Siegel, R.L., Miller, K.D. and Jemal, A. (2020). “Cancer statistics, 2020.” CA A Cancer J Clin, 70: 7-30.

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