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Screening and some care have been canceled or deferred. Will more illness and deaths result?
COVID-19 wreaked havoc last year and seems destined to trample through 2021, causing illness, death and healthcare disruption. But cancer experts and clinicians fear a subtler, slow-motion effect of the pandemic: more cancer-related illness and death for years to come as a consequence of people not being screened and treatment being delayed.
Some of those missed screenings and diagnostic tests may have been unnecessary, even harmful. American healthcare — including cancer care — has plenty of low-value care. And it’s too soon for evidence of increased illness and death (and expense) from deferred screenings and care to emerge. However, there is enough experience with the pandemic for researchers to start combing through data that show how much cancer screening and care decreased in 2020.
A study published in November 2020 in JCO Clinical Cancer Informatics is a prime example. A research team led by Debra Patt, M.D., Ph.D., MBA, FASCO, had access to data that included about 6.2 million Medicare fee-for-service claims. They sifted through the data to identify billing patterns for cancer screening services, evaluation and management, biopsies, certain cancer-related surgeries (mastectomy, colectomy, prostatectomy) and chemotherapy. They examined data from the first five months of the pandemic, March through July, and compared the claims with the same months in 2019.
Predictably, the sharpest drop-off in every cancer-related service, as reflected in claims, was in April. Patt and her co-investigators found an 85% decrease in mammography claims in April 2020 compared with April 2019. By July, the difference had decreased to 9%. Other services also bounced back a bit, but not all of them, and their results show that many categories of cancer care stayed well below 2019 levels from March through July. For example, claims for administration of chemotherapy drugs were approximately one-third lower in July 2020 than in July 2019. Overall, the study results paint a picture of a widespread, pandemic-related retreat from normal cancer screening and treatment.
Variations in care
Still, many cancer centers and oncologists responded to the pandemic by finding ways to maintain their level of service, especially when it came to treatment. At Virginia Commonwealth University (VCU) Massey Cancer Center in Richmond, cancer care was deemed an essential service. “We knew we needed to do everything possible to continue providing care,” says Khalid Matin, M.D., FACP, associate medical director of the Cancer Service Line at VCU Massey Cancer Center and interim chair of the Division of Hematology, Oncology and Palliative Care. “But, (as with) all other healthcare providers, we had to make a lot of decisions early in the pandemic about how to best provide care that kept patients and staff as safe as possible,”
VCU Health delayed elective procedures in March, April and May. “While this did not include cancer care, it did include some preventive screenings such as colonoscopies and routine mammograms,” Matin says. “The services reopened as we gained experience providing care during the pandemic and established appropriate safety protocols.” VCU Massey Cancer Center continued clinical trials in which patients were in active treatment. The opening of new clinical trials and nontreatment trials paused, says Matin, but enrollment resumed in the spring “when we became more comfortable with safety procedures.”
Consequence of delays
Direct evidence of the consequences of reduced screenings and deferred care may not be apparent for some time, but there are projections and a track record of research to use for comparison.
The National Cancer Institute (NCI) predicts there will be as many as 10,000 additional deaths during the next 10 years related to the delayed diagnosis of breast and colorectal cancers. “Although we do not have data to show a direct correlation to screening delays, we experienced an influx of (patients with newly diagnosed breast cancer) in the summer after providers began offering mammography services,” says Kandace McGuire, M.D., chief, section of breast surgery, at VCU’s Massey Cancer Center.
There is plentiful research showing that delays in cancer care can lead to additional illness and a greater likelihood of death. For example, evidence shows an association between a longer time-to-treatment period — the interval between diagnosis and the start of treatment — and mortality risk.
Research published in December in JAMA Network Open added to the evidence. Using pre-pandemic data for patients with breast, prostate, non-small cell lung and colon cancers, the researchers found the effect of treatment delay especially pronounced for patients with colon cancer. In a review study published in BMJ in November that combined data from 34 studies with 1.3 million patients, researchers found that that each four-week delay in surgical treatment for seven different cancers resulted in a higher mortality risk.
The more aggressive or fast-growing the cancer, the more dangerous the delays. Variability can occur among cancers that occur at the same site. “Slow-growing breast cancers may not change much within a year, but faster-growing breast cancers could have a more advanced stage and more limited prognosis with a year’s delay in diagnosis,” Patt notes.
The University of Michigan researchers developed the OncCovid model to weigh the risks and benefits of delayed treatment in a systematic way. They also folded in the risk of COVID-19 infection in healthcare settings. Their results, published in JAMA Oncology in December, showed the web-based tool may be useful in making judgments regarding cancer care delays based on the patient’s cancer and COVID-19 risk.
The NCI COVID-19 in Cancer Patients Study (NCCAPS) investigates how COVID-19 and cancer interact. Researchers are collecting blood samples, medical information and medical images from 2,000 people with cancer who also have COVID-19. They will be followed for up to two years. Researchers at Baylor College of Medicine in Houston are recruiting patients for NCCAPS.
“I think this study is incredibly important to obtain data on these two major current causes of mortality,” says Claire Hoppenot, M.D., assistant professor of gynecologic oncology at Baylor’s Dan L Duncan Comprehensive Cancer Center. Some study results have shown that patients with cancer are more likely to have poor COVID-19 outcomes. The cancer center at Baylor is prioritizing vaccination of patients with cancer who are receiving treatment, Hoppenot says.
The pandemic has affected cancer care beyond medical treatments. Cancer centers and clinicians now work to situate patients in a supportive web of nonmedical services — a web that has been frayed by the pandemic. Although canceling in-person support groups and restricting visitors helps reduce the spread of COVID-19, these measures can also have serious negative impacts for patients with cancer, says Elizabeth Koelker, M.H.A., FACHE, a director of The BDO Center for Healthcare Excellence & Innovation, a healthcare consultancy in Beavercreek, Ohio.
It is well documented and understood that the best practice in cancer care delivery is a treatment approach that addresses the mind, body and spirit of patients with cancer. Support groups address the loneliness and isolation associated with a cancer diagnosis, and exercise rehabilitation programs have scientifically proven positive effects on long-term survival. Although many efforts to resume screening and standardized treatment such as chemotherapy, radiation, and surgery have occurred, other treatments remain indefinitely suspended. “The negative impact to the overall well-being of (patients with cancer) is immeasurable,” Koelker says.
Although many healthcare systems are starting to loosen their visitor policies, cancer programs are mostly sticking to the no-visitor policy. “This can be a profound source of stress to patients who find comfort and strength in the presence of a trusted loved one during treatment,” Koelker says. “While it’s too soon to measure, many providers anticipate an overall decrease in (adherence) from patients missing their treatment appointments because their support person can’t be present.”
Some centers allow an exception to the no-visitor policy by permitting one visitor for initial consults, which tend to be overwhelming and full of crucial information. Overall, integrative services such as massage therapy, acupuncture, art and music therapy, and even exercise rehabilitation remain suspended at most comprehensive cancer programs, according to Koelker.
“As institutions move forward, they need to understand the importance of caring for the mind and spirit,” Koelker says. “Providers must enable patients to seek support in a virtual environment, such as virtual support groups, which can help patients feel more connected.”
What can be done
Providers needn’t stand idly by as people delay cancer care, Patt notes. She suggests three steps that providers can take:
Baylor College of Medicine is devising individualized cancer treatments for patients with early-stage cancers, such as early low-grade endometrial cancer or atypical hyperplasia, which can be treated effectively with hormonal therapy if surgery is delayed, Hoppenot says.
In hospitals where operating rooms aren’t in use, patients who can’t be moved to another hospital but have known metastatic ovarian cancer are being treated with chemotherapy, with a plan for surgery when operating rooms open again. “This is not an uncommon treatment plan for patients, even outside of COVID-19,” Hoppenot says. “Where we have to prioritize, algorithms include surgical risk algorithms (potential need for inpatient or ICU care), potential for cure of the cancer with surgery and symptom control, as well as those with alternative (hormonal or chemotherapy) options until they can have a surgery date.”
Approximately 40% of VCU Massey Cancer Center’s appointments are now virtual. Staff are working to keep patients out of medical facilities whenever possible but still allows visits for treatments, laboratory tests, scans and other things that can only be done in person, McGuire says.
VCU Massey Cancer Center also has implemented a robust testing system; all patients are tested for COVID-19 prior to treatment. Patients scheduled for surgery are tested 48 hours prior to their operation. If the patient tests positive, the procedure is delayed when possible. In rare cases where surgery cannot be rescheduled, special operating rooms are assigned for patients who tested positive for COVID-19.
Karen Appold is a medical writer in the Lehigh Valley region of Pennsylvania.