As outbreaks of the COVID-19 pandemic spiked across the country earlier this year, federal health officials and cancer societies advised people to delay seeking routine cancer screenings, including mammograms and colonoscopies, to keep them out of medical centers and away from potential exposure to the coronavirus. The result was a drastic decline in cancer screenings in March and April, data from the electronic medical records vendor Epic and Komodo Health, a San Francisco–based company that collects and analyzes health-care data, show.
Jennifer A. Ligibel, MD
Prevention in Oncology is guest edited by Jennifer A. Ligibel, MD, Chair of ASCO’s Energy Balance Working Group and a member of ASCO’s Cancer Survivorship and Cancer Prevention Committees. Dr. Ligibel is Director of the Leonard P. Zakim Center for Integrative Therapies at Dana-Farber Cancer Institute.
Each Prevention in Oncology column will address one of five areas in cancer prevention—alcohol use, obesity, tobacco use, vaccines to prevent cancer-causing infections, and germline genetics—with the goal of providing strategies to reduce the risk of cancer, as well as preventing cancer recurrence and second malignancy during cancer survivorship.
According to a white paper published by Epic, screening appointments for breast, cervical, and colon cancers in March 2020 decreased by between 86% and 94% compared with average volumes in the prior 3 years.1 A review of the billing records of 320 million patients released by Komodo Health show the total number of colonoscopies and biopsies performed plummeted nearly 90% by the middle of April compared with the same period in 2019. In addition, the company’s analysis found that new colorectal cancer diagnoses were down more than 32% by the middle of April, and the number of surgeries for colorectal cancer fell by 53% compared with the previous year.2
How might these delays in cancer screenings and the early diagnosis of cancer translate to cancers caught at more advanced stages and to worse survival outcomes? The ASCO Post talked about the potential ramifications of delayed cancer screenings due
Stephen B. Edge, MD, FACS, FASCO
to the coronavirus crisis with Stephen B. Edge, MD, FACS, FASCO, Vice President of Healthcare Outcomes and Policy and Professor of Oncology in the Departments of Surgical Oncology and Cancer Prevention and Control at Roswell Park Comprehensive Cancer Center in Buffalo; a member of ASCO’s Cancer Prevention Committee; and Co-Chair of ASCO’s Onco-Primary Care Physician Task Force, which is examining opportunities for collaboration with primary care specialty organizations, including in the area of cancer screenings.
Assessing the Willingness to Return to Preventive Cancer Care
Please talk about the importance of maintaining routine cancer screenings and the impact that not having timely screenings may have on the number of new cases of advanced cancers diagnosed. Will less intensive screening likely lead to a diagnosis of more advanced cancers?
This is, of course, a serious issue moving forward. We have seen the reports of dramatically reduced cancer screenings during the COVID-19 pandemic, which are the direct result of screening cessation. However, if you look at the science of screening, the understanding of how cancers develop over time, and the screening frequencies we recommend based on cancer type, the issue of delaying screening for a few months probably will have little to no impact on the stage of cancers and outcomes.
The bigger question now is that we’ve turned the screening switch off, how easy will it be to turn it back on? We told people to stop going to hospitals and screening centers in the middle of this crisis. Although that was the right thing to do, restarting screening will be much more difficult. We don’t know what will happen and how comfortable people will be to return to routine health care.
Many of us are seeing in news reports and personally in our own practices and clinics that people are still somewhat leery of coming in to see us. Much of that hesitancy may depend on where in the country people live as well as their personal and community experiences with COVID-19. Practices recognize they have a responsibility to accommodate patients who do want to return to routine preventive health care. Right now, we don’t know how big that demand is going to be in the short term. The real concern will be if a substantial proportion of people stop undergoing primary care and screening for a prolonged time.
Evaluating the Risks of Delaying Prevention Screenings
Which cancers might pose the biggest concern for patients if they are detected at a later stage?
A very broad-brush answer is that if you have an aggressive cancer, it is aggressive whether you detect it now or 3 months from now. So, there is no reason to think a 3-month delay in a cancer screening is going to impact the outcome of the cancer or result in many more people being diagnosed with advanced cancers. National organizations recommend mammography screenings every 1 to 2 years, with the longer interval advocated by some as providing virtually all the benefit of mammography. Delaying screening a few months because of the pandemic isn’t going to make a difference in a patient’s long-term outcome. Our recommendation for colorectal screening is every 5 to 10 years, so a delay of a few months is unlikely to make a big difference in the stage of that disease at diagnosis or in outcomes.
If I had to predict which cancers are the most worrisome in terms of presenting with an advanced stage of disease because of relatively short-term delays in screening or forgoing screening for a year or more, I would say lung cancers. We recommend annual, low-dose computed tomography screening for those people at very high risk of developing lung cancer based primarily on age and smoking history. We recognize those cancers are more likely to become more advanced quickly.
So, overall, as I said, I think our bigger concern is that people may not return for their routine cancer screening in a timely manner. And then when they do return in 1, 2, or 3 years, we will see cancers diagnosed at a more advanced stage.
The message to physicians and the public is we know screening is an effective tool. The answer to this current crisis is to promote the resumption of primary care and screening services. In doing so, physicians must be sure they provide these services in a safe manner and communicate this to the public.
Practices will need to be proactive in reaching out to people about when screening is due. If demand rebounds like it should, screening programs may need to extend hours, so people are not turned away. And, of note, we need to pay special attention to those in historically underserved groups and to people who have been suddenly left underinsured or uninsured by this crisis.
DISCLOSURE: Dr. Edge is the principal investigator of a study of clinical oncology pathways for which his institution receives research support from Pfizer.
1. Epic Health Research Network: Preventive cancer screenings during COVID-19 pandemic. Available at www.ehrn.org/wp-content/uploads/Preventive-Cancer-Screenings-during-COVID-19-Pandemic.pdf. Accessed July 14, 2020.
2. Komodo Health: Research brief: New colorectal cancer diagnoses fall by one-third as colonoscopy screenings and biopsies grind to a halt during height of COVID-19. Available at https://knowledge.komodohealth.com/hubfs/_RESEARCH_BRIEFS/COVID19_Impact_on_CRC_Patients_-Research_Brief_Komodo_Health_Fight_CRC.pdf. Accessed July 14, 2020.