From a dramatic drop in caseloads to missed screenings and diagnoses as well as the emergence of telemedicine, COVID-19 turned the world of oncology upside down. During the National Comprehensive Cancer Network (NCCN) Virtual Oncology Policy Summit, “Defining the ‘New Normal’ 2021 and the State of Cancer Care in America,” Murray Aitken, MA, MBA, Executive Director of the IQVIA Institute for Human Data Science, shared data-driven insights on the pandemic’s impact on cancer care.
Murray Aitken, MA, MBA
Polls of more than 700 oncologists conducted in the United States, the United Kingdom, four major European countries, and Japan by Mr. Aitken and colleagues throughout the pandemic have demonstrated a significant drop in oncologist-reported caseloads relative to pre–COVID-19 levels. In April 2020, oncologists reported caseloads that were 49% of the numbers before the pandemic. This percentage rose to 77% in October 2020 but fell to 74% of levels prior to the pandemic in February 2021. In other words, said Mr. Aitken, U.S. oncologists experienced a 26% reduction in caseloads from the period prior to COVID-19.
Relative to other countries, however, the United States has experienced the lowest level of caseload reduction. In Germany, for example, caseloads were reported at 49% of the level prior to the pandemic in early 2021, Mr. Aitken said.
Impact on Patient Care
COVID-19 has also altered the type of care being delivered to patients. More than three-quarters of U.S. oncologists reported delays in surgery, and 40% noted delays in chemotherapy. The incidence of telemedicine also increased from less than 10% of consultations prior to the pandemic to a peak of 46% in April 2020. Since then, however, use of remote consultation has declined and most recently comprised 26% of consultations in February 2021.
According to Mr. Aitken, oncologists expect approximately 20% of consultations to remain virtual on an ongoing basis after the COVID-19 pandemic. However, the role that these remote consultations will play in delivering care for patients and the impact they will have on outcomes are still not really understood, he added. Approximately one-third of oncologists also reported providing more support to patients because of the pandemic.
Screenings and Missed Diagnoses
Based on reimbursement claims submitted by clinics, oncology practices, hospitals, and screening centers, the incidence of diagnostic testing declined significantly in the United States because of COVID-19. In April 2020, mammograms, Pap smears, colonoscopies, and computed tomography (CT) scans were down 87%, 83%, 90%, and 53%, respectively, relative to expectations.
“Although these numbers have since improved, it’s estimated there were 20% fewer mammograms, 14% fewer Pap smears, 23% fewer colonoscopies, and 11% fewer CT scans for the full year,” said Mr. Aitken. “This translates to approximately 22 million fewer screening tests for these four cancer types in 2020 compared with what normally would have occurred. If a rate of positive cancer diagnoses per test is applied, approximately 68,000 patients may have delayed or missed cancer diagnoses in 2020,” he explained.
Mr. Aitken acknowledged that the rate of positive cancer diagnosis has not been well established; he noted it’s unclear whether patients who received screening in 2020 are representative of prepandemic demographic and clinical characteristics. Nevertheless, oncologists are still seeing screenings below prepandemic levels, he added, which could have lasting, harmful consequences.
“This disruption to routine screenings and diagnosis of patients is a major risk factor,” Mr. Aitken said. “There are patients who were used to having their biannual mammography or their colonoscopies every 5 years who lost the habit in 2020. If we don’t help them return to those habits, there could be serious backsliding in terms of the progress made in early diagnosis.”
Initial Presentation of Metastatic Disease
Mr. Aitken and colleagues have also tried to understand the pandemic’s impact on patients presenting with metastatic cancer. IQVIA data drawn from a panel of 400 United States–based oncologists demonstrated a “higher-than-normal” percentage of patients presenting with metastatic disease in 2020 (in all major cancers except prostate).
“Everyone is concerned about the increase in patients presenting with metastatic disease and whether this trend extends into 2021,” said Mr. Aitken. “It could just be that the mix of patients who sought care during the pandemic trended toward more metastatic cases…, but we’ll have to see whether being diagnosed later in the cancer journey has an effect on outcomes.”
According to Mr. Aitken, the decline in patients presenting with metastatic prostate cancer could reflect the increased incidence of patients with premetastatic disease due to treatment advances for that type of cancer.
Use of Oncology Medicines
Mr. Aitken also reported a “precipitous decline” in the volume of oncology medicines used around the world in 2020. Growth rates in the total number of defined daily doses of oncology medicines fell during the pandemic in Europe and Japan and reached negative rates in the United States.
“In 2018 and 2019, the volume of medicines used in oncology treatment in the United States grew 6.9% each year before falling dramatically to negative 0.1% in 2020,” said Mr. Aitken. “This is an issue of concern that reflects reduced caseloads, fewer patients being diagnosed, and fewer treatments being initiated.”
Although the use of checkpoint inhibitors continued to rise in 2020 both in the United States and Europe, Mr. Aitken and colleagues observed a slowdown in the rate of growth like the overall decline in oncology drug use. In 2018, the number of defined daily doses of immuno-oncology drugs increased by approximately 60%. That growth rate fell to 36% in 2019, however, and just 12% in 2020.
“The slowdown in percentage growth had already started for checkpoint inhibitors, but we saw a significant drop in use during the pandemic,” Mr. Aitken said.
Finally, Mr. Aitken highlighted a trend toward greater use of oral formulations of oncology drugs, which have significantly increased in number, and a decline in the relative share of intravenous infusions. This trend began prior to the pandemic and is expected to continue after as well, he said.
DISCLOSURE: Mr. Aitken has held other relationships with IQVIA.
Moderator of the session at the National Comprehensive Cancer Network Virtual Oncology Policy Summit, Clifford Goodman, PhD, Senior Vice President at The Lewin Group, said he was struck by the diverse impacts that the COVID-19 pandemic had on cancer care. One area that remained relatively...