For decades, healthcare professionals have worked diligently to teach individuals that screening is a valuable tool for preventing and detecting cancer. This has not been an easy mission, and nurses and physicians have had to debunk the myths, bias, and misinformation that deter patients from getting screened annually or according to specific guidelines set forth by organizations such as the Centers for Disease Control and Prevention (CDC) and the American Cancer Society (ACS). Although clinicians have been telling their patients—and the population at large—not to put off cancer screening because it saves lives, when the COVID-19 pandemic hit in March of this year, the dialogue changed.
Suddenly, individuals were being advised to stay at home and to delay tests or procedures that were not urgent. This message came from independent medical practices and hospitals, as well as from highly respected oncology societies. For example, as COVID-19 swept across the country, the American Society of Clinical Oncology (ASCO) updated its website with a statement recommending that cancer screenings requiring clinic or center visits (eg, mammograms and colonoscopies) be postponed “for the time being” to “conserve health system resources and reduce patient contact with health screening facilities.”1 Naturally, when organizations such as ASCO make these types of recommendations, people are inclined to listen.
I have been a nurse for more than 30 years and spent several months volunteering in a COVID-19 recovery unit during the pandemic, so I am aware of the significantly high numbers of patients who died during the pandemic, and I know that the virus is still claiming lives. In no way am I trying to minimize this fact. However, I also feel that more of an effort could have been made to continue cancer screening protocols during the pandemic, since delaying these screenings can have devastating consequences for many patients.
For example, I think it would have been possible to utilize open free-standing clinics, imaging centers, and practices that had screening capabilities, with a primary focus on getting high-risk patients through the process. Of course, this would have required following important safety protocols, including spacing out appointments and thorough cleaning between patients.
Over the past few months, I have read several reports documenting the significant decline in cancer screenings since the pandemic began, and the statistics are troubling. I believe that if we do not change course immediately, we will be faced with the detrimental effects of delayed screenings for years to come.
Delayed Cancer Screenings: What the Experts Are Saying
Numerous reports have documented the sharp decrease in cancer screenings since the pandemic began. According to a white paper published by Epic, an electronic medical record vendor, appointments for cancer screenings of the cervix, colon, and breast declined between 86% and 94% in March 2020, compared with average volumes in the 3 years before the first COVID-19 case was confirmed in the United States.2
“We’re also fairly convinced that even once they lift the lockdowns, we’ll still see the concerned patients a little bit more reluctant to go in. Truthfully, it does not take much to talk a person out of going in for a colonoscopy,” said Carl Dvorak, Epic President.3
In a study conducted by Komodo Health, which analyzed the billing records of 320 million patients in the United States, it was reported that screenings for cervical cancer fell approximately 68% in a 1-month period (March 19, 2020-April 20, 2020) compared with the previous 11 weeks and a comparable period in the previous year.4 The most significant declines were observed in COVID-19 hotspots, such as New York City and Massachusetts.
“We’re seeing a tremendous impact on preventative care, as well as on chronic conditions with massive implications for the healthcare system,” said Arif Nathoo, MD, Co-Founder and Chief Executive Officer at Komodo Health. “It speaks volumes to just how much COVID is impacting everyone’s health and wellness.”
The Consequences of Screening Delays
There is no doubt that the decline in screenings is resulting in delays in cancer diagnosis, which can translate to significantly poorer clinical outcomes for patients. In a recent study published online in JAMA Network Open, researchers at Quest Diagnostics evaluated weekly changes in the number of patients with newly diagnosed cancers before and during the COVID-19 pandemic. Results showed that there was a 46.6% weekly decline in diagnosis for 6 common cancers combined and a 51.8% weekly drop in breast cancer detection.5
The investigators also performed a cross-sectional study that included patients from across the United States who were screened for breast, colorectal, lung, pancreatic, gastric, or esophageal cancers and whose screenings were processed from January 1, 2018, to April 18, 2020. Mean weekly numbers of newly diagnosed patients were compared between the baseline period (January 6, 2019-February 29, 2020) and the COVID-19 period (March 1, 2020-April 18, 2020). Significant declines were observed in all 6 cancer types during the pandemic period.5
“Our results indicate a significant decline in newly identified patients with 6 common types of cancer, mirroring findings from other countries,” the researchers wrote.
“When cancer screenings and resulting cancer diagnoses are postponed, some of these cancers are likely to later be identified at more advanced stages, which will result in poorer outcomes and even increased death rates,” said Harvey Kaufman, MD, the study’s co-author and Senior Medical Director and Director, Health Trends Research Program, Quest Diagnostics.
Craig Bunnell, MD, MPH, MBA, Chief Medical Officer, Dana-Farber Cancer Institute, Boston, MA, echoed this sentiment in a statement regarding the results of the study. “The true incidence of these cancers did not drop. The decline clearly represents a delay in making the diagnoses, and delays matter with cancer. It means we need to safely perform these diagnostic tests and the public needs to not think of them as optional. Their lives could depend on them.”6
Laura Makaroff, Senior Vice President, Prevention and Early Detection, ACS, agreed, warning that “cancer certainly isn’t stopping due to the pandemic.”6
Strategies to Get Back on Track
Now that we understand the problem, it is imperative that we move forward with solutions to address it. For oncology practices that are now open, a plan to get patients back on track with cancer screenings can include some of the following suggestions, which can be tailored for specific patient populations.
- Reach out to patients
Practices should begin calling their patients who are at risk for cancer or those who are overdue for their cancer screenings and reestablish a connection.
- Offer education and encouragement
It is important to provide patients at a higher risk for cancer with a consistent message across all communication platforms, including television/radio advertisements and social media, which contain endorsements from the ACS, CDC, and large cancer centers, emphasizing the importance of screenings.
- Provide information regarding enhanced safety protocols and measures
Make sure that patients are aware of the protocols in place, such as temperature checks, screening questions, location of wait (eg, in their car), increased wait times, and the removal of high-touch items (eg, books, magazines). In addition, inform patients of your cleaning protocol, and explain that the screenings may take longer because of these new protocols. Let patients know that all staff will be wearing personal protective equipment and tell them that they will need to wear a mask during their appointment. In addition, advise them that bringing food or drinks into the facility is not allowed.
The amount of misinformation that has circulated since the beginning of the pandemic is frightening, and it is natural that many patients have felt the need to avoid going to physicians’ offices and large healthcare facilities. As healthcare professionals, we need to send a clear message to the oncology community and patient populations that cancer screenings are as important as ever. Most importantly, we need to make it our mission to try our best to undo the missed steps that happened during the COVID-19 crisis. Our patients and the population are counting on us.
- American Society of Clinical Oncology. Cancer screening, diagnosis, staging & surveillance. Updated June 22, 2020. www.asco.org/asco-coronavirus-resources/care-individuals-cancer-during-covid-19/cancer-screening-diagnosis-staging. Accessed August 21, 2020.
- Epic Health Research Network. Preventive cancer screenings during COVID-19 pandemic. May 1, 2020. https://ehrn.org/wp-content/uploads/Preventive-Cancer-Screenings-during-COVID-19-Pandemic.pdf. Accessed August 21, 2020.
- Robbins R. Routine cancer screenings have plummeted during the pandemic, medical records data show. May 4, 2020. www.statnews.com/2020/05/04/cancer-screenings-drop-coronavirus-pandemic-epic/. Accessed August 21, 2020.
- Respaut R, Nelson DJ. Exclusive: U.S. medical testing, cancer screenings plunge during coronavirus outbreak-data firm analysis. April 28, 2020. www.reuters.com/article/us-health-coronavirus-usa-screenings-exc/exclusive-u-s-medical-testing-cancer-screenings-plunge-during-coronavirus-outbreak-data-firm-analysis-idUSKCN22A0DY. Accessed August 20, 2020.
- Kaufman HW, Chen Z, Niles J, Fesko Y. Changes in the number of US patients with newly identified cancer before and during coronavirus disease 2019 (COVID-19) pandemic. JAMA Netw Open. 2020;3:e2017267.
- Mozes A. Cancer diagnoses plunge as Americans avoid screening during pandemic. August 4, 2020. www.medicinenet.com/script/main/art.asp?articlekey=241146. Accessed August 20, 2020.