Delays in cancer diagnoses amid COVID-19 signal downstream effect on long-term outcomes
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Strategies must be implemented to ensure individuals receive appropriate cancer screening and care amid the COVID-19 pandemic, according to studies presented at American Association for Cancer Research Virtual Meeting: COVID-19 and Cancer.
“On March 18, the Centers for Medicare and Medicaid Services issued guidance that called for a halt on all nonurgent medical procedures during the COVID-19 pandemic, which of course included routine primary care, as well as preventative visits and screenings,” Erica T. Warner, ScD, MPH, assistant professor in the department of medicine at Harvard Medical School, said during a presentation. “We must now reach out to community organizations to engage them in the process of bringing people back into the clinic for screenings. This will require tailored messaging that can be done by having a better understanding of the groups we are trying to reach, their different cultures and specific barriers they face.”
Messaging about preventive cancer screenings also needs to be more consistent, Warner added.
“One of the challenges of this pandemic has been inconsistent messaging,” she said. “People are hearing different things from different groups, making it difficult to know what applies to them. Having groups come together to form a consistent message could help wade through the confusion and uncertainty that has come along with the COVID-19 pandemic.”
National survey
Warner and colleagues sought to assess the impact of the COVID-19 pandemic on breast cancer screening, diagnosis and treatment. They surveyed individuals who received routine breast cancer screening, had been undergoing diagnostic evaluation for breast cancer or had ever been diagnosed with breast cancer.
“The English language survey opened on May 14 and closed July 10; however, the Spanish language survey opened June 1 and has yet to close because we had trouble accruing participants,” Warner noted.
Overall, 534 respondents completed the REDCap survey, which included questions about demographics; breast cancer screening and diagnosis; the extent to which screening, diagnosis or treatment had been changed, delayed or canceled because of COVID-19; personal protective practices; extent of worry about financial and health implications of COVID-19; and use of telemedicine.
Nearly half of respondents to the survey, administered online, were white (48.9%), whereas 21.2% were Black, 5.2% were Hispanic and 9.6% were of Ashkenazi Jewish descent. About 26% were aged younger than 50 years and 21.9% were aged 65 years or older.
Overall, 46.1% of respondents had been diagnosed with breast cancer and 5.4% were undergoing diagnostic evaluation for breast cancer. Among the 275 respondents with breast cancer and/or who were undergoing diagnostic evaluation, 7.6% had an abnormal mammogram awaiting diagnostic mammogram, ultrasound, MRI or biopsy. Of those newly diagnosed with breast cancer, 1.8% had not started treatment and 38.9% were undergoing active treatment.
Results showed 26.7% of respondents without breast cancer and 31.7% with breast cancer reported any delay in care due to COVID-19. The most frequently affected care (97.2%) included screening mammogram, ultrasound or MRI, according to the study abstract. Among respondents on active treatment, 20.6% reported delayed or canceled surgery, chemotherapy or radiation visits, the abstract stated. Further, 22.3% of respondents reported that an in-person visit had been changed to phone call or videoconference.
About one-third (34.3%) of those without breast cancer and 51.6% of those with breast cancer reported discussing COVID-19 with a health care provider.
Results also showed 33.7% of respondents with breast cancer reported they were worried or very worried that the COVID-19 pandemic would make it difficult to receive cancer care, whereas 40.2% of respondents without breast cancer worried that COVID-19 would make it harder to obtain health care, such as screening and diagnosis.
“It will be important for us to next look at how the impact of decreased screening and diagnosis differs demographically and geographically, since we did note there were significant differences between those with breast cancer and those without breast cancer in terms of characteristics,” Warner said. “We have to ultimately consider the long-term impact on breast cancer outcomes. With NCI models projecting an excess 10,000 deaths during the next 10 years from colorectal and breast cancer due to the pandemic, it is important that facilities prioritize their preventive care and create a culture and feeling of safety among patients. We must communicate through the uncertainty that still exists regarding the pandemic.”
Health care provider group
Another study showed the significant impact of the COVID-19 pandemic on breast and prostate cancer screening and early detection in a large central Massachusetts health care provider group.
“Massachusetts has been heavily impacted by the COVID-19 pandemic,” Mara M. Epstein, ScD, assistant professor in the department of medicine at University of Massachusetts Medical School, said during a presentation. “As of July 1, there have been more than 109,000 cases and more than 8,000 deaths [due to] COVID-19 in Massachusetts. Most non-COVID-19 care was paused in mid-March, including elective procedures and preventive care.”
Epstein and colleagues sought to quantify changes in the rates of mammography and PSA testing for screening and diagnostic purposes, as well as breast and prostate biopsies performed during the first 5 months of 2020 compared with the same months in 2019.
The analysis included men and women aged 30 to 85 years without a history of breast or prostate cancer who were active patients of the provider group between January 2019 and May 2020. Researchers used CPT codes in the group’s electronic health record to compare monthly rates of mammography, total PSA, and breast and prostate biopsy per 1,000 people between January and May of 2019 vs. the same period in 2020.
In total, 80,629 women and 65,312 men were included in the 2019 data analysis and 82,695 women and 66,396 men were included in 2020 analysis. Overall median age was 52 years for women and 53 years for men. Nearly 70% of the individuals in the analysis were white, 4% were Hispanic and 3% were Black.
According to study results, combined rates for mammography and tomosynthesis declined by 57% in March, 96% in April and 95% in May compared with the prior year. Testing essentially stopped completely during the peak of the pandemic, according to Epstein.
Researchers observed the sharpest decrease (97%) among women aged 75 to 85 years, as well as parallel declines across all racial/ethnic groups, Epstein added.
Breast biopsies decreased steadily between the 2 years, with declines of between 96% and 100% in April and between 89% and 97% in May.
Declines in PSA testing were slightly less than for mammography, Epstein noted. However, researchers observed a significant decline in PSA testing during the peak of the COVID-19 pandemic, by 64% in March, 83% in April and 69% in May compared with 2019.
“Current [U.S. Preventive Services Task Force] guidelines recommend that men aged between 55 to 69 years discuss screening with their doctors, and we know that screening is not currently recommended for older or younger men,” Epstein said. “Just under half of the men in our study were in the youngest age group and about one-third of men were in the target 55- to 69-year age range.”
The largest declines in PSA testing according to age group occurred among the youngest group of men (aged 30-54 years), with a decline of 86% in April and 73% in May. Declines in PSA testing rates across all categories of race/ethnicity were between 77% and 92% for April and between 67% and 74% for May.
Researchers did not observe significant decreases in rates of breast or prostate biopsies between the periods studied.
“The data on biopsies require more detailed investigation at the level of individual patients,” Epstein said. “Moving forward, we have to contact the community and contact trusted sources to get the word out about cancer screening. There is also some value in reaching out to patients on an individual level to find out who the women are who canceled their mammograms and have the clinic contact them to hear their fears and concerns and reassure them that it is safe to come back to the clinic. From a research perspective, in time, we will be able to see if and when individuals who canceled their screenings actually come back to the clinic, which will further our research on the long-term impact of these canceled cancer screenings during the COVID-19 pandemic.”
References:
- The following abstracts were presented at American Association for Cancer Research Virtual Meeting: COVID-19 and Cancer; July 20-22, 2020:
- Epstein MM. Abstract S11-03.
- Warner ET. Abstract S11-02.
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Warner ET. Abstract S11-02. Presented at: American Association for Cancer Research Virtual Meeting: COVID-19 and Cancer; July 20-22, 2020.
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