Late-stage cancer diagnoses rise after pandemic-related drop in screenings
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During the early months of the COVID-19 pandemic, the number of cancer screenings in the U.S. dropped sharply as states imposed stay-at-home orders and health care providers sought to reduce exposure to the virus and redeployed personnel.
A national survey study of more than 470,000 Americans showed screening declines of 2.13 million (6%) for breast cancer and 4.47 million (11%) for cervical cancer from 2018 to 2020. In that study, published in June in JAMA Network Open, Fedewa and colleagues also observed a 16% decline in the rate of colonoscopy during the period, offset by a 7% increase in home-based stool testing.
The screening delays and cancellations immediately raised concerns of associated increases in late-stage cancer diagnoses and mortality. In a June 2020 editorial published in the journal Science, then-NCI Director Norman E. “Ned” Sharpless, MD, wrote that modeling suggested nearly 10,000 excess deaths due to breast and colorectal cancer alone over the next decade.
Two years later, emerging data are reinforcing those concerns.
A study of U.S. Health Care Cost Institute and American Cancer Society data, published in April in The American Surgeon, showed increases not only in diagnoses of lung/bronchus (0.29%), pancreatic (1.46%), breast (2.89%), colorectal (19.72%) and prostate cancer (144.5%) in 2020 (P < .01 for all), but also in the total number of deaths due to colorectal, pancreatic, breast and prostate cancers from 2019 to 2021.
“My practice has specifically been impacted with lower rates of colorectal cancer screening, and having spoken to my colleagues who treat patients with breast cancer and lung cancer, we have all observed declines in screenings deemed nonessential — either by physicians or patients during the pandemic — within the past 2 years,” Mark A. Lewis, MD, director of gastrointestinal oncology at Intermountain Healthcare Cancer Center in Utah, said during an interview with Healio | HemOnc Today. “We are now 2 years in with the virus still very much with us, and we are unfortunately seeing rises in late-stage cancer diagnoses stemming from declines in cancer screening across the board.”
Healio | HemOnc Today spoke with oncologists and other experts about increases in late-stage colorectal, breast and lung cancer diagnoses following the COVID-19 lockdown, ongoing efforts to bring screenings back to pre-pandemic levels, and the potential long-term impact of screening disruptions on clinical practice.
Colorectal cancer
The 15% increase in stage III or higher colorectal cancer cases that Lewis and colleagues at Intermountain Healthcare observed — following a 50% decline in screening colonoscopies — is not limited to one location, Lewis said.
“We are seeing this increase in late-stage diagnoses across our eight-state health care system,” he said. “I am concerned about this regionally and I am very concerned about this nationally.”
A study of visits to Moores Cancer Center at University of California, San Diego Health in 2019 vs. 2020 showed a numeric increase in the percentage of patients with colorectal cancer who presented with stage IV disease (6.7% [n = 3] vs. 19.5% [n = 8]; OR = 0.3; 95% CI, 0.05-1.37) and a numeric decrease in the number who presented with stage I disease (17.8% [n = 8] vs. 14.6% [n = 6];OR = 1.26; 95% CI, 0.34-4.88).
“This is all a preventable tragedy,” Lewis said. “Colonoscopy is not just screening, it is arguably prevention — other than cervical cancer screening with colposcopy, I cannot think of another screening test that is a powerful prevention tool.”.
Late-stage disease also leads to more financial burden.
In an analysis of 2 million Medicare beneficiaries published in April in Current Medical Research and Opinion, researchers found an association of later stage at diagnoses for 17 common cancer types with up to seven times higher costs compared with earlier-stage diagnoses, and the difference endured for at least 5 years after diagnosis.
“From a purely fiscal standpoint, a patient meeting me and going through a course of chemotherapy that they otherwise didn’t require is hundreds of thousands of dollars,” Lewis said. “A colorectal surgeon is eminently capable of removing a stage III colon cancer, but we could have removed it at the polyp level and never even gotten to that later stage. We need to think creatively about shifting diagnoses much earlier. Some may think this is lead time bias but interrupting the adenoma to carcinoma sequence is true downstaging.”
Breast cancer
An even more dramatic shift has been observed in breast cancer diagnoses.
In the Moores Cancer Center study, Zhou and colleagues found 63.9% of patients with breast cancer (n = 138) presented with stage I disease in 2019 compared with 51.3% (n = 116) in 2020 (OR = 1.67; 95% CI 1.13-2.47), whereas 1.9% (n = 4) presented with stage IV disease in 2019 vs. 6.2% (n = 14) in 2020 (OR = 0.33; 95% CI, 0.09-0.98). Researchers additionally noted that data for January through March 2021 showed a continued trend toward fewer patients presenting with stage I disease and more patients presenting with stage IV disease (41.9% vs. 8%).
The shift reflects the impact of the pandemic on breast cancer screening, according to Daphna Y. Spiegel, MD, MS, assistant professor of radiation oncology at Beth Israel Deaconess Medical Center and Harvard Medical School.
“Multiple studies have reported substantial reductions in the rate of screening mammography during the pandemic shutdown period in 2020, with rates falling to about 40% then to 90% of their usual volume during that time period,” Spiegel said during an interview with Healio | HemOnc Today.
A study of Beth Israel Deaconess Medical Center data by Spiegel and colleagues, presented during ASCO Annual Meeting, showed a higher proportion of patients diagnosed with late-stage breast cancer in 2020 compared with 2016 through 2019 (12.6% vs. 6.6%; P < .001), with 92.9% of late-stage diagnoses in 2020 having occurred from June to December after the lockdown.
“We specifically observed 70% to 80% fewer screening mammograms during the pandemic shutdown period compared with the same time period in 2019,” Spiegel said. “Another study [by Chen and colleagues] that used administrative claims data for 60 million people across the U.S. showed an absolute deficit in breast cancer screening of 3.9 million people in 2020 compared with 2019. These reductions in screenings have raised concern that we will see more late-stage cancers that occurred during and following the pandemic shutdown compared with prior years.”
Patients themselves have questioned whether screening delays led to their advanced-stage breast cancer diagnosis, Spiegel said.
“It’s really heartbreaking to have patients tell me about missing a mammogram during the shutdown only to be diagnosed with late-stage disease later on, and I’m often asked, ‘If I had gone for my mammogram in April 2020 instead of September 2020, would this have happened?’” she said.
In a modeling study published in Journal of the National Cancer Institute, Alagoz and colleagues estimated a 0.52% cumulative increase in breast cancer deaths by 2030 due to the pandemic disruptions. Specifically, three established Cancer Intervention and Surveillance Modeling Network breast cancer models projected 950 cumulative excess breast cancer deaths associated with decreased screening, 1,314 associated with delayed diagnosis of symptomatic cases and 151 associated with decreased use of chemotherapy in women with hormone receptor-positive, early-stage disease.
“The implication here is that breast cancer morbidity and mortality increase with late-stage disease compared with early-stage disease. With late-stage disease, patients often require more extensive surgery, chemotherapy and adjuvant radiation, whereas if they are diagnosed with early-stage disease, they may be able to do very well with a more limited surgery or without chemotherapy or radiotherapy,” Spiegel said. “More treatments can lead to more treatment-related toxicities. Additionally, the cure rates are, of course, lower for late-stage disease compared with early-stage disease.”
Lung cancer
Jonathan Villena-Vargas, MD, cardiothoracic surgeon at Weill Cornell Medicine, and colleagues observed a significant increase in patients with stage IV lung cancer as COVID-19 restrictions eased following the start of the pandemic.
“We all completely pivoted toward worrying about COVID-19 and not about screening tests. Consequently, we observed a decrease of approximately 50% in screenings as patients who were supposed to come to the hospital for screening did not out of fear,” Villena-Vargas said during an interview with Healio | HemOnc Today. “This is obviously a big deal because the patients who should have had CT scans, either for initial screening, cancer surveillance or just to follow up an incidental lung nodule, did not get appropriate follow-up, and this translated to a lack of appropriate diagnosis and treatment.”
Villena-Vargas and colleagues sought to identify any disease stage shift that may have occurred in the diagnoses of non-small cell lung cancer among 554 patients who underwent screening at Weill Cornell Medicine in New York between July 2019 and March 2021.
Results of the study, published in May in Clinical Lung Cancer, showed a 50% decrease in the mean number of patients seen for screening during that time period (P = .004). Moreover, compared with the period before the pandemic lockdown, researchers observed a significant increase in the proportion of patients with stage IV disease after pandemic restrictions ended.
“We saw a stage migration in which there was an increase of about 10% in diagnosis of advanced disease and decrease in early-stage disease,” Villena-Vargas said. “Patients stopped undergoing necessary tests they may have needed, such as a biopsy, because we were not able to perform them, and that allowed for a lack of diagnoses of potentially earlier-stage cancers that eventually advanced. That is one of the trends that we noted toward the end of the pandemic. However, once restrictions from the pandemic were lifted, rates migrated back down given that patients were able to be screened or biopsied.”
Push for screenings
Experts with whom Healio | HemOnc Today spoke said collaboration with primary care physicians is key to bring cancer screenings back to pre-pandemic levels.
“As far as a solution goes, we need to come at this by going outside of oncology,” Lewis said. “This is something that we rely on our gastroenterologist colleagues and our surgeon colleagues for, but most of all, it is crucial that we do not forget about our primary care physicians. We need to make colorectal cancer screening as much a part of primary and preventive care as we have with mammography and cervical cancer screening. We do a fantastic job of normalizing those types of screening for women, but we have not done the same for colon cancer screening.”
Lewis said that when women go in for their annual mammography at Intermountain Health, they are given literature that reminds them to have their colorectal cancer screening, as well.
“One thing that we have thought about is if the patient is already at the point of care, perhaps we should co-dispense a stool screening test,” Lewis said. “That’s the kind of thing we’ve been thinking about creatively as we’re already screening individuals for other cancers — can we use that time to be more inclusive and thoughtful and also capture people who need to be screened for colorectal cancer?”
Spiegel agreed.
“There have been efforts across the board to increase awareness about the importance of cancer screening. As someone who treats patients with breast cancer, I am acutely aware of the need for annual mammography and I ensure that my patients are up to date with their follow-up imaging,” Spiegel said. “However, the bulk of the outreach is done before patients even get to my office. Our primary care physician colleagues and radiology colleagues have been working tirelessly during the height of the pandemic and afterward to call patients and send them letters or reach out via our electronic medical record software, urging patients to come in for their scheduled screenings and remind them when they are overdue for screening.”
Villena-Vargas said the increase in late-stage cancer diagnoses will be a “blip” in time and the increase in patients initially diagnosed with late-stage disease eventually will be corrected.
“The bright side of all this is the fact that people are much more aware of their health now, especially lung health, and there are more people undergoing X-rays and CT scans because of COVID-19,” Villena-Vargas said. “The broader implications are that it will be a ‘blip’ and we have already noted this. It may last a little bit longer, but overall, everybody is returning to the hospital and getting the appropriate screenings and follow-up.”
Spiegel said more access points to care are necessary for any future pandemic or natural disaster that may occur.
“We need to be mindful in the future if there are other situations like the COVID-19 pandemic, where things are essentially shutdown for prolonged periods of time,” Spiegel said. “Being mindful that situations like this can have a significant impact downstream is important, and we must create priorities so that patients can get their screenings done on time or with very minimal delays. It is so imperative to tell your family, friends and patients about the importance of screening mammograms and use any tools at your disposal to create awareness about it. For those of us physicians who are on social media, promote breast cancer awareness and remind your followers to get their mammograms and other screenings. That is probably the best thing that we can do to ensure that patients get back to being diagnosed early.”
References:
- Alagoz O, et al. J Natl Cancer Inst. 2021;doi:10.1093/jnci/djab097.
- Chen RC, et al. JAMA Oncol. 2021;doi:10.1001/jamaoncol.2021.0884.
- Concepcion J, et al. Am Surg. 2022;doi:10.1177/00031348221091948.
- Fedewa SA, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.15490.
- Lloyd MR, et al. J Clin Oncol. 2022;doi:10.1200/JCO.2021.39.15_suppl.528.
- Mynard N, et al. Clin Lung Cancer. 2021;doi:10.1016/j.cllc.2021.08.010.
- Reddy SR, et al. Curr Med Res Opin. 2022;doi:10.1080/03007995.2022.2047536.
- Zhou JZ, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2021.48581.
For more information:
Mark A. Lewis, MD, can be reached at Intermountain Healthcare, 5171 S. Cottonwood St., Bldg. 1, Suite 610, Murray, UT 84017; email: mark.lewis2@imail.org.
Daphna Y. Spiegel, MD, can be reached at Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215; email: dspiegel1@bidmc.harvard.edu.
Jonathan Villena-Vargas, MD, can be reached at Weill Cornell Medicine, 418 E 71st St., #21, New York, NY 10021; email: jov9069@med.cornell.edu.
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