The Effect of COVID-19 on Cancer Screenings

CBS News covered the stories of Rhonda Johnstone and Yvette Lowery, two women who waited months for their cancer diagnoses due to the backlog caused by deferred cancer screenings at the height of the pandemic. When they could finally get an appointment, both women were diagnosed with advanced stage breast cancer.

In June of 2020, The American Society of Clinical Oncology recommended that mammograms and colonoscopies be postponed to reduce the number of patients being exposed to COVID-19 at heath care facilities. Although well intended, this deferral in screenings has led to a reduction in cancer detection and an increase in late-stage cancer diagnoses.

This article discusses how COVID-19 has impacted cancer screenings, the importance of cancer screenings, and oncologists’ concerns about the expected effects of delayed screening.

COVID-19 has led to a dramatic decline in cancer screenings

Cancer screening is the detection of cancer or precancerous cells in asymptomatic patients. This differs from early diagnosis, which occurs after the onset of symptoms. Getting a Cancer screening certainly aids in early detection, and, in some cases (such cervical cancer), it can even prevent the development of cancer when precancerous cells can be treated or removed. Studies have shown that cancer screening allows for early treatment, which improves survival rates and quality of life.

In March 2020, the Epic Health Research Network (EHRN) reported an 86-94% decrease in breast, colon, and cervical cancer screenings at the onset of the pandemic in the U.S. Although screenings had increased by July 2020, they were still down by 29-36%, when compared to previous years. This study reported that in this 4-month period, a considerable number of cancer screenings were missed: breast (285,000), colon (95,000), and cervical (40,000).

Where possible, doctors are encouraging patient to take at-home tests, such as the fecal immunochemical test (FIT) used for colon cancer screenings. This would identify the patients that can’t afford to postpone a colonoscopy. Besides the reduction in cancer screenings, cancer treatments has also declined during the pandemic. A study of American senior cancer patients examined the number of medical claims for cancer drugs and reported a 26% decline in April 2020, which further dropped to 31% in July.

There are encouraging reports of cancer screenings that have returned to normal levels. A recent article in the Journal of General Internal Medicine, reported that breast and colon cancer screenings dropped significantly in March 2020 but had recovered by July. This demonstrates that heath care facilities worked diligently to restore cancer-screening programs. Of course, the restarting of programs does not mitigate the effect of missed appointments.

COVID-19 had similar effects on cancer care in Europe. In response to these effects, the European Cancer Organization released a 7-step plan to address issues such as, delayed screenings and prevention programs, symptomatic patients that have not yet been seen by a physician, and halted clinical trials.

Decreased cancer screening is expected to have detrimental effects, as late diagnosis is associated with a less favorable outcome. According to Dr. Mazen Mislmani, a radiation oncologist at West Michigan Cancer Center, “The goal is to catch patients when the tumor is as small as possible and as early as possible.”

Cancer statistics

Besides effectiveness, one of the criteria used by the World Health Organization (WHO) to condone the implementation of a screening program is the prevalence of the disease. After cardiovascular disease, cancer is the greatest cause of morbidity in the world.

Based on the latest cancer incidence rates (from 2017), the Centers for Disease Control and prevention (CDC), reported that 1 in 4 Americans die from cancer.

Breast (125 in 100,000) and prostate cancer (107 in 100,000) are the most commonly diagnosed, and lung cancer has the highest mortality rate in both men and women. Such data shows that cancer screening is certainly warranted. The main goal of cancer screening is to reduce cancer mortality.

Cancer screening is crucial to treatment and prevention

There has been some debate about cancer screening due to the 4 primary risks involved:

• (1)False positive results, in which an individual is incorrectly diagnosed with cancer,
• (2)False negative results, in which cancer goes undetected,
• (3)Over diagnosis, when a individual is diagnosed with a slow-growing cancer that would not cause adverse effects during their lifetime, and
• (4)The stress, discomfort, or unpleasant side effects associated with certain invasive tests.

For these reasons, cancer screening is advised based on a person’s relative risk, such as age and familial history. In this way, the benefit is expected to outweigh the risk.

After age 21, breast and colon cancer screenings are advised for high-risk persons, while those with an average risk should begin at age 45. Men are also encouraged to being prostate cancer testing at this age.

Cervical cancer testing for women is advised from age 25. Persons 55 and older, especially active or former smokers, should consult with their physician about lung cancer screening.

Besides screening, it is crucial to seek medical attention at the onset of symptoms. An article published in the British Journal of Cancer reported that the majority of breast, cervical, and colon cancers diagnoses were based on referrals from general physicians (47%), not screening results (5%). This emphasizes the importance of patients reporting symptoms.

Early detection allows cancers to be treated before they spread to neighboring tissues, at which point they are much more difficult to treat. Scientific studies have reported the benefits of screening for breast, cervical, colon, and prostate cancer.

The treatment of breast cancer that has not invaded neighboring tissues has a 100% 5-year survival rate. A Swedish study that included over half a million women, ages 40-69, found that breast cancer screening reduced the risk of dying from breast cancer within a 10-year period by 41% and the development of advanced-stage cancer was reduced by 25%.

The introduction of cervical cancer screening in the 1940’s has reduced the rate of cervical cancer mortality by 70%. Higher incidences of cervical cancer in developing countries is reportedly due to the absence of screening programs.

A 2013 report of 2 large U.S. cohorts reported that a colonoscopy reduced the risk for colon cancer development by 56%. Another study that included over 45,000 participants reported that annual stool tests reduced colon cancer mortality by 32%.

Prostate cancer screening has received criticism due to uncertainties about the added benefit of screening. In 2009, 2 studies reported contradictory results about the effect of prostate cancer on mortality. When researchers reviewed this data in 2017, they noticed and corrected inconsistencies, and concluded that both trials, in fact, showed that prostate cancer screening reduced mortality by 25-32%. The general consensus seems to be that screening is protective, but proper implementation will determine whether the overall result is beneficial.

Studies predict an increase in cancer mortalities

Experts can only estimate the effects of missed and delayed screenings caused by the COVID-19 pandemic. European researchers predict that missed screenings for breast, colon, throat, and lung cancer, will cause up to 3600 additional deaths over the next 5 years.

Studies in the U.S. show that about 22 million cancer screenings were delayed during the pandemic. The U.S. National Cancer Institute estimates that missed or delayed breast and colon cancers alone are expected to cause 10,000 extra deaths in the coming decade.

Professor Clare Turnbull, whose group published an article highlighting the expected effects of delayed screening in England, commented in a July 2020 article in Nursing Times that a 2-month delay in treatment could be the difference between a curable and incurable disease. She suggested that patients with the highest mortality risk should be prioritized for screening to reduce the mortality burden that is expected to come as a result of the delayed screening.

Take-home message

Oncologists have taken to the media to encourage patients to reschedule cancer screenings and to come in for treatment.

Dr. Randall A. Oyer, medical director of the Ann B. Barshinger Cancer Institute in Pennsylvania says, “We’ve learned how to keep our medical centers safe and we expect people to come in for their screenings and treatments. We now know how to continue providing live-saving care.”

Radiologist and director of breast imaging at Memorial Sloan Kettering in New Jersey, Dr. Nicole Saphier, closed a Fox News interview with these words, “COVID is bad, cancer is worse. When it comes to cancer, early detection saves lives.”

About the Author: Vinni Juneja, M.D.

Dr Juneja joins Maryland Oncology Hematology at the White Oak Cancer Center after 13 years of practice in Northern Virginia and Bethesda. He has subspecialized in breast, gastrointestinal, lymphoma, and myeloma in his prior practices. He is very interested in clinical research and cutting edge as well as precision medicine. Previously, he has designed clinical trials with Bristol Myers Squibb, been a medical officer at the FDA, and has been an investigator in several clinical trials.

Having survived cancer himself, he completely understands what it is like to be a patient. He lives with his wife, 2 children, dog, and enjoys playing piano, tennis, running, bicycling, and sailing.

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