200,000 Cancer Cases May Have Gone Undiagnosed at Start of Pandemic: What Do We Do Now to Get People the Care They Need?

The [study] ratifies the notion that 2020 saw a reduction in cancer diagnosis [for] all types of cancers, with the most significant reduction [seen in the number of] early-stage cancer diagnoses [accompanied by] an increase in advanced-stage cancers, states Dr. Reddy.

This decline, unfortunately, does not represent a real decrease in cancer during this time. Instead, it alerts us to the fact that many new cases of cancer were missed due to delays in cancer care from COVID-19-related shutdowns and quarantines.

That means these people could eventually be diagnosed with their cancers in later stages, needing more aggressive treatments or leading to poorer outcomes.

To help get these people the care they may seriously need, physicians will need to prioritize assessing their patients’ cancer risk and identifying those who fell off their screening schedules. And patients will need to be proactive in getting back to their doctors to get any screenings they missed.

The Study

Researchers surveyed the National Cancer Database (NCDB), which is a rich database of cancer cases from 1,500 Commission on Cancer (COC)-accredited cancer centers across the United States and Puerto Rico. The NCDB, therefore, gives us a unique insight into the incidence and clinical outcomes of various cancers, including lung, colorectal, pancreatic, breast, and prostate cancers.

The researchers looked at more than 4 million cancer cases that either were diagnosed and/or received their first course of treatment between Jan. 1, 2018, and Dec. 31, 2020.

Of these, around 1.2 million were treated in 2020, the year that saw the beginning of the COVID-19 pandemic. They looked at seventeen different cancer sites, including the brain, breast, gastrointestinal system, female and male genital systems, urinary system, and lungs, among others.

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The Pandemic’s Impact on Cancer Care

It helps to put 202 into perspective with previous years.

In terms of the sheer number of total new cases from all cancers, there was a 2.6% increase in new cancer cases in 2019 when compared to 2018. This increase was in keeping with the expected yearly trend in cases.

In a stark departure from this trend, there was a 14.4% decrease in the number of cases from 2019 to 2020. The researchers say this represents more than 200,000 missed cases during 2020.

To analyze this blip more granularly, the team looked at monthly trends in 2020. They observed the most precipitous decline in March and April 2020, months that correspond with the onset of the pandemic, stay-at-home orders, and amended triage guidelines.

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The reduction in new cases was not uniform across all cancers.

Some cancers declined by 10-12%, such as breast cancer, while others declined by more than 20%, such as thyroid cancer. There was a notable decrease in the percentage of early-stage cancers with a corollary increase in late-stage cancers across most cancers.

The Impact Is Significant

The drop in cancer cases during the first few months of the pandemic is somber news. Many cancers that would have been caught at early stages during normal times are now "missing."

That means these cancers have gone uncaught and unchecked, likely to progress to more advanced stages, when they will require much more aggressive treatments and be less curable.

Dr. Reddy foreshadows, "The reduction in screenings, which is still playing catch-up after 2 years, and the subsequent reduction in detection of early cancers strongly indicates that there will be an increase in more advanced cancer cases over the next few years. This will require careful analysis to be ascertained."

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The National Cancer Institute (NCI) estimates that there will be more than 10,000 excess deaths in the United States from colorectal and breast cancers over the coming decade due to delayed mammograms and colonoscopies.

Beyond compromising patient outcomes, this fall in NCDB cancer rates will disrupt the study of cancer trends and outcomes.

Researchers study these trends to report how successful cancer screening measures are, and how advances in treatments affect patient outcomes. Thousands of peer-reviewed articles have used the NCDB database.

Future studies that use this database and include statistics from 2019 should be carefully and meticulously contextualized, and it should be noted that trends from this year may not be indicative of the real-world cancer landscape.

These facts underscore the importance of preventative measures and cancer screenings in catching the disease at its early stages. Early-stage cancers, as compared to later stages, are significantly more curable with potentially less-harsh treatments.

Screening Is More Important Than Ever

Screening saves lives. Quite literally.

When done appropriately, screening can identify cancers when they are small, confined, and typically symptom-free. At such early stages, patients have the highest chance of beating their disease, possibly with less-toxic treatments.

For some cancers, screening can also identify pre-cancers, which can be preemptively treated to prevent the development of clinical cancers.

Many leading clinical bodies, such as the United States Preventative Task Force (USPTF) and the American Society of Clinical Oncology (ASCO), have formulated guidelines on screening for many common cancers, such as breast, cervical, prostate, lung, and colorectal cancers.

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Screening has tangible benefits for cancer care.

Pap smears and human papillomavirus (HPV) testing, which detect abnormal cells that can turn into cervical cancers, have led to a 45% decline in cervical cancers over the last few decades.

Colonoscopies, which can catch polyps with the potential for turning into colon cancers, have decreased colorectal cancer rates by 55% over the same time.

The Silver Lining

There may be a silver lining to the pandemic clouds: they have forced a strained healthcare system to rapidly adapt.

Instead of bringing patients in for in-person visits, many providers started to offer telemedicine appointments. Beyond the convenience, these appointments give physicians a chance to incorporate questions about patients' risks for different cancers.

Should this risk warrant further examination, testing, or cancer screening, the physicians can then bring these patients in.

Without telemedicine, such patients could have fallen through the cracks.

The cancer testing and screening industry has adapted as well. Many mammography centers now offer walk-in appointments, same-day mammogram results, and additional testing/imaging if necessary.

Home-based testing for colorectal cancers, such as fecal immunochemical test (FIT) which detects blood in stools, has gained popularity due to its convenience and cost.

While it is not a true replacement for a traditional colonoscopy, it can help identify the patients who are most at risk for developing colon cancer. They can then be brought in for follow-up coloscopies.

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Such evolutions in cancer screening methods are much-needed, especially in the case of a future pandemic. Dr. Reddy stresses, "Greater emphasis on screening will be critical. This is critical across all socio-economic classes and across all cancer where screening has been demonstrated to reduce [patient death]."

He continues, "Screening has historically been sub-optimal in underserved communities and the pandemic-related restrictions have only increased the difficulty. All community leaders, activists, and cancer and primary care clinics will need to work collectively to emphasize screening more than ever before."

Let's Get Back On Track

How can we help get the necessary care to these “missing” cases?

For patients, this means that they need to get back on track with their cancer screenings. While it may have been necessary to delay them during the thick of the pandemic, cancer screenings should be resumed on the recommended schedules as soon as possible.

Catching your cancer early could be the key to beating it!

For physicians, these results are a wake-up call. They need to be more proactive than ever in assessing their patients' cancer risks and recommending appropriate screenings.

This may require identifying and following up with patients who fell off their screening schedules as well as working with community outreach programs to highlight the importance of getting back on track.

Oncologists should additionally be prepared to handle the "missing" cancer cases as they are identified over the next few years. These cancers will likely have progressed to more advanced stages.

Dr. Larry An, Associate Professor of Internal Medicine and Assistant Director for the Community Outreach and Engagement program at the University of Michigan Rogel Cancer Center, has been working with Michigan Primary Care Association (MPCA), Michigan's statewide network for Federally Qualified Health Centers (FQHCs), to "to help catch up on cancer screenings that were missed during the pandemic."

He says, "We have been working with MPCA to raise awareness of the pandemic impact on cancer screening and to encourage catch-up on missed screening. Major strategies have included proactive outreach to patients who are overdue for cancer screening through the combined use of population health messaging tools and direct calls from community health workers. Our efforts have included the promotion of home-based stool testing."

The overarching goals of their efforts are to especially increase "screening for breast, cervical, and colorectal cancer and coordinate appropriate and timely follow-up for people with abnormal screening results.”

The healthcare system and the cancer screening industry should continue to evolve to develop more convenient and accessible testing so that if we encounter another healthcare crisis like the pandemic, we are better prepared to continue cancer screening in its midst.

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