As Pandemic Continues, Screening Concerns Grow

When the COVID-19 pandemic began, oncologists were mildly concerned about how it might affect cancer screening. Many months later, amid the continuing pandemic, their concerns about how extensively COVID-19 has disrupted screening have grown—along with their fears about the consequences.

“There's so much attention on COVID-19—and rightfully so—but I think people are forgetting that preventive services need to continue,” says Folasade May, MD, PhD, of the University of California, Los Angeles (UCLA).

UCLA and most other medical centers paused colorectal cancer screening for several weeks in March and April, leading to 90% fewer colonoscopies nationwide than usual. “It was just astounding,” May says. “It was as though someone took all the endoscopes overnight.” Moreover, colorectal cancer diagnoses dropped by 32%, even though “we know cancer didn't stop.”

Similarly, breast cancer screening largely halted. Constance Lehman, MD, PhD, of Massachusetts General Hospital (MGH) in Boston, estimates that more than 90% of mammograms were canceled in the United States due to the shutdown, including about 15,000 at MGH alone. The result: About half as many breast cancers as usual were diagnosed in April.

Skipped screenings or lengthy delays are concerning, May says, because the survival rate for stage I colorectal cancer is 90%, compared with 11% to 15% for stage IV disease. “I think, unfortunately, we'll have later stage at time of diagnosis for a while.”

Lehman has already seen this play out at MGH, where more than 90% of patients diagnosed with breast cancer through screening typically have early-stage disease, a percentage that has dropped to around 65%. Also concerning, Tari King, MD, of Brigham and Women's Hospital (BWH) in Boston has patients who felt a breast lump early in the pandemic but waited 6 or 7 months to seek care, resulting in more advanced disease.

Although screening centers now have COVID-19 safety measures in place, some patients are hesitant to reschedule. To combat this, providers are educating patients about precautions they're taking, and May emphasizes that no patients screened at the UCLA endoscopy unit have contracted coronavirus. “We're trying to use a data-driven approach to help patients feel [comfortable] coming in,” she says.

Eric Flenaugh, MD, of Morehouse School of Medicine and Grady Hospital in Atlanta, GA, who saw lung cancer screening drop by about 50%, has turned to public service announcements and a Facebook Live event to draw patients back.

Concerns remain, however, that that won't happen as patients juggle work and childcare—and deal with challenges such as losing health insurance. In particular, the pandemic may increase existing screening disparities for Black and Latino patients, who are disproportionately essential workers. “I'm a little bit worried that we're going to lose some of the success we've had in minimizing disparities,” May says.

King agrees. “The underrepresented minority population is the group that is not rescheduling” breast cancer screening, she says.

Flenaugh largely cares for medically underserved African American patients, who are at higher risk of disease yet often resistant to lung cancer screening. His center uses automatic reminders and presses primary care physicians to recommend screening. “Every institution is going to have to assess its patient population and come up with strategies to get these patients back in,” he says.

Yet there are some positive signs: May and Flenaugh are seeing screening rates for colorectal and lung cancer, respectively, rebound at their institutions. Breast cancer screening at MGH and BWH now tops 100% of the usual volume, in part due to centers opening on nights and weekends.

However, Flenaugh worries that screening may flag as coronavirus cases balloon again. “We will prioritize, we will take care of the acutely ill, we will get through this crisis,” he says, “but we also need to stay preventative.” –Catherine Caruso