The COVID-19 pandemic has forced some changes in how cancer care and treatment are provided, with enhanced safety protocols to ensure limited risk of exposure. Between taking cautionary measures and determining vaccination recommendations, oncology providers have been busy relaying up-to-date information to their patients for almost a year. While best practices are becoming increasingly well-defined, what is less clear are the long-term oncological implications stemming from the virus-with screening being one of these variables.
For example, Lisa Kennedy Sheldon, PhD, ANP-BC, AOCNP, FAAN, Clinical and Scientific Affairs Liaison at the Oncology Nursing Society, explained that one of the great changes in oncology treatment and diagnosis due to COVID-19 occurred in the early part of the pandemic, from March to May in 2020. This is when she and her colleagues began to see delays in treatment, an increase in telehealth, and an increase in oral agents.
"Most dramatically though, we saw a decrease in cancer screening, which has continued even past the original lockdown days of the pandemic. The decreases in breast and colorectal screenings were down almost 80 percent," Kennedy Sheldon said.
Norman E. Sharpless, MD, Director of the National Cancer Institute (NCI), shared that between clinical care facilities closing or reducing operations early on, and patient fears regarding entering health care clinics, cancer care has certainly been disrupted during the pandemic. As oncology professionals know that screening measures such as Pap smears, mammograms, and colonoscopies are effective in reducing cancer mortality, their delay is especially alarming.
From the data collected by a cloud-based electronic health record, Sharpless noted researchers have seen there was a dramatic decline in the screening of nonsymptomatic "healthy" patients from March through at least June of 2020, amounting to a greater than 90 percent decrease in screening visits.
"We've also seen a decreased diagnosis, as most patients don't discover their cancer through screening, but it's discovered when they present to a doctor with a symptom of cancer," Sharpless explained. "If patients don't come in for those evaluations because the clinics closed or they don't want to be out in pandemic times, then those new diagnoses will be delayed."
Sharpless added that, as the NCI has no reason to believe that the incidence of cancer has been cut in half during the pandemic, oncology leaders are concerned that a fraction of these cancers will end up being diagnosed at a later date. When diagnosed later, they may presumably be more advanced, harder to treat, and harder to cure.
"[We think that] a variety of measures, including decreased screening, decreased diagnoses, and decreased care are all going to translate into excess mortality," Sharpless said. "The challenge of the NCI is to figure out how we can make the impact of a pandemic the 'least bad' possible, and how we can mitigate those effects and sort of make up the screenings and try to catch up."
The Future of Screening
Moving forward, Sharpless noted the NCI is now starting to see screening return to pre-pandemic levels. However, the agency believes that since the onset of the pandemic, more than a half a million screenings were missed. Further, just as his team suspected, oncologists are finding that many of the patients returning for screenings they had missed have more advanced lesions.
"[Typically,] 8 percent of lesions will look like they might be cancer. In the catch-up data, now it's over 20 percent that look like they're suspicious for malignancy," Sharpless noted. "That's an ominous sign that if you don't diagnose the cancer today and wait 9 months to diagnose it later, there's a potential that you diagnose it at a later stage and [with a] worse outcome. Upstaging is what we worry about with delays in diagnosis."
To date, Sharpless does not believe there's been one cancer where there's been preservation of screening versus the other ones, but rather that the absence or delay of screenings has been generally uniform across the board. He believes the NCI needs to look into research on the stage of diagnoses, grade of tumors, and other elements of screening delay as they relate to morbidity. If certain cancer patients are diagnosed later, but the outcomes are exactly the same and the tumor is not upstaged, this will help the agency conclude that some cancer screening is not as important, indicating overdiagnosis and overtreatment.
"If we see evidence that cancers are presenting at a later stage, needing more aggressive surgery to be cured or more comprehensive chemotherapy, or that they're leading to excess mortality, this will be informative on the topic of screening," Sharpless shared. "We're very interested in the stage that people present at these screened detected cancers, the morbidity that new cancer causes; the side effects of treatments; the side effects of the cancer in those populations; and the eventual outcome, cure, or death. All of those endpoints are things that we will follow."
Ultimately, Sharpless reasons that patients must seek to answer what screening measures are immediate versus what can be deferred for some time while the pandemic continues. For example, a healthy young woman with no family history of breast cancer or breast pathology could potentially defer her mammogram for 6 months or a year after discussion with a physician.
"Should that same patient have a symptom, a new lump, or a painful breast lesion, then they should not defer that care," Sharpless explained. "The details of these matters make it hard to suggest general recommendations on what patients should do."
Instead of following general recommendations, Sharpless advises patients to discuss their cancer screenings with their health care provider, who should be well-informed of NCI best practices. Furthermore, the NCI has a number of resources for both providers and patients, including COVID-19 recommendations, on the agency's website (http://cancer.gov).
Overall, Sharpless concludes that health care professionals now have enough experience with the coronavirus in health care settings to be able to provide both great cancer care and great COVID-19 care. He believes this is extremely important because the NCI does not want to exchange one public health crisis, the pandemic, for another health crisis, the public health care crisis of excess cancer mortality.
"I think the NCI has an obligation to provide research funding to scientists to try and understand the effects of this decreased screening on cancer outcomes," Sharpless said. "We need to get back on track. That's the goal."
Lindsey Nolen is a contributing writer.