Fewer screenings early in the pandemic were expected to produce a wave of late-stage cancers afterwards. From our vantage point, it's still taking time to materialize.
In early 2020, as stay-at-home orders took hold across the United States and medical practices emptied, it didn’t take long for many of us in the oncology community to arrive at a scary conclusion. We believed that a precipitous and extended drop in cancer screenings would result in a wave of cancer cases going undetected. As restrictions eased and patient volumes rebounded, those cancers would finally be diagnosed, but at more advanced stages. Patients who might have survived had their disease been caught earlier might die, and more money would be spent on high-cost drugs for their advanced cancers.
It was—and is—a logical conclusion. Major media outlets warned of this looming "shadow" health crisis, featuring stories of patients presenting with metastatic disease that should have been caught earlier. Such anecdotes do not appear to have been cherry-picked. I recently asked members of New Century Health’s Radiation Oncology Scientific Board whether they have seen a higher number of advanced-stage cancer cases this year, and they all said yes.
This all makes it more perplexing that, so far, we at NCH have yet to see this expected surge.
True to initial expectations, the number of new authorizations for chemotherapy declined significantly across our health plan partners early in the pandemic.
From March through September 2020, there were 25% fewer authorizations as compared to the same period the year before. Cancer doesn’t take a break for COVID-19, so it follows that we would eventually see those missing cases.
We’ve continued to watch the trends, as the overall volume of cancer cases has approached pre-pandemic levels. With the exception of two of our health plan partners, we have not seen the rebound of numbers above pre-pandemic levels that we had anticipated. Higher numbers of later-stage diagnoses also have yet to materialize.
Why the disconnect? One possible reason is that we tend to notice what we expect to see. Providers today may be attuned to remember the cases of patients with advanced disease that might have been detected had they not cancelled a routine screening. It's possible these patients are the first ripples of a larger wave that has yet to reach us. However, similar cases also occurred before the pandemic. Are they happening more often today than before?
Another possible explanation is suggested by a study by Dana Farber researchers. They reported that while screenings plummeted during the early months of the pandemic, cancer diagnoses did not decrease by nearly as much. That is because screening tests had a much higher positivity rate than they did before the pandemic. The results suggest that many higher-risk patients overcame the social-distancing barriers and continued to get screenings. Yes, cancer diagnoses were down, but not by as much as we initially thought they might be.
Unfortunately, I still strongly suspect we will see a surge in advanced-stage cancers, even if it is not as dramatic as what we had feared. A small but growing body of research also backs this theory. For example, an oncology clinic in Turkey reported an 11% increase in the percentage of referred patients with inoperable or metastatic cancer in the first 10 months of the pandemic. In Northern Italy, an early COVID-19 epicenter, a two-month halt on mammograms was associated with increases of more than 10% in the rates of more advanced breast cancers.
A wave of more advanced-stage disease may take longer to ramp up in 2022 and have a longer plateau than originally predicted, but it's hard to fathom that it will not come.
About the AuthorFollow on Linkedin More Content by Andrew Hertler, MD, FACP