As Backlog of Delayed Cancer Screenings are Addressed, Inequities in Care Persist

When the COVID-19 pandemic forced patients with cancer to stay home and take extra precautions, it also forced thousands of others to delay routine screenings that would inform them of a potential cancer diagnosis. According to a study conducted by the Community Oncology Alliance (COA), there were significant reductions in breast (-85%), colon (-75%), prostate (-74%), and lung cancer (-56%) screenings at the beginning of COVID-19 in April 2020, compared with April 2019.¹

At the time of the study’s publication, lead study author Debra Patt, MD, PhD, MBA, FASCO, said that as cancer becomes more advanced, it becomes a ticking time bomb—the impact of these delayed screenings will be felt for years to come as rates of morbidity and mortality increase.

Now, a new study from COA showed that in 2022 breast cancer screenings have increased from their 2020 lows, but screening disparities among White patients and patients from minority backgrounds have been exacerbated.² For example, mean monthly mammogram screening rates of White Medicare Fee-For-Service beneficiaries dropped to 0.6% in April 2020, but by June 2020 recovered to 6.5%.

In comparison, American Indian/Alaska Native Medicare beneficiaries had a mean monthly screening rate of 0.5% in April 2020 that recovered to 3.1% in June 2020, still below the approximate 4% screening rate before the pandemic started.

In an interview with Targeted OncologyTM, Patt, executive vice president of policy and strategic initiatives at Texas Oncology and member of the COA Board of Directors, discussed the highlights of these studies and what the lasting impact of delayed cancer screenings could look like for patients. Moreover, she addresses what has been done about this issue and what still needs to be worked on.

TARGETED ONCOLOGY: What are some of the highlights of the original study COA conducted?

Patt: We characterized utilization of screening, diagnostic, and treatment services for cancer in 2020 vs 2019. What we observed is that for the 6 million patients in the study, there was a substantial decrease in screens for cancer for patients with breast, colon, lung, and prostate cancer observed during 2020.

Furthermore, these decreases in screenings also translated into decreases in cancer related biopsies, surgeries, and treatment, meaning patients in 2020 did not get appropriate cancer therapy. One could then estimate that the natural consequences of delays in diagnosis is that patients will present with later stages of cancer, which will increase morbidity and mortality related to those cancers, because when you diagnose the cancer at a later stage, it's less likely to be curable.

We've been tracking this over time, and what we observed in 2020 is the utilization characteristics were inversely proportional to rates of COVID, meaning that when COVID spiked people did not get their appropriate screenings. We also know that Medicare had a beneficiary survey and they characterized that a lot of Medicare beneficiaries chose not to get a screening, either because they were fearful of leaving their homes, or they didn't have a way to get screening reliably, or there wasn't the availability of screening in their clinics.

What are the prognostic models showing how COVID-19 is impacting cancer mortality now?

There are prognostic models that estimate cancer mortality changes over time because of the delays [from COVID-19], but I think that they're not inclusive of the whole picture, because they were done early in the pandemic. Cancer is something that grows over time, and sometimes it grows quickly or slowly, so I suspect it may be 3 to 5 years before we get a good estimate of all the implications on cancer mortality.

How does that look in a real-world scenario?

[For instance,] I'm a breast cancer specialist and if we were to diagnose a patient with stage III estrogen receptor-positive breast cancer this year, it would have been stage I in 2020. If that happens, the patient would [now] require more treatment; they will have to have chemotherapy, they will have to have a more aggressive surgery, and they will have to have radiation instead of maybe just surgery.

What we're observing at this point is what we call a stage migration, where patients are diagnosed at later stages of cancer, but I think that true estimates of cancer mortality will take several years to manifest.

How have patients from ethnic minority groups been impacted differently by delays in care from COVID-19 than other patients?

For individuals that are ethnic minorities, and individuals of lower socioeconomic status, they already have barriers to appropriate health care. During the pandemic those barriers were magnified and it was more difficult for these patients to get health care.

For example, there was an African American patient of mine who felt her breast mass grow, but she was struggling with her job and managing her family's competing priorities. Because of her competing priorities demanding so much of her, she felt like she didn't have time to address the growing mass in her breast. When she presented to me in 2021 with a stage III inflammatory locally advanced breast cancer, it seems the cure was out of reach, and she would have been better off if she presented earlier. [However], we were still able to put her on chemotherapy and immunotherapy, which is highly effective for people like her with advanced triple-negative breast cancer.

It eradicated her cancer before she went to surgery and she will have a good outcome, but she was far less likely to have a good outcome because of [when] she presented. Her situation was complicated because she has barriers in her life that make it more challenging to attain health care, [and this was emblematic of how] ethnic minorities and individuals with other barriers to health care saw those barriers exacerbated by the pandemic.

What were some of the efforts you were a part of to address this issue?

One of the things we did in collaboration with COA in a [screening awareness] campaign is that we identified a universal hotline [for people to contact so they] would understand the availability of screening studies in various communities.

That's important because you have states where screening is available, and generally if you have commercial insurance then screening, like a mammography, is covered. However, there's a lot of individuals that don't have health insurance. I live in the state of Texas, where there are about 30 million Texans, and 5 million Texans without any health insurance, so screening becomes a problem when you must pay for it.

_References

_{1. New study finds COVID-19 substantially reduced cancer screenings, diagnosis, and treatments in 2020. Community Oncology Alliance. Published October 21, 2020. Accessed August 9, 2022. https://bit.ly/3bG1Ipk}

_{2. Breast cancer screening rates improving from pandemic lows, but recovery remains unequal for certain minority groups. Community Oncology Alliance. Published March 14, 2022. Accessed August 9, 2022. https://bit.ly/3A6QrYr}