As the COVID-19 Pandemic Continues, Fewer Patient-Physician Encounters Suggest Later-Stage Disease at Presentation

When the Centers for Disease Control and Prevention issued guidance recommending against any gathering of 50 or more people on March 15, 2020, it started a cascade effect in which many medical apppointments—such as office visits, elective surgeries, and screenings—were cancelled, rescheduled, or delayed. The next day, on March 16, 2020, President Donald Trump issued new guidelines urging people to avoid social gatherings of more than 10 people and to restrict discretionary travel. Since then, in order to mitigate the potential spread of the disease, patientphysician encounters have been limited. With fewer physician visits occurring, some experts have surmised that decreases in preventive health screenings may result in more late-stage disease diagnoses at presentation.

This has been especially true for patients with new and current neoplasms that were malignant and benign. Investigators in the Department of Cancer Biology at the Sidney Kimmel Cancer Center of Thomas Jefferson University in Philadelphia, Pennsylvania, quantified the effects that the coronavirus disease 2019 (COVID-19) pandemic has had on current and prospective patients with cancer by reviewing records from the Cancer Research Network’s TriNetX platform. TriNetX is a global federated health network that aggregates data from electronic medical records, including demographics, diagnoses, procedures, medications, laboratory testing, and genomic information. It includes academic medical centers, community hospitals, and physician practices. The study investigators evaluated 20 United States institutions that represent more than 28 million patients.¹

Investigators identified cancer cohorts based on current (January 2020 through April 2020) and pre-COVID (January 2019 through April 2019) patient-physician encounter data. There were 2 main cohorts: patients with health care organization encounters who had diagnostic ICD-10 codes for neoplasms (C00-D49) and those with diagnostic ICD-10 codes for a subset of malignant neoplasms (C00-C96, D37-D49).

Both cohorts were further stratified so that within each, a subgroup of patients with newincidence encounters—defined as those having no previous encounter with the health care organization related to the indicated diagnosis— was added. These patients with new-incidence disease may have been seen at the health care organization for screening, initial diagnosis, second opinion, or treatment initiation. Investigators similarly analyzed data from a health care institution in the United Kingdom.

The study authors reported a significant decline in encounters with all current cohorts. The number of encounters with patients with malignant cancer decreased by −3.5% (138,269 to 133,468) in January 2020 versus 2019, whereas February 2020 showed a decline of −6.3% (130,576 to 122,400) (FIGURE 1).

For patients with new incidence of malignant cancer, in January and February there was an increase in the number of patients in 2020 compared with 2019 (11.5% and 4.3%, respectively). This trend had reversed by March 2020, with a change of −22.3% (12,297 to 9,551) and further decreased to −65.2% in April (13,783 to 4,791) (FIGURE 2).

The largest decrease in the number of patients with malignant cancer seeing clinicians occurred in April 2020 at −50.0% compared with the year prior. By malignant tumor type, the lung, colorectal, and hematologic cancer cohorts demonstrated smaller decreases in the number of cases in April 2020 versus 2019 (−39.1%, −39.9%, and −39.1%, respectively) compared with decreases for breast cancer, prostate cancer, and melanoma (−47.7%, −49.1%, and −51.8%, respectively) (FIGURE 3).

Cancer screenings also declined drastically, in particular mammograms (down 89.2%) and colonoscopies (down 84.5%) (FIGURE 4). This may have the greatest impact looking ahead, potentially resulting in an increase in the presentation of later-stage disease for newly diagnosed patients in future months.

_Reference

_{1. London JW, Fazio-Eynullayeva E, Palchuk MB, Sankey P, McNair C. Effects of the COVID-19 pandemic on cancer-related patient encounters. JCO Clin Cancer Inform. 2020;4:657-665. doi: 10.1200/CCI.20.00068}