Michael Zinner, MD

As administrators, physicians, and researchers at cancer centers, we are well aware of the significant impact that the COVID-19 pandemic is having on cancer care worldwide. We are dealing with what I refer to as a “ticking time bomb”―one that will alter the oncology landscape for years to come. Although some of its effects are still unknown, one thing is no longer a mystery: The projections made in the early phase of the pandemic―that the decrease in cancer screenings and disruption in services would result in later-stage diagnosis and poorer outcomes―are now a reality and are only going to worsen. The slow-burning and unpredictable fuse on our ticking time bomb, unlike those designed expertly for pyrotechnics, cannot be fully controlled by us. But as it smolders and sparks on the way down its path, we cannot afford to ignore its warning flares.

Approximately 1.9 million people are newly diagnosed with cancer in the US each year, and that number is expected to grow to 2.3 million by 2030.¹ Across the globe, 10 million people died from cancer in 2022. Timely screenings are known to increase earlier detection, with a lower stage at diagnosis typically leading to a more favorable treatment response. A study published in JAMA Oncology revealed that the pandemic resulted in a shortfall of 9.4 million screenings in the US for breast, colorectal, and prostate cancer alone.² We know that government- imposed lockdowns, travel restrictions, staffing and supply chain problems, coupled with the lack of a vaccine, made it difficult for most to access cancer screenings and care at the start of the pandemic. For some, those hardships have persisted. In addition, the understandable fear experienced by many kept them from hospitals and doctors’ offices even as safety precautions were enhanced, vaccines were developed and administered, and the medical and scientific communities gained a better understanding of the virus.

Miami Cancer Institute Numbers

At Baptist Health Miami Cancer Institute, we performed a retrospective study to determine the impact of the COVID-19 pandemic on potential stage migration of melanoma, breast cancer, and colorectal cancer. We analyzed 2168 patients, comparing clinical and pathological diagnosis staging values for the 22 months before COVID-19 and for the 22 months after COVID-19 and found the following:

• In the population with breast cancer, there was a statistically significant increase (+4.24%) between the number of patients diagnosed and staged with clinical stage T2 (ie, larger tumors). There was also a statistically significant decrease (–2.21%) in the number of patients diagnosed and staged with pathological stage 2 (ie, at an earlier stage).

• In the population with colorectal cancer, there was a statistically significant decrease (–8.73%) between those diagnosed and staged with clinical stage T1—that is, again, not the earliest stage. And there was a statistically significant increase (+12.67%) between those diagnosed and staged with clinical stage T4, the largest tumor stage, and a statistically significant decrease (–2.80%) between those diagnosed and staged with clinical stage 0, or the earliest stage of disease.

• There was no statistical difference noted for the population of patients with melanoma.

Additionally, we looked at those populations with diagnosis dates of 12 months before COVID-19 and 12 months after COVID-19. There were statistically significant increases in colorectal cancer clinical stage and in the population of patients with melanoma.

Our findings are consistent with a delay in diagnosis and lack of screening, and although showing a single institution’s experience, our results, which were submitted for publication, may be able to be generalized to the nationwide oncologic population. To improve understanding of the comprehensive impact of COVID-19 on patients with cancer, additional studies over expanded time intervals should be performed.

Tactics for Success

Our “true north” at Miami Cancer Institute is our patients and the community. They deserve top-quality cancer care. As we considered how to proceed to counteract the obstacles that COVID-19 threw our way, we turned to true north to guide us in our daily work. We opened our screening protocols and reopened all our sites as quickly as we could. We implemented strict safety precautions. We spoke to primary care practitioners about the importance of reminding patients that screenings save lives and encouraged them to write prescriptions for appropriate screenings as quickly as possible.

Every health care organization in the country has had difficulty returning to preCOVID-19 staffing levels, and the problem persists in 2023. In high demand, nurses, imaging techs, and others are difficult to recruit, and in this very competitive market, the financial burden on health care facilities has grown immensely. In an American Hospital Association report, Data Brief: Health Care Workforce Challenges Threaten Hospitals’ Ability to Care for Patients, it was reported that staffing shortages, over the course of the first year of the pandemic alone, had cost hospitals $24 billion.³

In addition to bringing more people on board, we have worked diligently to find solutions that improve access to care. We have several areas of focus at Miami Cancer Institute, including the following:

• Incorporating artificial intelligence (AI).

We want to grow our use of AI to help with everything from analyzing large data sets, streamlining administrative tasks, improving operational efficiencies, and enhancing the patient experience. AI can better the efficient utilization of patient-needed and revenue- generating assets, such as radiology suites and chemotherapy chairs, and align patient visits so they can be seen expeditiously.

• Addressing disparities in care.

We are fortunate to have an extremely diverse population in Miami, Florida, which makes us a very attractive partner in clinical trials. We offer several hundred clinical trials a year and 65% of our participants come from underrepresented individuals. That is almost unheard of elsewhere. Yet, like the rest of the world, we still grapple with the issues surrounding health care inequities among underserved populations― exacerbated by COVID-19. We know there are often problems with transportation, childcare, language, and communication. At our institute, we have been working to get navigators within the community who speak the same language and understand the culture. Funded by wonderful philanthropists, we recently established the Center for Equity in Cancer Care & Research to help identify social determinants of health and improve access to clinical trials.

• Developing a more collaborative workplace.

The more complex cancer care has become, the more crucial it is to break down silos and work in a multidisciplinary setting. This ensures that patients receive the most appropriate and timely interventions. We also have a deeply inclusive culture, recognizing that all team members’ engagement is key to success. As we move from 2023 and into 2024, we will continue to nurture that culture, understanding that many of the best ideas come from the front lines; build programs that recognize, reward, and share success; and support our teams with mental health programs that address stress, anxiety, work, and personal demands. A culture of empathy, compassion, and patient centeredness is possible only when you have an environment where everyone feels valued.

Reason for Optimism

We are getting better at developing highly targeted and effective therapies that offer improved outcomes for patients. We have cures where we used to have none. We have doubled life expectancy among some of the worst types of cancer. We continue to revise cancer screening guidelines to apply a personalized approach. We are on the cusp of having liquid biopsies widely available, making detection more accessible and less expensive. We are pushing the frontiers of care.

If we can make these astonishing advances in cancer care, there is no reason we cannot work together to not only lessen the impact that COVID-19 has had on our ability to deliver the highest quality care, but to also exceed pre–COVID-19 numbers in screenings and other measures.

We have a responsibility to ourselves and our patients to remember our true north. I have every reason to be optimistic, and I hope you do, too.

Michael Zinner, MD, is CEO and executive medical director of Miami Cancer Institute in Florida.

REFERENCES

1. Cancer facts & figures 2022. American Cancer Society. December 1, 2023. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancerfacts-and-figures/2022/2022-cancer-facts-and-figures.pdf. Accessed.

2. Chen RC, Haynes K, Du S, Barron J, Katz AJ. Association of cancer screening deficit in the United States with the COVID-19 pandemic. JAMA Oncol. 2021;7(6):878-884. doi:10.1001/jamaoncol.2021.0884

3. Data brief: health care workforce challenges threaten hospitals’ ability to care for patients. American Hospital Association. October 2021. Accessed December 4, 2023. https://tinyurl. com/2p8y5brk