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Yvette Lowery usually receives her annual mammogram around March. But last year, as the pandemic gained a foothold and medical facilities closed, the center she was visiting canceled her appointment. No one could tell him when to postpone.
“They just said keep calling back, keep calling back,” said Ms. Lowery, 59, who lives in Rock Hill, SC.
In August, Ms Lowery felt a lump under her arm but still couldn’t get a date until October.
Eventually, she was diagnosed with stage 2 breast cancer, started chemotherapy in November, and had a double mastectomy this month.
“I’ve seen a lot of late stage patients,” said Dr. Kashyap B. Patel, one of Ms. Lowery’s doctors and CEO of Carolina Blood and Cancer Care Associates. If his cancer had been detected in May or June last year, he likely would have been caught before it spread, said Dr Patel.
Months of lockdowns and waves of rising Covid cases throughout the past year have closed clinics and testing labs, or reduced hours in other locations, leading to a sharp drop in the number of screenings, including for breast and colorectal cancers, experts said.
Numerous studies have shown that the number of patients screened for or diagnosed with cancer decreased during the first months of the pandemic. As of mid-June, the screening rate for breast, colon and cervical cancers was still 29 to 36% below their pre-pandemic levels, according to an analysis of data from the Epic Health Research Network. Hundreds of thousands of fewer screenings were made last year than in 2019, according to network data.
“We still haven’t caught up,” said Dr. Chris Mast, vice president of clinical informatics for Epic, which develops electronic health records for hospitals and clinics.
Another analysis of Medicare data suggested that as Covid cases increased during certain periods in 2020, cancer screenings fell. The analysis – conducted by Avalere Health, a consulting firm, for Community Oncology Alliance, which represents independent cancer specialists – found that test levels in November were about 25% lower than in 2019. The number of biopsies , used to diagnose cancer, was reduced by about a third.
Although it is too early to assess the full impact of delays in screening, many oncologists are concerned that patients are coming in with more serious illness.
“There is no question in practice that we are seeing patients with more advanced breast cancer and colorectal cancer,” said Dr. Lucio N. Gordan, president of the Florida Cancer Specialists & Research Institute, l one of the largest independent oncology groups in the country. He’s working on a study to see if, overall, these missed screenings resulted in more patients with advanced cancer.
And although the number of mammograms and colonoscopies has rebounded in recent months, many people with cancer still go undiagnosed, doctors report.
Some patients, like Ms. Lowery, could not easily get an appointment after clinics reopened due to pent-up demand. Others skipped regular tests or ignored worrying symptoms because they were afraid of getting infected or after losing their jobs they couldn’t afford the cost of a test.
“The fear of Covid was more tangible than the fear of missing a screen that detected cancer,” said Dr. Patrick I. Borgen, president of surgery at Maimonides Medical Center in Brooklyn who also runs its breast center. His hospital treated so many coronavirus patients early on that “we are now associated with the Covid hospital,” he said, and healthy people have stayed away to avoid contagion.
Even patients at high risk because of their genetic makeup or because they had previously had cancer missed critical screenings. Dr Ritu Salani, director of gynecologic oncology at UCLA Health Jonsson Comprehensive Cancer Center, said a woman at risk for colon cancer tested negative in 2019 but did not get her usual screening l last year due to the pandemic.
When she went to see her doctor, she had advanced cancer. “It’s just a devastating story,” said Dr Salani. “Screening tests are really designed when patients don’t feel bad.”
Ryan Bellamy didn’t feel rushed last spring to postpone a canceled colonoscopy, even though the presence of blood in his stool had prompted him to look for symptoms. “I really didn’t want to go to the hospital,” Mr. Bellamy said. He decided he was unlikely to have cancer. “They don’t follow up with me, so I agree with Google,” he told himself.
A resident of Palm Coast, Florida, Mr Bellamy said that after his symptoms worsened, his wife insisted he get tested in December, and he had a colonoscopy in late January. With a new diagnosis of stage 3 rectal cancer, Mr. Bellamy, 38, undergoes radiation therapy and chemotherapy.
Colon screening remained significantly lower in 2020, down about 15% from 2019 levels, according to data from the Epic Network, although overall screenings were down 6%. The scan looked at screenings for more than 600 hospitals in 41 states.
Lung cancer patients have also delayed seeking appropriate care, said Dr. Michael J. Liptay, president of cardiovascular and thoracic surgery at Rush University Medical Center in Chicago. One patient had imaging that showed a stain on his lung, and he was supposed to follow up, just as the pandemic hit. “An examination and further care have been postponed,” said Dr Liptay. By the time the patient was fully evaluated, the size of the cancer had increased. “It was not a good thing to wait 10 months,” said Dr Liptay, although he was not sure that earlier treatment would have changed the patient’s prognosis.
Just as previous economic recessions led people to forgo medical care, the downturn in the economy during the pandemic also discouraged many people from seeking help or treatment.
“We know cancers exist,” said Dr. Barbara L. McAneny, CEO of New Mexico Oncology Hematology Consultants. Many of his patients stay away, even if they have insurance, because they cannot afford the deductibles or co-payments. “We see that, especially with our poorest people who are living on the edge anyway, from paycheck to paycheck,” she says.
Some patients ignored their symptoms for as long as they could. Last March, Sandy Prieto, a school librarian who lived in Fowler, California, had an upset stomach. But she refused to go to the doctor because she didn’t want to have Covid. After having a telehealth visit with her primary care physician, she tried over-the-counter medications, but they did not relieve the pain and nausea. She continued to decline.
“It got to the point where we had no choice,” said her husband, Eric, who had repeatedly urged her to go to the doctor. Yellowing and very uncomfortable, she went to the emergency room at the end of May and was diagnosed with stage 4 pancreatic cancer. She died in September.
“Without Covid and we could have found a place for her earlier, she would still be with us today,” said her sister, Carolann Meme, who had tried to persuade Ms Prieto to go to a university medical center where she could have participated in a clinical trial.
When patients like Ms Prieto are not seen in person but treated virtually, doctors can easily miss important symptoms or recommend medication rather than telling them to come in, said Dr Ravi D. Rao, the oncologist at the clinic. treated Mrs Prieto. Patients may downplay how sick they feel or neglect to mention hip pain, he said.
“In my mind, telemedicine and cancer don’t travel together,” Dr Rao said. Although he also used telemedicine during the height of the pandemic, he says he worked to keep his offices open.
Other physicians have championed the use of virtual visits as an essential tool when office visits were too dangerous for most patients and staff. “We were grateful to have a robust telemedicine effort when people just couldn’t get into the center,” said Dr Borgen of Maimonides. But he acknowledged that patients were often reluctant to discuss their symptoms during a telehealth session, especially a mother whose young children could listen to what they said. “It’s not private,” he noted.
Some health networks say they have taken strong measures to try to counter the effects of the pandemic. During the initial stay-at-home order last year, Kaiser Permanente, the large California-based managed care company, spotted a decrease in the number of breast cancer screenings and diagnoses in the North. State. “The doctors got together immediately” to start contacting patients, said Dr. Tatjana Kolevska, medical director of the Kaiser Permanente National Cancer Excellence Program.
Kaiser also relies on its electronic health records to make appointments for women who are late for their mammograms when they make an appointment with their GP or even want a prescription for new glasses.
As Dr. Kolevska says she is waiting to see data for the system as a whole, she was encouraged by the number of patients in her practice who are now up to date with their mammograms.
“All of these things put in place have helped tremendously,” she said.
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