More Than 10,000 Excess Cancer Deaths due to COVID-19 Delays

Roxanne Nelson, RN, BSN

June 24, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

UPDATED with comments June 26, 2020 // A model created by the National Cancer Institute (NCI) predicts that tens of thousands of excess cancer deaths will occur over the next decade as a result of missed screenings, delays in diagnosis, and reductions in oncology care caused by the COVID-19 pandemic.

Dr Norman Sharpless

"As director of NCI, I am deeply concerned about the potential impacts of delayed diagnoses and deferred or modified treatment plans on cancer incidence and mortality," said Norman "Ned" Sharpless, MD.

"In the past 3 decades, we have seen steady and strong progress against death and suffering from cancer, thanks to improvements in prevention, screening, diagnosis, and treatment. I worry that the SARS-CoV-2 pandemic has put those decades of steady progress at risk and may precipitate reversals of these trends."

In an editorial published June 19 in Science, Sharpless highlights modeling performed by the NCI that predicts an excess of 10,000 deaths from breast and colorectal cancer over the next 10 years.

The number of excess deaths per year would peak in the next year or two, likely sooner for colorectal than for breast cancer, but "for both cancer types, we believe the pandemic will influence cancer deaths for at least a decade."

In an interview, Sharpless pointed out that this analysis is conservative because the researchers only evaluated two types of cancer. They chose breast and colorectal cancer because these are common cancers (accounting for about 1/6th of all cancers) with relatively high screening rates.

"We didn't model other cancer types, but we have no reason to think that we're not going to see the same thing with other types of malignancies," he told Medscape Medical News. "That is a significant amount of excess mortality."

Delayed Diagnosis, Modified Therapy

One of the effects of the pandemic has been to cause delays in cancer diagnosis.

"Routine screening has plummeted and is running at less than 90% in some systems," Sharpless said.

"Most cancers are diagnosed when people experience symptoms and go see their doctors, and those symptomatic screening events are also not happening," he continued. "Fear of contracting the coronavirus in healthcare settings has dissuaded people from visits."

In some cases, a delay in diagnosis will allow the cancer to progress to a more advanced stage. "The earlier the diagnosis, the better, and if the stages are more advanced, patients will not do as well for virtually every kind of cancer," he said.

In addition to delays in diagnosis, treatments are being postponed or modified for patients recently diagnosed with cancer. Because of delays and reductions in curative therapies, patients may be receiving less than optimal care.

"We are seeing a lot of nonstandard care," said Sharpless. "All of these things add up to increased cancer morbidity and mortality."

He also pointed out that the term "elective" is confusing and problematic. "It doesn't mean that it's not needed, just that it's not an emergency and doesn't need to be done today," said Sharpless. "But if we're talking about chemotherapy and surgery, we don't think they can be delayed for too long — maybe a week, but not for several months."

Sharpless feels that overall, it is time for cancer care to resume as much as possible, because "ignoring cancer for too long is an untenable choice and may turn one public health crisis into another."

"If we act now, we can make up for lost time," he writes in the editorial.

"Clearly, postponing procedures and deferring care due to the pandemic was prudent at one time, but now that we have made it through the initial shock of the pandemic, I believe it is time to resume robust cancer care."

Through their network of cancer centers, researchers with the NCI can develop innovative solutions that allow screening and treatment to move forward while maintaining safety. "We need to make patients feel safe, and we have to answer important questions quickly," he said.

Real Phenomenon

Approached by Medscape Medical News for an independent comment, Otis Brawley, MD, Bloomberg Distinguished Professor of Oncology and Epidemiology at Johns Hopkins University, Baltimore, Maryland, agreed that the delay in diagnosis and treatment is a real phenomenon and that it will result in some increased deaths.

"The effect could last 10 years, and the CISNET program that Ned Sharpless is quoting showed that the big drivers from March to end of May are more from delays in diagnosis of symptomatic tumors and treatment," said Brawley.

"This means women who find a mass in their breast will not be diagnosed in a timely manner and men and women with blood in their stool will not get it evaluated. There are also some known, already diagnosed cancers that have delayed treatment as well."

Brawley pointed out that its not only the shutting down of clinics in March and April that are driving these delays but also the "fact that even now that clinics are open, patients are afraid to come see the doctor for fear of catching COVID. The heart attack and stroke rate have gone down over the past 3 months for the same reason.

"In this screen-screen world, we forget that a substantial proportion of breast cancers are still found by women taking a shower, feeling a mass, and going to the doctor," he added. "The screening impact on mortality, as noted in Sharpless's public presentation to the National Cancer Advisory Board, is minimal as long as the shutdown in healthcare is a few to even 6 months."

Another expert wished that Sharpless had distinguished seeking care for symptoms from screening. "We ought to be encouraging women who feel new breast lumps to come in for a diagnostic mammogram ― whatever the local COVID risk," said Gilbert Welch, MD, MPH, senior investigator, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts. "Encouraging all women to get screened is a different kettle of fish ― particularly now.

"It is now clear that the substantial decline in breast cancer mortality we've experienced over the past 30 years primarily reflects improved treatment, not screening," he told Medscape Medical News. "Screening may help a very few women avoid breast cancer death, but it leads many more to be overdiagnosed and many, many more to be told they need follow-up testing and biopsy."

He added, "This is the time for us to focus on the sick, not to turn more people into patients. Does medical care really need to be adding more anxiety to an already anxious world?"

Impact of COVID-19 on Cancer Care

The COVID-19 pandemic has overwhelmed healthcare systems worldwide and has created major challenges for clinicians who are caring for patients with cancer.

As previously reported, hospitals reprioritized resources for an impending onslaught of COVID-19 patients. Services and procedures deemed to be nonessential were canceled or delayed, including surgeries and imaging.

In a survey conducted by the American Cancer Society Cancer Action Network (ACS CAN), half of the 1219 respondents reported changes, delays, or disruptions to the care they were receiving. The services most frequently affected included in-person provider visits (50%), supportive services (20%), and imaging procedures to monitor tumor growth (20%).

In addition, 8% reported that their treatment, including chemotherapy and immunotherapy, had been affected by the COVID-19 pandemic.

In the United Kingdom, Cancer Research UK estimated that because of the disruption to cancer services, 2.4 million people did not undergo cancer screening or further testing or did not receive cancer treatment and that tens of thousands of cases have gone undiagnosed.

Similarly, a survey by Macmillan Cancer Support showed that almost half (45%) of cancer patients have experienced delays or cancellations of cancer treatments, or their treatments have been altered as a result of coronavirus, leaving many living in fear. Calling cancer "the forgotten C" of the pandemic, it warned of a potential cancer "time bomb" when, as the number of deaths from COVID-19 falls, cancer returns as the leading cause of death in the United Kingdom.

Last month, a report also predicted that there will be an excess of cancer deaths in both the United States and United Kingdom because of patients not accessing healthcare services.

The authors calculated that there will be 6270 excess deaths among cancer patients 1 year from now in England and 33,890 excess deaths among cancer patients older than 40 years in the United States.

Welch has disclosed no relevant financial relationships.

Science. Published online June 19, 2020. Editorial

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