Cancer Diagnoses Plummet During Pandemic in Troubling Trend

Nancy A. Melville

August 17, 2020

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

Rates of new cancer diagnoses in the United States declined substantially during the early months of the COVID-19 pandemic amid recommendations that screenings be postponed, with potentially significant consequences.

"While residents have taken to social distancing, cancer does not pause," say the authors of a new analysis published online in JAMA Network Open.

"The delay in diagnosis will likely lead to presentation at more advanced stages and poorer clinical outcomes," the authors warn.

The National Cancer Institute (NCI) has recently warned of the impact that the pandemic could have on cancer outcomes, predicting more than 10,000 excess cancer deaths during the next decade as a result of missed screenings, delays in diagnosis, and reductions in oncology care caused by the COVID-19 pandemic.

The new analysis was conducted by Harvey W. Kaufman, MD, and colleagues at Quest Diagnostics, Secaucus, New Jersey. The researchers evaluated testing data from the diagnostics company from January 1, 2018, to April 18, 2020. Using ICD-10 codes, they identified patients who had been diagnosed with any of six cancer types (breast, colorectal, lung, pancreatic, gastric, and esophageal).

Two groups of patients were compared ― those diagnosed during the baseline period, from January 6, 2019, to February 29, 2020 (n = 258,598, 92.8%), and those diagnosed during the COVID-19 period, from March 1, 2020, to April 18, 2020 (n = 20,180, 7.8%).

The mean weekly number of patients newly identified as having cancer during the baseline period included 2208 with breast cancer, 946 with colorectal cancer, 695 with lung cancer, 271 with pancreatic cancer, 96 with gastric cancer, and 94 with esophageal cancer.

During the pandemic period, the total mean weekly number for the six cancers combined fell by 46.4% (from 4310 to 2310). There were significant declines in all cancer types.

Mean weekly diagnoses for breast cancer declined by 51.8%, from 2208 to 1064 (P < .001). For pancreatic cancer, diagnoses declined by 24.7%, from 271 to 204 (P = .01).

With regard to age, overall, patients who were diagnosed with cancer during the COVID-19 period were within 1 year in age compared to those diagnosed during the baseline period. Those with esophageal cancer who were diagnosed during the COVID-19 period were slightly older (mean age, 69.5 vs 68.4 years; P = .04). For all other cancers, patients were diagnosed at a younger age during the COVID-19 period.

There were no significant differences in sex distribution of cancer diagnoses during the two periods, with the exception of pancreatic cancer, for which there were fewer women in the baseline group (P = .01).

Similar Impact in Other Countries

The declines in cancer diagnosis in the United States reported in this article occurred in light of recommendations from the American Society of Clinical Oncology that, to conserve overburdened health system resources and reduce patient contact with healthcare facilities, "cancer screening procedures that require clinic/center visits, such as screening mammograms and colonoscopy, be postponed for the time being."

The findings are consistent with reports of declines from other countries. For example, the Netherlands Cancer Registry found that the weekly cancer incidence declined by 40%. A report form the United Kingdom describes a striking 75% decline in referrals for suspected cancer since the implementation of COVID-19 restrictions.

On a broader level, there have been reports from hospitals of significant drops in the numbers of patients with heart attacks, strokes, and appendicitis. One study of nine US cardiac catheterization laboratories found a 38% decrease in patients treated for ST-elevation myocardial infarction, a life-threatening condition.

"Our findings are consistent with previous research and they call for urgent planning to address the consequences of delayed diagnoses," the authors emphasize.

"Planning may entail more robust digital technology to strengthen clinical telehealth offerings and other patient-clinician interactions, including self-service scheduling across specialties and well-designed collection processes."

NCI Director: "Decades of Progress" at Risk

The NCI model predicting that the pandemic could result in more than 10,000 excess deaths from cancer was authored by NCI Director Norman "Ned" Sharpless, MD.

Speaking to Medscape Medical News, Sharpless commented: "In the past three 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."

He called for a resumption of cancer care as much as possible. "Ignoring cancer for too long is an untenable choice and may turn one public health crisis into another," Sharpless writes in an editorial.

"If we act now, we can make up for lost time," he said.

Approached for comment on the NCI predictions, an expert on cancer screening emphasized the difference between routine screening and evaluation of symptoms.

A key message that should be emphasized to patients is that routine screening is one thing, but when symptoms are present, time is of the essence, commented Gilbert Welch, MD, MPH, senior investigator, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.

"We ought to be encouraging women who feel new breast lumps to come in for a diagnostic mammogram ― whatever the local COVID risk," Welch said.

The authors are employees of and own stock in Quest Diagnostics. Sharpless is the director of the NCI. Welch has disclosed no relevant financial relationships.

JAMA Netw Open. Published August 4, 2020. Full text

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