THERESE BEVERS HAS LONG SUSPECTED the COVID-19 pandemic is impacting the health of Americans in ways beyond directly contracting the virus.
As medical director of the Cancer Prevention Center (CPC) at the University of Texas MD Anderson Cancer Center in Houston, Bevers keeps a close eye on cancer screening trends and administers breast exams herself. In the early months of the pandemic, like many nonessential health care settings, the CPC shuttered its doors and stopped screenings.
By the end of 2020, following federal guidance, it resumed screenings. Many patients, however, did not return.
“Women didn’t want to come in; the vast majority did not want to come in,” Bevers says. “A lot of women went two-plus years without a mammogram.”
Of even greater concern to Bevers, as the months turned into years, was an uptick in breast cancer diagnoses at later stages. Her patients’ tumors were larger or had spread to their lymph nodes.
“I saw many more palpable tumors than I commonly see,” Bevers says, adding that she and her colleagues feared their experiences were part of a national trend. “We anticipated seeing articles published about delays in diagnosis and later-stage diagnosis.”
Now, that moment of confirmation has arrived. A study published in Lancet Oncology this August by researchers at the American Cancer Society (ACS) found “substantial cancer underdiagnosis” across the United States after the pandemic arrived in the early months of 2020, compared with years prior. In addition, of the cancers that were diagnosed, researchers observed increases in the proportion of later stage diagnosis, likely worsening prognoses for tens of thousands of Americans.
“The drop [in diagnosis rates] was pretty consistent and strong across all cancer types,” says co-author Xuesong Han, scientific director of health services research in the Surveillance & Health Equity Science Department at ACS.
To conduct the study, Han and her colleagues mined the U.S. National Cancer Database for monthly cancer diagnostic statistics collected in 2018, 2019 and 2020. In addition to looking for changes in diagnostic rates, researchers also looked for disparities by age, sex, health insurance status, geographic location, race and ethnicity, and other measures.
The first shock came in April 2020, when total monthly cancer diagnoses fell to 36,679 cases, a dramatic drop from the pre-pandemic average of about 70,000. By summer, the monthly diagnosis rates returned to near normal, but dropped again in the winter when another COVID-19 wave hit.
Han and colleagues observed a correlation between spikes in COVID-19 mortality and drops in cancer diagnosis rates. Han says that was likely due to some combination of the virus overwhelming health care infrastructure, the closing of doctor’s offices, and patient fear about entering health care settings.
The study found dramatic drops in diagnoses for nearly all major cancer types. The changes in stage distribution were prominent for cancers that are typically caught early by routine screenings, such as breast, colorectal, and prostate cancers. But diagnosis rates for melanoma as well as lung, kidney, esophageal and stomach cancer also dropped dramatically, likely due further breakdowns of referral processes, imaging tests, and other diagnosis activities.
In total, the data show at least 125,000 fewer Americans were diagnosed with cancer in 2020 than in 2019, a drop of about 15%.
Evidence of Disparities
But not all groups of Americans were impacted equally, the Lancet Oncology study found.
People of Hispanic, Asian, and Pacific Islander ethnicities saw the largest decrease in stage I diagnosis, about a full percentage point ahead of both white and Black people. Han says besides cultural and language barriers, additional research has found that racism likely played a role in people forgoing care amid the COVID-19 pandemic, especially among Asians, due to the initial COVID-19 outbreak in China.
“Asian Americans and Hispanics are among the populations that have the largest delay in forgoing care, and they also have the highest experience of racial discrimination,” Han says. “[There are] also cultural and language barriers, low trust in health care systems and financial shocks, loss of employment. Those are all possible barriers.”
Health insurance enrollment also mattered greatly. Uninsured Americans and those ages 18 to 64 on Medicare, saw drops in stage I diagnosis of about 23%, compared with just 18% of those on private health insurance. Typically reserved for seniors, Americans under 65 who have a disability, end-stage renal disease, or ALS are also eligible for the program.
Bevers says the problem was likely exacerbated by many Americans losing their jobs and health care benefits. Many centers only take private insurance.
“I think understanding the fragility of many people [is important],” Bevers says. “They walk a very fine line in their job security and thus insurance coverage. And when we have a downturn, they lose their job and their insurance, and they don’t go to the doctor.”
Bevers and Han worry about the lasting effects of the pandemic. It’s not yet known whether the decreases in diagnoses observed in 2020 have led to an increase in cancer morbidity in the years since. Han suspects it has, but data won’t become available until the end of 2023 at the earliest.
Meanwhile, ongoing challenges hamper the push to get people back into care. A COVID-era policy that kept many Americans on Medicaid expired in March, Han says, with experts predicting as many as 15 million Americans could lose their coverage. Many Americans who do have insurance still haven’t returned to normal cancer screening routines, and skipping a year or two of routine visits has led to a false sense of complacency, Bevers says.
Han says the insurance problem is undoubtedly a large and challenging one for U.S. society to solve as a whole, as peer nations like Canada and England saw less substantial disruptions in cancer diagnoses.
But Bevers adds that many Americans still have it within their power to ensure they don’t add to troubling statistics in the years ahead by resuming screening in line with national guidelines, such as those from the ACS.
“Go back to the recommended screening,” Bevers says. “Talk to your doctor, make sure you know what the recommended screening is.”
Cancer Today magazine is free to cancer patients, survivors and caregivers who live in the U.S. Subscribe here to receive four issues per year.