When the University of Texas MD Anderson Cancer Center in Houston paused cancer screenings in March to follow national guidance for dealing with the COVID-19 pandemic, Therese Bevers, MD, medical director of the Cancer Prevention Center, thought they would be able to reopen after a couple of weeks.
Instead, the screening center was transformed into a COVID-19 testing site and the cancer screenings stopped for more than three months.
“I wasn’t concerned about delaying screening for two weeks, but that turned into three to four months,” Bevers said. “I’ve seen women who tell me they found a lump [in their breast] in March, and when I’m seeing them [in July] it’s in the lymph nodes.”
In the early weeks of the pandemic, many patients forewent appointments and procedures that were considered “nonessential” as health care providers followed state and national guidance aimed at preserving personal protective equipment, opening more intensive care unit (ICU) capacity, and protecting workers and patients from catching the virus.
“I’ve seen women who tell me they found a lump [in their breast] in March, and when I’m seeing them [in July] it’s in the lymph nodes.”
Therese Bevers, MD
Medical director of the Cancer Prevention Center at MD Anderson Cancer Center
Now, physicians are taking stock of the long-term impact that delaying standard care has had on non-COVID-19 conditions, such as cancer, heart disease, and diabetes, and they are grappling with how to keep up that care while simultaneously dealing with the ongoing pandemic.
“Early in the pandemic, we were all in acute crisis response,” said Dhruv Kazi, MD, the director of the Cardiac Critical Care Unit at Beth Israel Deaconess Medical Center in Boston, Massachusetts. “There’s a growing recognition that we’re in this for many months more.”
Cancer — more deadly than COVID-19
At Massachusetts (Mass) General Hospital in Boston, breast cancer screenings were paused for about two months during the first surge of the pandemic.
Now, the screening centers have reopened with extra precautions, such as requiring masks, enforcing social distancing, and limiting waiting room capacity. But many centers across the country are overwhelmed trying to catch up with the backlog, according to Connie Lehman, MD, PhD, a professor of radiology at Harvard Medical School and chief of breast imaging at Mass General.
“At this time, some of our screening centers have limited openings for screening mammograms — with some booked until October,” Lehman said. “We are working together to build capacity and open access to safe and essential screening mammography.”
Lehman said that her team is looking at expanding hours and shifting resources to centers where patients need them most to increase accessibility.
In Houston, Bevers worries that many people don’t understand the implications of putting off cancer screenings, not realizing that advanced breast cancer could be even more deadly than COVID-19.
One study published in the Journal of the American Medical Association (JAMA) this month found that the mean weekly number of new diagnoses for six common cancers dropped by 46%, with breast cancer diagnoses declining the most (52%), in March and April compared to the two months prior. Another study in the Journal of Clinical Oncology analyzed data from 20 institutions and found that, in the first four months of 2020 compared to the same time last year, breast cancer screenings were down by 89% and colorectal cancer screenings were down by 85%.
The National Cancer Institute generated a prediction model in June that estimated an additional 10,000 deaths in the United States from breast and colorectal cancers over the next decade due to delays in diagnosis and treatment.
Norman Sharpless, MD, the institute’s director, wrote in an editorial for Science that many hospitals in the country had postponed cancer surgeries and offered less-intense chemotherapy or radiotherapy, which weaken the immune system and make patients more vulnerable to COVID-19 complications. These decisions may have resulted in suboptimal treatment and a worse prognosis. He also said that the pandemic had disrupted research and clinical trials for cancer treatments, potentially setting back progress for years.
“Clearly, postponing procedures and deferring care as a result of the pandemic was prudent at one time, but the spread, duration, and future peaks of COVID-19 remain unclear,” he wrote. “However, ignoring life-threatening non-COVID-19 conditions such as cancer for too long may turn one public health crisis into many others.”
Marina Del Rios Rivera, MD, an emergency medicine physician at the University of Illinois Hospital and Health Sciences System in Chicago, has started seeing more patients with advanced complications from conditions like diabetes and heart disease.
“These are chronic conditions that are typically well-controlled with good management,” she said.
Kazi’s team studied data from March and April at the Beth Israel Deaconess Medical Center and found that heart attack hospitalizations were down by 33% compared with the two months prior, stroke hospitalizations were down by 58%, and referrals for new breast and blood cancers were down by more than 60%.
The Centers for Disease Control and Prevention (CDC) published a similar study in June that found that, from March to May, emergency department visits across the country declined 23% for heart attacks and 20% for strokes.
All of that delayed care has started to manifest itself in negative outcomes for patients.
“We certainly know we didn’t cure heart disease overnight,” said Martha Gulati, MD, the division chief of cardiology at the University of Arizona College of Medicine - Phoenix and editor-in-chief of CardioSmart.org, an online resource produced by the American College of Cardiology.
Gulati believes that, in addition to being afraid to go to the emergency room for risk of being exposed to COVID-19, many people missed regular check-ups with their doctors, ran out of medication, were impacted by clinical trial disruptions, had procedures delayed, or lost insurance coverage because of unemployment — all possibly contributing to worse outcomes and even avoidable death.
One study published in JAMA by researchers at Virginia Commonwealth University and Yale University looked at excess deaths — the number of deaths over what would be expected based on previous years — in March and April. The researchers found that 56,246 (65%) of the 87,001 excess deaths in the United States were documented as attributed to COVID-19. In 14 states, more than half of the excess deaths were attributed to other underlying causes, including heart disease, which is the leading cause of death in the country.
Protecting children with immunizations
Pediatricians are also concerned about another aspect of delayed care that could have long-term repercussions: childhood immunizations.
Many parts of the United States have seen a decline in young children receiving the recommended vaccines against preventable diseases. Without these vaccines, kids — who are largely, though not entirely, spared the more severe complications of COVID-19 — might be vulnerable to other outbreaks.
“The dangers to young children of measles are perhaps even greater than the dangers of COVID-19.”
Janet Englund, MD
Professor of pediatric infectious diseases at the University of Washington School of Medicine and Seattle Children’s Hospital
“What we are seeing is that parents do not want to bring their children into the doctor for well care at this time,” said Janet Englund, MD, a professor of pediatric infectious diseases at the University of Washington School of Medicine and Seattle Children’s Hospital.
A CDC report published in May showed a notable decline in the number of vaccines ordered and administered through the federal Vaccines for Children Program in March and April.
Englund said that children without up-to-date immunizations could be vulnerable to Streptococcus pneumoniae, pertussis (whooping cough), Haemophilus influenzae, and measles, among other serious illnesses. She’s particularly concerned about a potential resurgence in measles, which can have serious complications, especially in children under the age of 5.
“The dangers to young children of measles are perhaps even greater than the dangers of COVID-19,” she said.
Adapting to health care in a pandemic
As the pandemic stretches on without an end in sight, providers and health systems are juggling COVID-19 precautions and treatment with providing care for other conditions that haven’t gone away.
In Phoenix, Gulati said that her hospital is now working through a backlog of procedures, prioritizing patients who are sickest, but it remains a challenge as the ICU gets hit with periodic COVID-19 surges.
“We have to be careful. We do need to have ICU beds and staff,” she said. “It is a fine balance.”
At the same time, she believes there have been lessons learned from the first few months of the pandemic response — including the importance of keeping up routine outpatient care.
She and other physicians with the American College of Cardiology have reached out to patient groups and stressed the importance of maintaining their care.
“We wanted patients who are living with heart disease to understand that their disease didn’t go away,” she said. “We’ve still got to take care of them.”
Bevers from MD Anderson said that staff at cancer screening centers are proactively calling patients to encourage them to get their mammograms, just as Englund has been encouraging pediatricians to reach out to families about immunizing their children.
According to several of the physicians, telehealth appointments have filled an important role that has been a silver lining of the pandemic, but there is still room for innovation.
“This has really been a challenge to the health system and to patients in general,” Gulati said. The pandemic has “definitely displayed the vulnerabilities of our health system. The good part is maybe we can shake it up and make it better and modernize it.”