Healthcare providers across the U.S. are seeing more patients with late-stage cancer, the consequence of the pandemic's pause on screenings and routine doctor's visits.
As COVID-19 restrictions lift and more people get vaccinated, patients are scheduling screenings and following up on unchecked symptoms. Some patients are receiving treatment for undiagnosed cancers, and providers are concerned that they will be treating more acute conditions for years to come.
New Mexico Oncology Hematology Consultants is one of many cancer centers that is hiring more doctors and nurses as volume and acuity increases.
"We've been seeing a gradual increase in new patients, but it's patients who have later-stage disease," said Dr. Barbara McAneny, CEO of the group, which operates cancer centers in Albuquerque and Gallup.
People who've been living with rectal bleeding have more advanced and aggressive cancer, she said. Breast cancer patients have a lot more lymph nodes in their armpits and above their clavicle, she said.
Nearly 10 million breast, colorectal and prostate cancer screenings were missed last year, according to a study published in May in JAMA Oncology. Screenings are intended to catch cancer in the early stages, when it is less deadly and easier to treat.
But people avoided doctor's offices due to fear of catching COVID-19, some practices stopped seeing patients in person and other providers canceled "elective" procedures.
Now, with more than half of U.S. adults fully vaccinated, patients are returning to their doctors and getting bad news. There is no data yet on whether more people are being diagnosed with advanced cancers due to COVID-19, but experts had long warned that the pandemic could have an adverse effect on both cancer rates and the severity of illnesses.
"We have more patients with advanced cancers and complex cancers right now than simple ones," said Dr. Pat Basu, president and CEO of Boca Raton, Florida-based Cancer Treatment Centers of America.
There were 1.7 million new cancer cases and nearly 600,000 fatalities from the disease reported in 2018, according to the most recent data from the Centers for Disease Control and Prevention (CDC). The annual rate of new cancer diagnoses has been declining since 2015 and the rate of deaths has been dropping for decades, the CDC data shows.
Despite the lack of hard evidence about the effect of the pandemic on cancer diagnoses, doctors across the country anecdotally report that patients are sicker.
In some cases, patients who thought they had COVID-19 actually had an advanced form of lung cancer, said Dr. James Perry, an oncologist at Alliance Cancer Specialists, which serves patients in the Philadelphia area.
Over March, April, and May of this year, the practice saw a 40% increase in new patients compared to the same time period in 2019 and a 300% increase compared to the same three months of 2020.
More of those patients have advanced disease than would be typical in a normal year, Perry said. "The prospects for curing them become more limited," he said.
And it's not yet clear whether cancer screenings are back to pre-pandemic levels, meaning more people could be diagnosed with advanced cancers later this year or even next year.
Breast, colon and cervical cancer screening rates were down by 13%, 25% and 21%, respectively, from March 2020 to March 2021, according to an analysis published earlier this month by the Epic Health Research network.
In states that lifted COVID restrictions later than most, such as California, cancer testing still has not rebounded to pre-pandemic levels.
"Screenings have not returned to normal. That spells a bad future," said Annette Walker, president of City of Hope of Orange County cancer center. She said cancer screenings in Orange County are still 30% lower than they were before COVID-19. "We have a lot of concerns as to what's in the pipeline that people don't know they have," she said.
While there hasn't been a significant decline, some Tryon Medical Partners patients put off colonoscopies, mammograms and other screenings during the pandemic, said Dr. Ryan Shelton, an internal medicine physician at the Charlotte, North Carolina-based independent physician group.
"The biggest issue we saw during the pandemic was postponing preventative care," said Shelton, who urged people to book appointments. "The complexity of the undiagnosed illness can become much higher and treatment options are more limited."
Nearly 70% of 752 office-based clinicians said their volumes for preventative care and chronic care management visits remained below pre-pandemic levels as of this spring, PricewaterhouseCooper's found.
In states where vaccination rates are lagging and COVID-19 continues to spread at rates higher than the rest of the country, doctors are concerned people could put off screenings for even longer.
"Some people are still afraid to go to the doctor, still afraid to get vaccinated – that's the group of people who haven't come out yet," said Dr. Miriam Atkins, an oncologist at Augusta Oncology in Augusta, Georgia. "They'll probably come out later this year and we'll see more advanced cancers and problems."
COVID-19 hospitalizations are up 26% in Arkansas compared to last week's seven-day average, meaning there are fewer beds for cancer patients who need surgery, said Dr. Omar Atiq, an oncologist in Little Rock, Arkansas, which had one of the highest cancer rates in the country in 2018.
Atiq already is seeing more advanced cancers after the past year and he's worried more COVID-19 cases will worsen the situation, he said. "I'm afraid we are going toward a situation that would be similar to what we had last year around this time," he said.
There are equity concerns as well. Before the pandemic, the CDC was making inroads in getting women, particularly women of color, screened for breast and cervical cancer. People of color were already more likely to be diagnosed with cancer at later stages.
While Chicago-based primary-care provider VillageMD has seen a spike in primary-care demand in many of its markets, volume is still lagging in communities with lower socioeconomic status.
"Those who were most able to manage their care with the pandemic are ones that have computers at home and high-speed internet," said Dr. Clive Fields, VillageMD's chief medical officer and co-founder. "I worry that this inequity gap isn't just in healthcare, it's in education and other elements of society. That may not play out this year or next but for a long time to come."
Most cancer screenings are done by primary care doctors, which Black, Latino and Asian people are least likely to have. And while many people received care during the pandemic through telehealth, communities of color are least likely to have access to reliable internet.
"We're seeing an amplification of something that is always a problem in our system—access is fairly limited for people with fewer means," said Dr. Eric Schneider, senior vice president for policy and research at the Commonwealth Fund, a former primary care physician. "By the time they come in it's a bigger problem, whether their diabetes is out of control or they are having a stroke."
Waiting for care feeds into a vicious cycle. People with diabetes could develop vascular complications and lose limbs. Worsening conditions heighten anxiety or depression. Doctors also shoulder that anguish when a patient comes in with an ulcer that requires surgery instead of antibiotics. More doctors retire sooner, worsening access to care in their communities.
"All these things compound on one another," Schneider said, noting that more of his physician peers are retiring.
Some health systems are proactively reaching out to at-risk patients. Capitation and other alternative payment models tend to give providers more flexibility there, whereas fee-for-service medicine tends to cater more to people who have means, Schneider said.
State and federal authorities should direct funding toward community health centers in vulnerable communities, particularly pediatric centers, and state Medicaid managed care programs can be an important vessel to reach patients in need, Schneider said.
"The major causes of mortality and morbidity are still killing Americans at a greater rate than COVID-19," Schneider said.