Although cancer centers have kept up essential treatments and surgeries for patients during the COVID-19 pandemic, routine preventive screenings such as mammograms and colonoscopies were by and large put off.
Now as states look to ease stay-at-home restrictions, leaders at cancer centers are anticipating their clinics will see an influx of new cancer diagnoses and potentially worse prognoses.
"Though most cancers grow pretty slowly, some are likely to be more advanced" from delayed screenings, said Dr. Lawrence Shulman, deputy director for clinical services of the Abramson Cancer Center at the University of Pennsylvania.
Most cancer centers postponed routine screenings for three to six months to reduce visitor traffic and protect patients and staff from potentially coronavirus exposure. Even so, the practice is opening up concerns that some cancers are going undetected and untreated for longer.
Dr. David Cohn, chief medical officer of the Arthur G. James Cancer Hospital and Solove Research Institute in Ohio, said he's wondering once screenings resume if he'll see "more advanced cancers that would've come in earlier if we hadn't had the pandemic."
Some patients who have health concerns are also holding off care, which means their cancers are worsening. A recent report from Cigna Corp. found the rate of hospitalizations for some acute conditions decreased from February to March.
"We have seen a number of patients who are coming in sick with very advanced cancer who tell us they avoided coming in for medical care for fear of becoming infected," Shulman said.
Similarly, Dr. Cardinale Smith, chief quality officer for cancer services at Mount Sinai Health System in New York, said, "Mount Sinai Hospital was almost entirely a COVID-19 unit. There were tons of patients in that hospital before. Where did they all go and what did they do? It's a worry."
While cancer centers continued to provide services deemed vital for patients during the pandemic like chemotherapy and surgery, centers are looking into the safest ways to return to usual services such as screenings and surveillance visits given the time sensitive nature of cancer.
"We delayed what we could … but people can only be delayed for so long," said Dr. Mary Mulcahy, associate director of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago.
States are also easing restrictions on healthcare services, particularly allowing elective surgeries.
Smith said Mount Sinai is planning to ramp back up services like screenings as New York City sees its new COVID-19 case volumes fall. The health system expects to see an increase of new cancer diagnoses as a result. Postponed surgeries and treatments are also going being rescheduled although Smith said Mount Sinai will maintain many of the practices implemented during COVID-19 to protect patients and staff.
Centers have started calling patients before their appointment to ask if they are experiencing COVID-19 symptoms, taking temperatures upon entrance to the clinic, requiring patients and staff to wear masks and limiting how many guests can come with a patient for treatments.
"I would imagine so many of the things we have put into place to protect our healthcare workers and patients and families — some of those are going to persist," Cohn said.
Similar to other service lines, cancer centers have seen a significant increase in telehealth visits and some anticipate that will continue depending on CMS regulation.
"We have about 40% less in-person visits in the cancer center and some of this I hope we will be able to maintain by alternating in-person visits with video visits," Mulcahy said. "It's better to have less crowds and it's (telehealth) more convenient for patients."
Cancer centers are using telehealth to check in on survivorship patients who had in-person appointments, patients after treatments and new patients to determine the course of treatment.
"We have gone to great lengths to decrease the density of people in our center," Shulman said.
Although there are drawbacks to the expansion of telehealth visits. Connecting with patients is important for oncologists and it's harder to support patients over the phone or via video, Mulcahy said.
"Anyone who went into oncology, they know that not only the medicine part is important but the emotional connection that you make with the patient and their family," she said. "We have to figure out a new way to maintain a connection with patients and families in this new technology-driven medical care … It is hard to hang up with someone having heard all of this information and knowing they are alone."