FORBES Magazine, by Dr. Miriam A Knoll, M.D. I'm a radiation oncologist and mom covering the intersection of medicine, culture, and social media.
A “cancer screening” attempts to find cancer when it’s small and curable, and is important tool for reducing the cancer burden in the world. The U.S. Preventatives Services Task Force recommends routine screening for breast, colon, cervical, and lung cancers. When reports out of Wuhan showed that patients with cancer were at higher risk of contracting and dying from COVID-19, cancer societies quickly came to a consensus that routine cancer screenings should be delayed, to avoid exposing patients to coronavirus. The thought was: keep healthy people at home and don’t use healthcare resources for cancer screenings.
The American College of Radiology endorsed guidelines published by CHEST (the American College of Chest Physicians) on April 24th 2020, suggesting to delay surveillance of patients for lung cancer. The American Society of Clinical Oncology recommended “cancer screening procedures that require clinic/center visits such as screening mammograms and colonoscopy be postponed for the time being” (this guideline was most recently updated on May 8th 2020). The Susan G. Komen foundation issued a statement last month stating that “healthy women of average risk delay routine breast cancer screening until later this year.” “Screening studies like pap smears and annual mammograms are tests done on a scheduled basis for people who have no signs or symptoms of cancer. Because screening studies are intended to pick up pre-cancerous lesions or early stages of cancer, postponing them for a few months is unlikely to cause serious harm in most patients,” said Tatiana M. Prowell, MD, a medical oncologist at Johns Hopkins. Recommendations such as these were widely adopted, so it’s not surprising that a recent study found that cancer screenings across the U.S. dropped between 86%-94% in March 2020, as compared to March 2019. Mean weekly cancer screenings in the U.S. (courtesy of EPIC Health Research Network) Mean weekly cancer screenings in the U.S. [+] EPIC HEALTH RESEARCH NETWORK 5.4.2020 Yet, there are some concerns about the across-the-board delays in cancer screenings. Here are some reasons why: Some patients are at higher risk of cancer “Delaying routine cancer screenings during the COVID-19 pandemic has made sense for many patients who are considered normal risk for cancer. I think it has created a lot of anxiety, however, for people who are at increased risk, such as patients with a hereditary cancer risk, such as a BRCA mutation or Lynch syndrome,” said Merry-Jennifer Markham, MD, FACP, FASCO, an oncologist at University of Florida. For higher risk patients, it may be appropriate to begin these cancer screenings again, assuming the hospitals and centers conducting these screenings have measures in place for physical distancing and appropriate PPE for both healthcare workers. Individuals with mutations that confer a high cancer risk, such as BRCA1 and BRCA2 (and others) should have scans at routine intervals to look for early cancers, and coronavirus should not get in the way for too much longer. Screenings can likely be done safely The good news is that hospitals and medical offices have quickly adapted to new protocols to protect patients, including in-office physical distancing, having staff and patients wear personal protective equipment (PPE), and strict sanitation. This has set the stage for screenings, and office visits to resume. “I understand the fear and anxiety so many are experiencing right now. I recently spoke with one of my patients whose follow-up CT scans indicated that their cancer had grown. Understanding this person’s concerns about COVID-19, I reassured the patient that we are taking the right measures to reduce exposure to the virus during a hospitalization,” said Costanzo DiPerna MD, a thoracic oncologist at Dignity Health in California. “Rather than delay the surgery by six months, my patient felt confident enough following our conversation to move forward with the life-saving surgery.” Cancer diagnoses should not be delayed Leslie Lopez Montgomery, M.D., FACS, a breast surgeon at Hackensack University Medical Center in NJ, stressed the importance of patients not ignoring worrisome symptoms. “Unfortunately, cancer does not wait for the pandemic. It is very important that anyone who is experiencing any concerning breast symptoms reach out to their primary care physician or gynecologist for an immediate evaluation. By now, medical facilities have policies and procedures in place to protect patients and staff including temperature checks upon arrival, social distancing in waiting rooms, PPE for staff and patients, and immediate cleaning of all surfaces as a patient leaves the waiting room, the examination room, and the check-out area. Every precaution is being taken to protect our patients.” The purpose of a screening mammogram is to detect tiny cancers- that’s not the scenario if someone has a breast mass they can feel. Anyone who experiences symptoms or has questions should call their doctor right away. Delaying may be OK, but omitting isn’t Another concern is- will some patients to delay their mammogram or colonoscopy indefinitely, and simply omit them altogether? This is especially worrisome given the known health disparities both in screening and coronavirus. “Before the pandemic, we already had significant gaps in cancer screening, particularly among underrepresented minorities, including Hispanics and African American patients, which are also those reported to be very much affected by SARS-COv-2 infection. Amid COVID-19, these gaps have widened across all backgrounds, and along with loss of employment, insurance and financial stability plus deferral of ‘elective’ procedures, cancer screening is another victim, which will likely reflect in a surge in late-stage cancer cases, and delay of care for many patients,” said Arturo Loaiza-Bonilla, MD, MSEd, FACP, a medical oncologist at Cancer Treatment Centers of America in Philadelphia. Coronavirus isn’t going away anytime soon Given that COVID-19 isn’t showing signs of going away for good, we need to adopt a new normal of routine health management, i.e. everything health related that has nothing to do with COVID-19. Over 600,000 people are estimated to die from cancer in the U.S. in 2020, and over 1.8 million will be diagnosed with cancer. In contrast, COVID-19 has killed over 80,000 Americans so far. Antonio Passaro MD PhD, an oncologist in Milan, Italy, a part of the world that was overwhelmed with coronavirus, said it best: “It is so important, in this critical period for public health, to be even closer to our patients, who find themselves redefining the benchmark of cancer uncertainty during this pandemic.” Amen. For more straight talk on coronavirus and healthcare, follow me on Twitter @MKnoll_MD and on Instagram @Dr.Mimi.K