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Clinical Context

The COVID-19 pandemic has had profound societal effects, including how health care is practiced. Many routine healthcare services were negatively affected by the pandemic. A previous study by McBain and colleagues, which was published in the June 2021 issue of the Journal of General Internal Medicine,^[1] used data from a large US commercial health insurance database to assess rates of mammography and colonoscopy from January 15, 2020 to March 13, 2020 with rates from March 14, 2020 to July 31, 2020. The US government declared a national emergency because of COVID-19 on March 13, 2020.

Researchers found that the respective total decreases in the median weekly rates of mammography and colonoscopy in comparing the prepandemic and postpandemic periods were 96% and 95%. By the end of July, rates of mammography and colonoscopy had rebounded moderately but not to prepandemic levels. The decline in colonoscopy screenings was most profound in counties with a higher mean income.

The current study by Englum and colleagues provides a more comprehensive view of cancer-related visits, examining screening procedures and new diagnoses of cancer across 2020.

Study Synopsis and Perspective

The COVID-19 pandemic has led to substantial declines in cancer screenings and new cancer diagnoses, according to a large analysis published on December 6 in Cancer.^[2]

Mining data from more than 9 million US veterans, researchers reported a 13% to 23% drop in diagnoses of prostate, lung, bladder, and colorectal cancers in 2020 compared with 2018 and 2019. The most significant dip occurred in the early days of the pandemic, when COVID-19 surges and lockdowns across the US delayed cancer screenings and care, but the backlog continued to accumulate through the end of 2020, according to the study's lead author, Brajesh Lal, MD, director of the Center for Vascular Research at the University of Maryland, in College Park, Maryland.

Early on, "all of us were so focused on the impact of the [COVID-19] surge, infection, and deaths resulting from it that naturally and appropriately we marshalled all our resources to attack that," Lal told Medscape Medical News. "What surprised me was the extent to which the reduction in these health services persisted well beyond the acute surge. We have still not recovered."

Lal and colleagues embarked on the current study to better understand how the pandemic affected cancer screenings and diagnostic procedures, and consequently new cancer diagnoses, by examining data from millions of patients in the Veterans Health Administration: the largest integrative dataset in the United States.

Using 2018 and 2019 cancer-related healthcare encounters, cancer screenings, and diagnoses as a baseline, the researchers calculated pandemic-fueled changes in diagnostic and screening procedures as well as new diagnoses of prostate, lung, bladder, and colorectal cancers in 2020.

Lal and colleagues found that colonoscopies decreased the most, by 45%; however, diagnostic and screening procedures in the other 3 categories also experienced a big decline: Prostate biopsies dropped by 29%, cystoscopies for bladder cancer by 21%, and chest computed tomography (CT) scans for lung cancers by 12%.

These deficits varied by location, although "no consistent pattern by geographic region or state size" emerged, the authors noted. For instance, two-thirds of states demonstrated declines in prostate biopsies greater than 25% in 2020 compared with 2018 and 2019, and just over one-third of states showed a similar decline in cystoscopies.

New cancer diagnoses also dropped significantly in 2020, with the largest decrease occurring in the first few months of the pandemic. For instance, between March and May, prostate cancer diagnoses fell by more than 50%. The authors observed "similar proportional decreases" in new colorectal, lung, and bladder cancer diagnoses.

Although new cancer diagnoses began to pick up starting in June 2020, they never reached prepandemic levels.

"As a result, the deficit of new cancer diagnoses continued to accumulate throughout 2020," the authors wrote.

Overall, the researchers estimated a 23% decline in new prostate cancer diagnoses, 20% for colorectal cancer, 18% for bladder cancer, and 13% for lung cancer throughout 2020 compared with 2018 and 2019.

The authors highlighted several reasons why diagnoses did not rebound, including pandemic-related financial hardships, perceived risks for invasive procedures such as colonoscopies, and patients falling out of their healthcare routine. Lal also noted that resource shortages caused by the pandemic, including nursing shortages and hospital closures, may have also prevented a return to normal.

Lal pointed to several limitations of using the Veterans Affairs (VA) database. For one, the data are exclusive to veterans, who are predominantly older White men. The VA population also has fewer healthcare-related financial pressures than non-VA patients, so it is possible the findings would be worse for non-VA patients.

Next, the research team plans to analyze the impact of these delays on patients' long-term health.

Several reports have already begun to highlight the consequences of delayed cancer diagnoses.^[3] For instance, a survey from the American Society for Radiation Oncology,^[4] published in March 2021, found that two-thirds of physicians reported diagnosing more severe disease in new patients in early 2021 vs before the pandemic.

"We are going to be seeing the impact of the pandemic 2, 5, 10 years down the road because of how it impacted early diagnosis of cancer," Lal told Medscape Medical News.

The study was supported by a grant from the Department of Veterans Affairs. Lal reported receiving grants from the Department of Veterans Affairs and the National Institutes of Health.

Clinical Implications

• A previous study by McBain and colleagues found that the median weekly rates of mammography and colonoscopy declined by 96% and 95% in comparing the pre--COVID-19 pandemic period with a postpandemic period through July 2020. There was a moderate rebound of these screening procedures by July 2020 but not to prepandemic levels.
• In the current study by Englum and colleagues, rates of healthcare visits for prostate cancer were lower in the COVID-19 pandemic period compared with the prepandemic period; however, visits for bladder, lung, and colorectal cancer were not affected. Screening tests for all of these types of cancer declined during the pandemic.
• Implications for the healthcare team: The healthcare team should continue to emphasize routine cancer screening among eligible patients, regardless of the COVID-19 pandemic.

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