The Unhappy Intersection of Cancer and COVID-19

In this issue of ONCOLOGY®, investigators who were led by John Nakayama, MD, from the Seidman Cancer Center at Case Western Reserve University in Cleveland, have provided a very large sample of patients with cancer and compared cancellation rates of oncology appointments in 2020 and 2019.

In this experience, more than 340,000 visits for clinic, lab, radiation, and surgery were compared between calendar year 2019 and 2020. The 2019 experience represented the control arm for the COVID-19–related 2020 experience. The authors report on the clinical, lab, radiation, and surgery appointments for these time periods and compare the cancellation rates in the control year versus the experience year presumably by reviewing all their electronic medical record data. Patients with cancer were identified by using more than 2000 International Classification of Diseases (ICD) codes, although many of these may have included patients who were not on active treatment.

In comparing the overall treatment cancellations for 2020, the authors report that there was an approximate 5% increase in cancellations which extended across clinic visits, lab visits, and surgical visits. Radiation visits, however, were not changed substantially. In addition, although younger patients have historically a higher cancellation rate, the increase in this group was minimal compared with those over 40 years of age in 2020. Whereas previously, men showed somewhat more than a 15% baseline cancellation rate for clinic visits versus about 1% lower for women, in the COVID-19 era women somewhat exceeded men, perhaps representing greater propensity for caution. Also, cancellation rates were 5% to 6% higher in 2020 for White but much lower in Black patients, and this extended across various types of visits.

Some additional considerations may apply here. One statistic not reported in the study was treatment volumes and cancellations during these time periods. Visit cancellations may have been at the request of providers and may have been partially compensated by telemedicine visits. Certainly, in my institution, we have been seeing about 5% telemedicine visits by volume since COVID-19. Furthermore, treatments may have switched to oral agents in the era of COVID-19 with the object of keeping patients at home. Finally, some
patients may have switched to more local practices.

The most critical information that we would like to know however, is the effect of delays in diagnosis for people who do not yet have a cancer diagnosis or related ICD code. This is the group that we are now beginning to see in our clinics who have more advanced stage cancers. For example, this week I saw a 33-year-old man with very advanced rectosigmoid cancer who was told for months that his symptoms were COVID-19 related. This unfortunate downstream effect of the coronavirus pandemic will be with us for the next few years as we see an uptick in cancer incidence and an increase in cancer mortality due to loss of early diagnosis and prevention.

What can we do in this situation? As the fourth wave of the pandemic accompanies the emergence of the delta variant, we may be seeing another round of reduced access to oncology care and screening. However, as physicians we must encourage the public to continue their medical visits and cancer screenings. We must make sure that mammography, colonoscopy, and radiology screening tests are available to our patients and not let COVID-19 put off diagnoses for yet another year. We can do this as leaders in oncology and we should lead these efforts.