The role of Family Physicians in mitigating COVID-19’s impact on missed and delayed cancer diagnoses
The COVID pandemic has brought unparalleled changes to our lives and health care system. The need to increase hospital capacity and redirect health care resources led to the unprecedented suspension of cancer screening during the first wave, decreased screening in subsequent waves and delays in cancer diagnosis and treatment.1 Although we will not be able to fully comprehend the impact of these delays on cancer mortality rates for several years, family physicians are critically placed to encourage their patients to resume screening activities in order to mitigate further deleterious outcomes.
Cancer screening was halted from mid -March 2020 to May 2020, and the gradual resumption of screening was further impacted by subsequent COVID-19 waves in 2021 and 2022. A review of Ontario’s breast, lung, colon and cervical screening programs showed that in 2020, there were 41% (951,000) fewer screening tests compared to 2019. Screening volumes recovered after May 2020, but were decreased by 20% from pre-pandemic levels.2 Based on historical detection rates, this reduction in screening translates into fewer invasive cancers diagnosed: 1412-1507 less breast cancers, 1148-1222 less cervical cancers and 393-462 less colorectal cancers.3 In Ontario, as of December 2021, the estimated cancer screening backlog is 89,347 Pap tests, 307,617 mammograms and 297,299 fecal immunohistochemical tests (FIT).4 In Quebec, the number of FIT tests in 2020-2021 was 26% lower than the year previous, and the number of screening mammograms was decreased by 24%.5 Similar trends were noted in Manitoba during cessation of screening in the first wave, with a 54% decrease in screening mammograms, an 83% decrease in pap tests and an 81% reduction in fecal occult blood tests (FOBT). Although screening volumes returned to expected values by September 2020, there was a significant cumulative backlog noted in August 2021 of 17,370 screening mammograms, 22,086 pap tests and 5253 FOBTs.6
Follow-up investigations for abnormal screens were backlogged during the shutdown. In Quebec, the number of diagnostic mammograms in 2020-2021 was decreased by 13% from the previous year.7 In Ontario, diagnostic lags for abnormal breast and colon screens were noted in April 2020, however, these were recovered by May 2020.8 Some backlogs persisted, with 33.2% of Ontarians with a high-grade screening cervical cytology result prior to the start of the pandemic still awaiting colposcopy as of August 2020.9 Patients living in neighbourhoods in the lowest quintile of income were more likely to have diagnostics delays following an abnormal breast, colorectal or cervical screen than those in higher income neighbourhoods.10
Patient hesitancy to be seen in person, coupled with virtual care and decreased health care resources for diagnosis, including biopsy and imaging, decreased the number of symptomatic cancers diagnosed. Approximately 30% of cancers were diagnosed through emergency departments in COVID waves one and two, compared to a baseline of 11%.11,12 A survey of radiologists showed that prostate biopsies ceased during the shut-down, and gradually resumed by August 2020.13 One Ontario study noted a decrease of 85% in expected rates of skin biopsies from January to September 2020, with only 27% of the usual volume of biopsies for melanoma. This led to a deficit of 595 cases of melanoma diagnosed in 2020 compared to 2019.14 A similar impact was seen in the diagnosis of lung cancer at a cancer centre in Quebec, with a decrease of 34.7% in new lung cancer cases from March 2020 to February 2021 compared to one year previous. The lung cancers that were diagnosed were noted to be at a slightly more advanced stage.15 Analysis of the Manitoba Cancer Registry showed a decrease of 23% in new cancer diagnoses in April 2020, accompanied by a 21% in the volume of pathology reports and a drop of 43% in surgical resections.16 Quebec data revealed a 5% decrease in pathology reports positive for malignancy in 2020-2021 compared to the year previous.17 Canada-wide, the number of cancer surgeries decreased by about 20% in 2020 compared to 2019.18
The impact of screening delays on cancer incidence and stage has been modelled and has been shown to increase late stage cancer diagnoses and mortality. In one model, a three month interruption in breast screening resulted in 310 more breast cancers diagnosed at a later stage (IIIA), and 110 more deaths. Similarly, a three month interruption in colorectal cancer resulted in the diagnosis of an additional 1100 colon cancers, with 60% of these at an advanced stage (III or IV) and 480 more deaths.19 These findings were echoed in a second modelling study, which projected cancer mortality in Canada to increase by 2.0% between 2020 and 2030, with a peak of 6% excess mortality predicted in 2022. This model anticipates 21, 247 excess cancer deaths over the next ten years due to the pandemic.20
The impact on of COVID on cancer is far-reaching: screening backlogs, delayed work up of abnormal screens and symptomatic patients, and delays in cancer treatment and research, all exacerbated by patient apprehension to be seen in person. It is clear that there is not only a lost cohort of screened patients, but also a subset of missed cancer diagnoses due to delays in patient presentation and assessment, leading to stage migration in those cancers that are diagnosed. Modelling suggests missed diagnoses and late stage cancer diagnoses will translate into higher mortality, and higher costs can be anticipated with the more intensive treatments required for advanced cancers. As gatekeepers of screening and cancer diagnosis, family physicians have an invaluable role in mitigating the effects of the impact of COVID on cancer. We must take an active role in surveying our practices for patients who are overdue for screening and advocating for this preventative care. Family physicians must be judicious in our use of colonoscopy and should not utilise this finite resource for screening low risk patients, so as to increase capacity for the work up of positive screens. We should monitor for the expected increase in symptomatic cancers and facilitate expeditious workup. Family physicians are uniquely placed in our health care system to decrease the collateral damage of the COVID pandemic and reduce avoidable cancer deaths.
Dr Anna N. Wilkinson is Assistant Professor in the Department of Family Medicine at the University of Ottawa in Ontario, a family physician with the Ottawa Academic Family Health Team, a general practitioner oncologist at The Ottawa Hospital Cancer Centre, Program Director of PGY-3 FP-Oncology, Chair of the Cancer Care Member Interest Group at the College of Family Physicians of Canada, and Regional Cancer Primary Care Lead for Champlain Region.
References
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