In recent months, the COVID-19 pandemic has caused many institutions to pause routine cancer screenings—delays that may not be problematic for patients but can create challenges for healthcare providers.
Routine screening of patients without symptoms plays an important role in the early diagnosis of various cancers, including breast, colorectal, and cervical cancers. However, the COVID-19 pandemic has caused many institutions to pause screenings, as healthcare providers balance the risk of COVID-19 with that of waiting weeks or perhaps months to test patients.
“We know that cancer screening saves lives and is extremely important,” says Amanda Fader, MD, of Johns Hopkins University in Baltimore, MD. The Pap test, for example, has drastically reduced cervical cancer incidence and mortality since it was introduced in the 1940s. Yet, a recent report estimates that appointments for cervical, colon, and breast cancer screening were down 86% to 94% in March, as organizations such as the National Comprehensive Cancer Network recommended postponing them, and institutions followed suit.
Fader isn't necessarily concerned about a delay of a few months in cervical cancer screening, noting that a Pap test is recommended only every 3 to 5 years—although providers should track delayed screenings and send reminders to patients. Importantly, she says, institutions need a plan to deal with a surge in screening—and new cancer cases—when it restarts.
Sara Tolaney, MD, MPH, of Dana-Farber/Harvard Cancer Center in Boston, MA, agrees, noting that the number of new breast cancer cases at her institution has declined since screening was paused. When it begins again later this month, Dana-Farber will add extra weekend and evening hours. “We're honestly not entirely certain how the wave will go,” for screening and new cases, she says, “but at least we want to be ready for it.”
A delay of a couple months in breast cancer screening shouldn't be problematic, Tolaney says. A concern, however, is that patients will skip screening entirely: Mammograms are often done every 2 years, so a missed screening could result in up to 4 years between tests. Thus, tumors “could be bigger at presentation,” Tolaney says.
Kimmie Ng, MD, MPH, also of Dana-Farber, thinks that a temporary delay in getting a routine colonoscopy shouldn't be concerning, but “only time—and further research—will tell whether that has an impact on stage of diagnosis.”
Higher-risk patients present a trickier challenge. Douglas Johnson, MD, of Vanderbilt-Ingram Cancer Center in Nashville, TN, sees patients who no longer have active melanoma but need regular surveillance. “We're having to do tough risk–benefit assessments, and, in many cases, needing to delay their visits to reduce the risk of catching the virus,” he says, but “that does increase the risk of having later-stage disease” if tumors recur. Oncologists at Dana-Farber are calling patients with a history of breast or colorectal cancer to make sure that they reschedule surveillance scans and procedures as soon as it's safe.
The pandemic has also pushed providers to consider whether screenings can be done remotely—an option more feasible for some diseases than others. Self-exams aren't highly beneficial for breast cancer screening, for example, but a photo or video can help with skin cancer checks; at-home stool tests are available for colorectal cancer. Cervical cancer may have the most untapped potential, as various studies have investigated self-collection for Pap tests.
“I suspect we're going to see a resurgence of self-screening research within the context of the COVID-19 pandemic,” Fader says. She adds that when it comes to screening—and other aspects of care—“providers and patients are going to have to learn how to adapt to the changing healthcare environment.” –Catherine Caruso