Beyond its direct toll on public health, the COVID-19 pandemic has also resulted in other healthcare challenges – perhaps none more noticeable than in routine cancer screening over the past year. For at-risk individuals, this could have devastating consequences. I believe that pathologists have a clear role to play in getting cancer testing back on track to reduce the chances of negative outcomes from prolonged delays.
In the last year, there has been a major drop in the number of patients seeking testing for cancer diagnosis and recurrence monitoring. A survey of more than 4,000 US adults run by the American Society of Clinical Oncology found that 24 percent of adults had delayed or canceled routine cancer screening tests due to COVID-19 (1). Separately, the Epic Health Research Network reported in May 2020 that preventive cancer screenings in the US had plummeted, with 86 percent fewer colon cancer screenings and 94 percent fewer breast and cervical cancer screenings than in prior years (2).
Aside from concerns about COVID-19 exposure, access to regular screening may have been challenging for some patients because many commercial laboratories and hospitals were appropriately focused on performing large-scale COVID-19 testing. This was a necessary shift, but one that limited some labs’ capacity to provide other forms of needed testing. Many hospitals went to great efforts to put in place measures designed to protect patients and pave the way for other types of testing – such as facilitating off-site blood draws – but these measures were not always sufficient to reassure patients that it was safe to keep up with cancer screening.
This trend is concerning. Regular cancer screening is critical for early detection, treatment, and long-term monitoring. In the case of chronic myeloid leukemia (CML), for instance, patient care can be more effectively managed in the chronic stages with routine monitoring tied to oral treatments. However, if a relapse is missed because a patient has not been monitored regularly, dramatic interventions may be required. Monitoring cancer through frequent testing is a key aspect of keeping most CML cases manageable.
For many CML patients, the advent of targeted therapies extended survival by a decade or more. Unfortunately, mutations in the cancer mean that a fair number of patients eventually develop resistance to the first targeted therapy – but new generations of targeted therapies can be swapped in to add to progression-free survival. The key is to switch medications before the patient develops widespread resistance. CML monitoring assays measure BCR-ABL1 to flag cancer progression and give physicians insight into whether and how a given CML therapy is working so they can adjust when needed. Such monitoring makes it possible to follow a patient’s drug response and pick up on signs of resistance before the patient’s prognosis worsens. For patients who achieve remission and can discontinue treatment, long-term monitoring is equally important for detecting the earliest signs of recurrence and getting patients back on an effective targeted therapy in the event of any recurrence – before symptoms occur.
Current guidelines from the National Comprehensive Cancer Network recommend that cancer monitoring should be performed every three months. If a patient’s condition is relatively stable and they miss a single monitoring test, there will probably be few significant consequences. But after more than a year of the pandemic, many patients have skipped multiple screenings – and that’s something they may not be able to afford. As patients return to their doctors’ offices, we may see more relapses and advanced disease than we would typically expect. To contain the human and monetary costs associated with managing late-stage cancer, it is imperative to return to pre-pandemic levels of screening and monitoring for all cancer patients.
With the availability of vaccines for COVID-19, hospitals and clinical laboratories are now moving past “pandemic response mode” and resuming routine testing. As they do, it will be essential to help patients feel comfortable in the clinical environment again without worrying too much about COVID-19 exposure. Some of this will happen organically as more of the public gets vaccinated and restrictions on social interaction are further relaxed. In fact, the Epic Health Research Network published an update to its initial findings last summer (3), noting that the number of cancer screenings had already begun to rise (though they still had not returned to pre-pandemic numbers).
The effects of the recent gap in testing may not be evident for some years to come. For now, getting patients back into the clinic for regular screening should be a priority. Pathologists will be critical in helping to achieve this – not least by reassuring the physicians they work with that their labs are open for business and can handle the levels of cancer screening needed.
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References
- ASCO, “National Cancer Opinion Survey” (2020). Available at: https://bit.ly/3bdBVRR.
- Epic Health Research Network, “Delayed Cancer Screenings” (2020). Available at: https://bit.ly/3bewWjK.
- Epic Health Research Network, “Delayed Cancer Screenings – A Second Look” (2020). Available at: https://bit.ly/3bl7mtA.
