Ben White is a staff writer for Brief Policy Perspectives and a first-year MPP student.
Under most circumstances a 46% decrease in cancer diagnoses would be cause for great celebration, but in the era of COVID-19 this data is deeply concerning. These large decreases in cancer diagnoses are not the outcome of a new form of preventative medicine but are actually attributable to worldwide decreases in preventative cancer screenings as a result of the COVID-19 pandemic. We will not feel much of the fallout from this cancer screening gap for years to come, but decision makers still have time to enact policies that can help fill the screening gap and increase cancer screening rates.
The Trolley Problem
In the early phases of the COVID-19 pandemic, many countries halted all elective and non-essential medical procedures in an attempt to curb the spread of the coronavirus and to enable hospitals to reallocate staff to most effectively treat a large influx of COVID-19 patients. Healthcare professionals did not make this decision lightly, and some across the medical community compared the situation to the “trolley dilemma”, a classic thought experiment in which impossible decisions must be made about which lives to save. The CDC estimated that up to 41% of US adults delayed or averted medical treatment in response to the pandemic. While this is worrisome for all medical conditions, it is particularly concerning in cancer patients where delayed screenings may lead to later stage diagnoses with drastically increased mortality rates.
Routine cancer screenings like mammograms and colonoscopies are vital in the effort to minimize preventable cancer deaths. When cancer is caught earlier it is easier to treat, and patients with early stage diagnoses have much better outcomes and survival rates. One U.S. based study found that through the first peak of the pandemic in April 2020, cancer screening across the US fell by as much as 85% and remained low in all the months following. A similar CDC study followed cervical cancer screenings in southern California and found that even after California’s stay at home orders were lifted, cervical cancer screening rates remained at least 20% below the baseline for all age groups.
Expected Increases in Cancer Deaths
Without intervention, the COVID-caused downturn in preventative cancer care will likely result in an increase in cancer mortality in the years to come. Modeling data from the National Cancer Institute predicts that as a result of COVID-19 screening delays, over the next ten years in the United States, 10,000 excess breast and colorectal cancer deaths will occur. A similar study from the UK used predictive modeling to estimate that in five years, additional cancer deaths attributable to delays in screenings and treatment caused by the COVID-19 pandemic will range from a 4.8% increase in lung cancer deaths to a 16.6% increase in colorectal cancer deaths. These models predict alarming increases in excess cancer deaths if policymakers do not intervene.
Despite the troubling concerns that the COVID-19 pandemic has brought to cancer care, there are also some silver linings.The pandemic has helped to accelerate the adoption of some modes of cancer treatment and prevention that will increase access to care for rural and underserved communities. The first of these changes was the expansion of telehealth which has allowed oncologists to offer an alternative option to some visits that would have previously required in-person care. Telehealth visits have allowed for easier access to care for many vulnerable and underserved populations and have proven to be both effective and satisfying for patients.
The pandemic has also helped to increase the popularity of at-home colorectal cancer screening called fecal immunochemical testing (FIT). FIT tests have comparable detection rates to colonoscopies but are considered less invasive and can be sent through the mail helping to ease the burden of colorectal cancer screening for many rural and underserved populations. A recent modeling study showed that increasing FIT test usage by just 7% nationwide over the next three years could minimize the impact of reduced colorectal cancer screening rates caused by the COVID-19 pandemic.
Closing the Gap
Closing this cancer screening gap caused by the COVID-19 pandemic on a short timeline presents many challenges. Time is of the essence and by the time new programs could be developed and implemented, the window of opportunity may close. The most efficient and effective way to increase capacity for cancer screenings across the US would be to aggressively increase funding to the CDC’s Cancer Prevention and Control Division in fiscal year 2022.
This division oversees four critical cancer control programs: The National Program of Cancer Registries (NPCR), The National Breast and Cervical Cancer Early Detection Program (NBCCEDP), The Colorectal Cancer Control Program (CRCCP), and The National Comprehensive Cancer Control Program (NCCCP). While there is a large amount of federal funding available for cancer research, these programs are among the only federally funded programs focusing on cancer prevention. These programs are already running across the United States, and they have proven to be highly effective. The CRCCP for instance has shown to increase colorectal cancer screening rates by up to eight points within the first two years in communities where the program has been implemented.
US policy makers could also create a pilot program to follow the UK’s bowel cancer screening model in which all UK residents who fall into the recommended screening ages are automatically mailed a FIT test every two years. Congress could consider legislation to fund a pilot program to automatically mail eligible Medicare and Medicaid enrollees FIT tests to increase colorectal cancer screening rates. This low cost option has shown positive results in small initial trials and would increase access to screening for many underserved populations. A program of this nature could not only help fill the covid cancer screening gap, but could help to permanently increase colorectal cancer screening rates across the US.
COVID-19 has claimed over 3 million lives worldwide, and it is clear that we will continue to feel the effects from the pandemic for years to come. While the predictive modeling for expected excess cancer deaths as a result of the pandemic is disheartening, there is still time to enact policies to fill the cancer screening gap. If policymakers take decisive policy action now to strengthen national cancer screening programs, they can help limit excess cancer deaths caused by the recent screening and treatment delays.