Cancer experts seeing advanced cases with care delayed by pandemic fears

cancerexam-300x225One consequence of the coronavirus pandemic may be showing up in tragic fashion: Cancer specialists say they are treating a wave of advanced cases in which patients might have benefited from earlier care had fear of Covid-19 infection not kept them away from doctors’ offices and hospitals.

The information about the harms of missed appointments, especially for important cancer tests and screenings, is, at present, more anecdotal than quantifiable in hard data, the New York Times reported. But the newspaper quoted doctors across the country reporting this:

“While it is too early to assess the full impact of the delays in screenings, many cancer specialists say they are concerned that patients are coming in with more severe disease. ‘There’s no question in practice that we are seeing patients with more advanced breast cancer and colorectal cancer,’ said Dr. Lucio N. Gordan, the president of the Florida Cancer Specialists & Research Institute, one of the nation’s largest independent oncology groups. He is working on a study to see if, overall, these missed screenings resulted in more patients with later-stage cancers.”

Better data are available about how the pandemic slammed accepted practices to detect common cancers early and treat them, with potentially better outcomes, the newspaper reported:

“Months of lockdowns and waves of surging Covid cases throughout last year shuttered clinics and testing labs, or reduced hours at other places, resulting in steep declines in the number of screenings, including for breast and colorectal cancers, experts have said. Numerous studies showed that the number of patients screened or given a diagnosis of cancer fell during the early months of the pandemic. By mid-June, the rate of screenings for breast, colon and cervical cancers were still 29% to 36% lower than their pre-pandemic levels, according to an analysis of data by the Epic Health Research Network. Hundreds of thousands fewer screenings were performed last year than in 2019, according to the network data … Another analysis of Medicare data suggested that as Covid cases spiked during certain periods in 2020, cancer screenings fell. The analysis — conducted by Avalere Health, a consulting firm, for Community Oncology Alliance, which represents independent cancer specialists — found that testing levels in November were about 25% lower than in 2019. The number of biopsies, used to diagnose cancer, decreased by about one-third.”

The newspaper article reported several sad stories about patients, including those with known predisposition to or existing problems with cancer, delaying check-ups or check-ins with their doctors, especially if treatment meant visits to offices and hospitals that were handling hefty coronavirus caseloads. The patients ignored symptoms and warning signs of advancing cancer.

Dr. Patrick I. Borgen, the chair of surgery at the Maimonides Medical Center in Brooklyn and leader of its breast center, told the New York Times this was the difficult assessment people made:

“The fear of Covid was more tangible than the fear of missing a screen that detected cancer.”

Doctors and hospitals, to their credit, campaigned to get patients to maintain essential care. They called and reached out in other ways to try to schedule care. Specialists also adapted to pandemic circumstances, struggling to diagnose and treat a difficult disease like cancer via online technologies, notably telehealth — video and audio conference sessions.

Novel approaches may have allowed other clinicians to have greater confidence that in-person visits, postponed or canceled during the pandemic, would not be as detrimental as feared. But cancer experts are less sure, and the experiences of recent months will be the subject of significant research.  Experts also, no dobut, will drill into another related topic — how the pandemic’s giant job losses affected patients’ health insurance coverage and whether financial considerations kept them away from medical care.

In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them by misdiagnoses and medical error. In pre-pandemic times, researchers found that medical errors were lethal to as many as 250,000 patients in this country annually and had become the third-leading killer of Americans, trailing only heart disease and cancer. Other studies have found that diagnostic errors affect an estimated 12 million Americans each year and likely cause more harm to patients than all other medical errors combined.

Before coronavirus-related restrictions crushed typical medical services delivery in this country, cancer misdiagnosis and over diagnosis, in particular, created significant problems for patients and their potential outcomes with the disease. But over testing and over treatment, in general, also caused big challenges, adding $200 billion in unnecessary care expenses, with over-treatment costing 30,000 lives a year of older (Medicare) patients alone.

Patients who experience these symptoms should not ignore them and should see their doctors for examination and possibly for tests, the American Cancer Society says:

  • Fatigue or extreme tiredness that doesn’t get better with rest.
  • Weight loss or gain of 10 pounds or more for no known reason
  • Eating problems such as not feeling hungry, trouble swallowing, belly pain, or nausea and vomiting
  • Swelling or lumps anywhere in the body
  • Thickening or lump in the breast or other part of the body
  • Pain, especially new or with no known reason, that doesn’t go away or gets worse
  • Skin changes such as a lump that bleeds or turns scaly, a new mole or a change in a mole, a sore that does not heal, or a yellowish color to the skin or eyes (jaundice).
  • Cough or hoarseness that does not go away
  • Unusual bleeding or bruising for no known reason
  • Change in bowel habits, such as constipation or diarrhea, that doesn’t go away or a change in how your stools look
  • Bladder changes such as pain when passing urine, blood in the urine or needing to pass urine more or less often
  • Fever or nights sweats
  • Headaches
  • Vision or hearing problems
  • Mouth changes such as sores, bleeding, pain, or numbness

When you visit a medical office, clinic, or hospital, it is vital that you doctors don’t just start ordering a blizzard of unexplained tests or procedures, including cancer screenings. Doctors must safeguard your fundamental right to informed consent. This means that you, as a patient, are told clearly and fully all the important facts you need to make an intelligent decision about what treatments to have, where to get them, and from whom.

There’s a line between doctors making important but delayed diagnoses, including for serious conditions in returning patients — and some potentially also turning them into profit machines. Ask lots of questions about every aspect of your medical treatment — and know you should get patient, clear, and detailed explanations.

If you’re uncertain about tests or procedures, you may want to look at the Choosing Wisely site, with recommendations of respected experts in the field about common but often unnecessary medical care. You also may want to study the online site of the U.S. Preventive Services Task Force, the voluntary and blue-ribbon expert panel that advises the federal government about the safety and effectiveness of tests, screenings, and other procedures. The influential panel, by the way, recently increased its recommendation about lung cancer screening.

We have much work to do to both detect and treat well dangerous illnesses, while also ensuring that we do not encourage wasteful, invasive, and painful tests and diagnostics that can lead to a cascade of unneeded and even harmful treatment.

Photo credit: National Cancer Institute, patient undergoing thyroid cancer exam
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