Breast, colon, prostate, and lung cancers did not stop for COVID-19 in 2020, but screenings and treatments did. Dramatically. The result, say doctors, could be a catastrophe in the making.

A new study published online ahead of the November issue of the journal JCO Clinical Cancer Informatics shows a considerable drop in cancer screening, diagnosis, and treatment for American seniors and Medicare beneficiaries this year. Oncologists who were part of the study's research team say they are already starting to see the traumatic results, as cancers are caught at later stages requiring more complex treatments, resulting in higher morbidity, or worse, death.   

The study, conducted for the non-profit Community Oncology Alliance (COA) by Avalere Health, examined the billing frequencies from March-July 2020 for common cancer procedures, including screenings, infusion therapies such as chemotherapy, surgeries, and radiation therapy. It found significant reductions in breast (-85%), colon (-75%), prostate (-74%), and lung cancer (-56%) screenings at the first peak of the pandemic in April 2020, compared with April 2019.

In the early days of the pandemic, shelter-in-place orders and patient concerns about COVID-19 caused a massive drop in common, preventative screenings, such as mammograms and colonoscopies, as well as the cancer therapies and surgical procedures that occur as a result. While this reduction in services was expected as lockdowns took place, several cancer care providers have reported first-hand that they have not seen the complete resumption of services as states have reopened, as reflected in the analysis in the continued reductions in utilization of key cancer services through latter months of 2020.

Lead author, Debra Patt, MD PhD MBA FASCO, executive vice president, policy and strategic initiatives at Texas Oncology, and member of the COA Board of Directors, warned that the worst could be yet to come.

"When cancer becomes more advanced before it is detected it becomes a ticking time bomb. The decrease in screenings, diagnosis, and treatments this year will lead to later stage cancers for patients, increasing morbidity and mortality for years to come. We need to detect cancers and stop them before it is too late. We need to alert all patients that they need to stop medical distancing and get appropriate screening and health care," she said.

A downstream ripple effect throughout the cancer care continuum may also be observed from the drop-off in screenings and diagnoses, reflected in decreases in patient visits, biopsies, and cancer treatments in the months following peak drops in screening. The study shows decreased billing frequencies across a number of services at the height of the shelter-in place-orders, but after a slow rebound, the data highlights additional declines in the month of July. Billings for the top physician-administered chemotherapy drugs were lower in July than they were in April (-31% vs. -26% respectively), which could be attributed to reduced screenings and declines in new patient visits of 30–70% since the beginning of the pandemic.

The study also looked at the differences between independent, community oncology and hospital or institutional care settings. The analysis observed an average difference of 10 percentage points in billing frequencies between the settings for cancer-related services from March-July 2020. This is likely a reflection of the dramatic impact of COVID-19 on hospital resources to treat COVID-19 patients, in addition to the ability of community oncology practices to keep their doors open while complying with CDC guidelines and state reopening requirements. Furthermore, community oncology practices have been able to invest resources needed to rapidly adopt telehealth services, providing a critically important treatment option for patients in need.

Lucio Gordan, MD, study co-author, president and managing physician of Florida Cancer Specialists & Research Institute, and member of the COA Board of Directors, applauded community oncology for adapting and taking on new patients and maintaining open clinics for established patients on treatment during the pandemic.

"Community oncologists and their team members showed incredible resilience and resolve to deal with this severe crisis, by adopting telehealth very quickly, reorganizing workflows, enhancing safety processes at their clinics, and migrating staff to work from home, among other strategies. Although a decrease in services was inevitable, I think the resilience of these practitioners absorbed what could have been a much worse situation," he said.

A shining light during the period was the adoption of telehealth. While many providers quickly pivoted to virtual telehealth visits, its use was only able to slightly lower the reduction in E&M utilization (-73% without telehealth services vs. -58% with telehealth services in April 2020). Further highlighting the different experiences of care settings during the pandemic's summer months, utilization of telehealth has been almost entirely driven by providers in non-hospital settings of care, such as independent physician offices, who provided approximately 95% of telehealth E&M services in April through July.

COA and Avalere Health also report reductions in cancer biopsies in April 2020 and July 2020 compared with those months in 2019 for breast (-71% to -31%), colon (-79% to -33%), and lung (-58% to -47%), respectively. The study also finds a marked decrease in cancer-related surgeries in April and July 2020 compared with those months in 2019, including mastectomies (-56% to -44%), colectomies (-61% to -37%), and prostatectomies (-56% to -43%), respectively.

For the study, COA and Avalere conducted a retrospective analysis leveraging utilization data from a large, proprietary Inovalon provider-sourced data clearinghouse. The clearinghouse data represent 5-7% of the total volume of Medicare Fee-for-Service (FFS) claims nationally, including CMS-1450 claims from Institutional providers and CMS-1500 claims from Non-Institutional or Professional providers. The analysis sought to characterize changes in utilization of cancer care services and gain insight into the impact of COVID-19 on the U.S. cancer population, including identification of new patients, gaps in access to care, and disruption of treatment journeys. The full data set was then limited to claims that were 1) submitted for adjudication between January 1, 2019 and July 31, 2020, inclusive, and 2) specific to targeted cancer-related services of interest, including diagnostic screenings (breast, colon, etc.), physician office visits, hospitalizations, surgeries, and infusion therapies administered in an outpatient setting, resulting in a sample of 6.2 million Medicare claims. For each service or service category, the number of services billed by each rendering provider was tracked and trended, and the mean change in volume (2019 vs. 2020) was estimated and compared, statistically, using a Wilcoxon rank-sum test. All data manipulation and statistical analyses were carried out using SAS 9.4 (SAS Institute, Cary, NC), assuming a p-value (α) of 0.05.

As the COVID-19 pandemic continues, COA and Avalere will continue to track the pandemic's impact on cancer care and issue updates to the study when new data are available. Given the potential of a third surge of COVID-19 cases in the winter months of 2020, future analytics will need to assess the continued barriers to cancer care and the potential longer-term impact on outcomes.

About the Community Oncology Alliance:

COA is a non-profit organization dedicated to advocating for community oncology practices and, most importantly, the patients they serve. COA is the only organization dedicated solely to community oncology where the majority of Americans with cancer are treated. The mission of COA is to ensure that cancer patients receive quality, affordable, and accessible cancer care in their own communities. More than 1.5 million people in the United States are diagnosed with cancer each year and deaths from the disease have been steadily declining due to earlier detection, diagnosis, and treatment.