COVID-19 Drives Decreases in Cancer Screening, Diagnoses, and Treatments

A significant decline in cancer screenings, biopsies, surgeries, office visits, and therapies was observed with variation by cancer type and site of service among senior patients with cancer from March to July 2020, during the coronavirus disease 2019 (COVID-19) pandemic, according to a study published in JCO Clinical Cancer Informatics.¹

Moreover, in April 2020, at the peak of the COVID-19 pandemic, screening rates for breast, colon, prostate, and lung cancer were 85%, 75%, 74%, and 56% lower than the baseline rates of the previous year, respectively.

“When cancer becomes more advanced before it is detected, it becomes a ticking time bomb,” said lead study author Debra Patt, MD, PhD, MBA, FASCO.² “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.”

The COVID-19 pandemic has had a profound effect on cancer care throughout the United States.1 In response to the outbreak, the Centers for Disease Control and Prevention implemented guidelines with the goal of diminishing exposure to the virus. Stay-at-home orders, short-term treatment adjustments, telehealth utilization, and delayed surgeries were among some of the safety precautions that have been put in place by cancer care facilities across the country.

As of late September 2020, over 7 million people throughout the United States had been infected with COVID-19.

With the health care system navigating how to best keep elderly and high-risk patients safe, many individuals have experienced decreased access to care, including preventive tests such as cancer screening. Patients with cancer have also reported increased challenges in cancer management visits and surgery.

Although the stay-at-home orders have been lifted, the lasting effect of those peak months on disease progression, cancer morbidity, and cancer mortality has yet to be fully understood. 

As such, the retrospective analysis aimed to assess the effect of COVID-19 on the utilization of health services.

Data from a proprietary provider clearinghouse registry, comprised of approximately 5% to 7% of all Medicare Fee for Service (FFS) claims submitted between January 1, 2019 and July 31, 2020, were sourced. Centers for Medicare and Medicaid Services (CMS)-1450 claims from institutional providers and CMS-1500 claims from non-institutional or professional providers were included in the database.

Setting of care was determined using the claim type rather than the site of service modifier to include services delivered via telehealth. This was an important step as additional regulatory and billing flexibilities were finalized by CMS as a result of the public health emergency. 

The data set included claims that were incurred during the first 7 months of each year and were specific to targeted cancer-related services of interest, including diagnostic screening, physician office visits, hospitalizations, surgeries, and infusion therapies administered in the outpatient setting. 

Using these data, the number of procedures billed by each rendering provider was tracked and trended. The mean change in volume from 2019 to 2020 was estimated and compared.

In total, 6,227,474 Medicare FFS claims were included in the analysis.

Further data revealed that the most significant reductions in screening occurred in April 2020 versus April 2019.

Additionally, the 23 top physician-administered oncology products, including their respective biosimilars, were found to have a 26% decrease in billing frequency in April 2020 and a 31% drop in July 2020. The products were: denosumab (Prolia), filgrastim (Neupogen), lanreotide (Somatuline Depot), palonosetron (Aloxi), pegfilgrastim (Neulasta), atezolizumab (Tecentriq), bendamustine, bevacizumab (Avastin), bortezomib (Velcade), brentuximab vedotin (Adcetris), carfilzomib (Kyprolis), cetuximab (Erbitux), cyclophosphamide, daratumumab (Darzalex), ipilimumab (Yervoy), nab-paclitaxel (Abraxane), pembrolizumab (Keytruda), nivolumab (Opdivo), pemetrexed, pertuzumab (Perjeta), rituximab (Rituxan), ado-trastuzumab emtansine (Kadcyla), and trastuzumab (Herceptin).

Chemotherapy administration services also experienced a drop in April, May, and July in the professional (28%, 30%, and 31% drops, respectively) and institutional settings (21%, 21%, and 31% drops, respectively).

In April 2020, a 71% reduction in breast cancer biopsies was reported, with a 79% reduction in colon cancer biopsies, and 58% reduction in lung cancer biopsies. In July 2020, reductions of 31%, 33%, and 47% were reported, respectively.

Surgical interventions, including mastectomies, colectomies, and prostatectomies, were also consistently reduced in April 2020 through July 2020.

In April 2020, a 74% reduction in hospital outpatient evaluation and management (EM) visits was reported. New patient visits experienced a greater drop versus established patient EM visits (70% vs 60%, respectively). Overall, cancer-related hospitalizations declined 30% in March, 41% in April, 36% in May, 31% in June, and 38% in July.

Despite the uptake of telemedicine, virtual EM visits only mitigated the drop in EM visits from 73% to 58% in April. Nearly all (95%) of telemedicine EM visits were delivered by professional providers from April through July.

“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,” said Lucio Gordan, MD, study co-author and medical oncologist at Florida Cancer Specialists & Research Institute.² “Although a decrease in services was inevitable, I think the resilience of these practitioners absorbed what could have been a much worse situation.”

The disruption in routine screening for cancer over the last 6 months could have profound and lasting consequences, explained the study authors in the paper.1 It is critical to start reassuring elderly and high-risk patients that they are able to seek safe and appropriate care at cancer facilities.

The lower rates in screening, EM visits, and administration of anticancer therapies confirmed by the retrospective analysis suggests that patients may present with more advanced disease and higher cancer-related mortality.

“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,” explained Patt.²

Additionally, further studies should be conducted to identify the scope of the effect of COVID-19 on specific patient populations, concluded Patt and study authors.¹

References

1. Patt D, Gordan L, Diaz M, et al. The impact of COVID-19 on cancer care: how the pandemic is delaying cancer diagnosis and treatment for American seniors. Published online ahead of print October 21, 2020. Accessed October 22, 2020. JCO Clin Cancer Inform. doi:10.1200/CCI.20.00134
2. New study finds COVID-19 substantially reduced cancer screenings, diagnosis, and treatments in 2020. News release. Community Oncology Alliance. October 21, 2020. Accessed October 22, 2020. https://prn.to/3khxMPc