The new coronavirus kept people away from their regular cancer screenings in droves last year, with many studies noting sharp declines in preventive screening throughout the U.S., particularly in breast, colorectal and prostate cancers.
But “cancer did not go away during COVID-19,” said Dr. Nancy Davidson, vice president of Fred Hutchinson Cancer Research Center and president and executive director of its clinical-care partner Seattle Cancer Care Alliance. “It’s not that the pandemic in some fashion mitigated the diagnoses or the need for treatment for cancers.”
With COVID-19 on the retreat, caregivers, cancer researchers, and community health educators are pulling out all the stops to get preventive screenings back on peoples’ calendars — with some even calling for innovative old-school strategies to play catchup.
According to Davidson, it’s vital to bring people back into the screening process “so we can regain ground as rapidly as possible.” A longtime breast cancer oncologist and translational researcher, Davidson knows well that catching a cancer early is crucial. Missed screenings can mean later-stage cancers. The later the stage, the harder to cure.
“I’m worried people will come in with a more advanced stage of disease and that may be associated with worse outcomes,” she said. “Ultimately, there may be more deaths and the need for different kinds of therapies that can be more intensive, have more side effects and more costs. Screening is one of the cornerstones in our efforts to reduce the burden of cancer. We need to act on this.”
So how are clinicians, community health educators and public health researchers at Fred Hutch playing catchup now that vaccinations have started to send the pandemic packing?
In all kinds of ways, some of which may even surprise you.
Watch a video tour of the OCOE's giant inflatable colon in English.
Davidson, who holds the Raisbeck Endowed Chair for Collaborative Research, said a delayed screening of a month or so shouldn’t make much of a difference. It all depends on the cancer.
“For the cancers where we do screenings — breast and lung and colorectal and cervical cancers — those are all relatively slow growing tumors,” she said. “If people are following the guidelines, we could argue that a two-month lag for any one patient may not have much of a role [in a cancer’s progression]. For other cancers, it would be more problematic.”
The key thing, she said, is for people to get back into the “screening pipeline.”
“COVID has been all-consuming for over a year,” she said. “But it’s really important that people don’t let COVID stand in the way of attending to their general health, and that includes being adherent to cancer screening guidelines.”
Screening delays have already begun to show up in the numbers, according to data shared at the recent annual meeting of the American Society for Clinical Oncology, or ASCO. One Boston hospital saw twice as many patients diagnosed with late-stage breast cancer in 2020. Normally, it’s 6.6% of screened patients; last year, 12.6% of patients were diagnosed with stage 3 or 4. Most of these cancers were found after the initial shutdowns ended in July 2020; as is often the case, economically-disadvantaged patients and those with medical comorbidities were harder hit. Such was the case at a New York hospital, as well, where the COVID-19 screening hiatus led to more cases with advanced stages of disease and exacerbated racial disparities in accessing breast-screening services.
Another study using projection models from CISNET, the Cancer Intervention and Surveillance Modeling Network, predicted around 2,500 extra breast cancer deaths in the U.S. by 2030 because of the reduced screenings, delayed diagnoses and reductions in treatment.
And that’s just in one type of cancer.
Davidson hasn’t seen any uptick in later-stage diagnoses at SCCA but said “we’re still in the thick of [catching people up on screening].” The main thing, she said, is for people to know “the health care system is very safe.”
“We’re all in it for the wellness long haul,” she said.
The Fred Hutch/University of Washington Cancer Consortium’s Office of Community Outreach and Engagement (OCOE) also collaborates on screening programs with community-based organizations in the state. The OCOE’s focus is on health equity, making sure the people most at risk for disease due to structural racism or socioeconomic hardship — non-English speakers, Indigenous people and those living in rural areas; Black and African-descent populations; Hispanic/Latino and LGBTQ+ folx — have access to preventive screenings, cancer care and other resources, as needed.
“Screening is on our radar!” said OCOE assistant director Kathy Briant. “But it’s not at the forefront of most peoples’ minds.”
Briant said the people they serve have been hit hardest by COVID-19 — many are frontline workers; others have lost their jobs — and understandably are “focused on bigger priorities, like how to pay the rent or put food on the table for the family.”
“It’s more about day-to-day survival than thinking about preventing cancer and finding time to get a screening,” she said.
That’s why Briant and her team of community health educators are pushing out the message to “get those screening appointments back on the books.”
The Hutch’s satellite office in Eastern Washington, the Center for Community Health Promotion, usually holds health fairs, home health parties and other events for the largely rural, Spanish-speaking residents of the Yakima Valley as part of its health equity research.
Its promotores, or community health educators, have continued to encourage cancer screenings and breast awareness throughout COVID-19, Briant said, “talking about the importance of understanding what your breasts normally look like so if you do see changes, you’ll know that’s a red flag.” And events are slowly and safely starting back up.
“We had one event a month ago, a drive-through health fair, hosted by a local radio station, KDNA,” said Briant.
Unfortunately, some patients may face a shortage of resources post-COVID-19.
Komen Puget Sound, which funded screenings for many low-income women in the area, closed in late 2020, along with all of Susan G. Komen’s regional affiliates. Additionally, the Breast Cervical and Colon Health Program, funded by the CDC and administered by Public Health Seattle and King County, recently lost its funding to perform colorectal screenings. The program, which provides free screening to eligible participants in Washington state, is now “back to just breast and cervical screenings, as when the program first started,” Briant said.
The longtime health disparities researcher worries that cuts in these programs will have a ripple effect that will be seen in 2022. That’s why she and others are “reminding people that screening is the most important thing you can do for your health.”
She and the OCOE team have produced two colorectal cancer screening video tours, one in English and one in Spanish, of their giant inflatable colon, CECE — short for Colorectal Education Cancer Exhibit. The videos explain colorectal cancer’s often-sluggish progression and how it can be stopped through colonoscopy and other forms of screening.
They’re also readying CECE for its first post-COVID-19 road trip in Western Washington. Their other rolling colon, CASPER (short for Capture All Suspicious Polyps and Eradicate Rapidly) tours Eastern Washington.
“We haven’t taken either of our colons out this year,” she said. “But we have a request to go out in the Yakima Valley later this summer.”
A gastroenterologist and assistant professor at the Hutch and the University of Washington, Dr. Rachel Issaka has kept a watchful eye on COVID-19’s impact on colorectal screening rates for a year and a half.
National screening rates for prostate and breast cancer bounced back to pre-COVID levels by July 2020. But colorectal cancer screening rates did not. A JAMA Oncology study showed them 13% below 2019 rates.
“It’s estimated that an additional 4,000 people will die of colorectal cancer over the next decade because of losses to screening,” she said. “And the longer COVID-19 lingers, the higher the likelihood that number will increase. This is an opportunity to think creatively about what we can do moving forward to minimize risk.”
Issaka has been actively promoting the use of FIT kits, or fecal immunochemical tests, a low-cost, at-home, non-invasive stool-based screening test developed in the 1980s, that can be done in minutes, as a way to catch up.
“From a clinical practice perspective, we can use the stool test to risk stratify people now that things have opened back up,” she said. “Those with abnormal stool tests should be prioritized for colonoscopy as they have the higher risk of colorectal cancer.”
Data show Black people are 20% more likely to be diagnosed and about 40% more likely to die from colorectal cancer than any other racial/ethnic group. Colorectal cancer is also trending in younger populations, prompting the U.S. Preventive Service Task Force (USPSTF) to lower the recommended screening age from 50 to 45.
Issaka’s research on FIT kits shows their usefulness. In a study she published last year, FIT kits mailed to Medicare patients resulted in a 5% increase in colorectal screening completion. Another study, published in April, showed, via a simulation model, mailed FIT kits could actually “mitigate the consequences of reduced screening rates during the pandemic.”
Issaka, who works with the Hutchinson Institute for Cancer Outcomes Research, points to other stopgap solutions: increasing clinic hours, hiring additional administrative staff, and offering evening and weekend screenings.
She also promotes the idea of taking science and screening out to the community.
“Mobile vans that offer healthcare services including collecting detailed family histories, performing physical examinations, and disseminating at-home colorectal cancer screening options can be deployed to churches, barber and beauty shops, and other community gathering spaces in urban and rural Black communities,” she wrote in a Seattle Medium guest editorial. “When colon cancer is discovered in the early stage, over 90% of people survive five or more years.”
Dr. Yaw Nyame, a urologic oncologist at SCCA and health disparities researcher with the Hutch and the University of Washington, also believes in taking science to the community.
The OCOE program lead for African American/African-descent populations, Nyame’s research focuses on prostate cancer screening and treatment and how barriers to both contribute to prostate cancer disparities. For many in underserved communities, health care is seldom accessible — and it is unclear how the pandemic will further exacerbate disparate outcomes in prostate cancer.
Recent findings from the OCOE showed in Washington state alone, Black men are 1.6 times more likely to be diagnosed with prostate cancer and 2.4 times more likely to die from it than their white counterparts.
“These are glaring disparities that we want to address through raising awareness, more screening and further studies,” said OCOE community health educator Dante Morehead in one of OCOE’s cancer prevention videos. “Prostate cancer is very treatable if we catch it early through screening or PSA testing.”
Unfortunately, studies suggest Black men may have slightly lower screening rates, a trend that may have been exacerbated by previous recommendations against routine screening from the USPSTF and other organizations.
Nyame hopes to change that. In a study published last month in the Journal of the National Cancer Institute, he and Hutch biostatistician Dr. Ruth Etzioni used microsimulation models to pinpoint the sweet spot in time for prostate cancer screening in Black men.
“We found that if we drop the screening age from 55 to 45 and screen men every year until they’re 70, we could decrease the number of Black men who die from prostate cancer by an additional 10% compared to standard screening practices here in the U.S,” Nyame said in a recent presentation, “What Black Men Need to Know About Prostate Cancer.”
But first, they need to show up.
“It’s an important effort to get people back to their cancer screenings,” Nyame said.
He plans to do outreach to understand what barriers exist to preventive screenings and treatment for Black men in Washington state next month as he launches a new study. The recent recipient of a Distinguished Researchers Grant from the Andy Hill Cancer Research Endowment (CARE) Fund, as well as the Dr. Beti Thompson Cancer Health Equity Research Award, Nyame and colleagues at the Hutch and UW have started a community-based research coalition BACPAC (the Black and African-Descent Collaborative for Prostate Cancer) to facilitate this work.
Nyame, Morehead and others plan to work with patients and community advocates to improve prostate cancer outcomes.
“Starting in July, we’re going to perform a series of interviews to hear what the needs and priorities are for Black men in the Greater Puget Sound area when it comes to screening and treatment for prostate cancer,” Nyame said. This work will be part of a series of projects that aims to prioritize local research and interventions.
But the work hardly stops there, he said, pointing to the fact that research and interventions may not address the larger context of social, economic, environmental, and structural factors that impact health. These social determinants of equity and health govern whether a person has access to a safe neighborhood, nutritious food, clean air and water, and available, compassionate quality health care. All of these things contribute to a good cancer outcome.
“Screening is one part of the equation, but the benefit of early detection only matters if there’s subsequent access to treatment,” he said. “I don’t know if the benefit of earlier detection will have the same impact if we don’t address the context wherein everything else occurs.”
Diane Mapes is a staff writer at Fred Hutchinson Cancer Center. She has written extensively about health issues for NBC News, TODAY, CNN, MSN, Seattle Magazine and other publications. A breast cancer survivor, she blogs at doublewhammied.com and tweets @double_whammied. Email her at email@example.com. Just diagnosed and need information and resources? Visit our Patient Care page.
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