When Representative Chip Roy (R., Texas) was diagnosed with stage 3 Hodgkin’s lymphoma nine years ago, he was “blessed” to receive treatment before his cancer had a chance to progress to stage 4.
Would he be so lucky if faced with the same situation today, amid the coronavirus pandemic?
That’s the question Roy posed on the House floor last month, imploring policymakers to focus more attention on the unintended consequences of COVID policies, including the cancellation of elective procedures such as cancer screenings.
“We had a family friend who just found out she has stage 3 breast cancer. She had delayed going in and getting a screening, so maybe it would’ve been stage 2, maybe it would’ve been stage 1,” he said in an interview with National Review.
National Cancer Institute director Ned Sharpless warned recently that the pandemic could reverse the U.S. streak in improved cancer mortality that has lasted more than 25 years.
“All this deferred care — it’s going to have costs for patients with cancer,” he said at the American Society of Clinical Oncology 2020 annual meeting. “It may mean more cancer suffering outcomes for our patients. What we don’t know yet is the scale of these bad outcomes.”
As governors and hospitals canceled elective procedures, and many patients avoided medical facilities for fear of contracting coronavirus in the spring, colon-cancer screening rates dropped by about 86 percent and breast and cervical cancer screenings decreased by about 94 percent, according to American Cancer Society senior vice president of prevention and early detection Laura Makaroff.
“It’s important to recognize that cancer screening has a huge role in the early detection of cancer,” she said. “So when we’re not screening for cancer there’s a likelihood that we’re missing cancers or diagnosing them at a later stage when prognosis can be poorer.”
From March 1 to April 18, the mean weekly number of patients newly diagnosed with breast, colorectal, lung, gastric, pancreatic, and esophageal cancers plunged 46.4 percent compared with a baseline period of January 2019 to February 2020, according to a JAMA Network analysis of weekly numbers from Quest Diagnostics.
Cancer patients in active treatment have been affected as well, with 27 percent reporting a delay in their care, according to a survey from the American Cancer Society Action Network.
As with lockdowns and other COVID-policy-related decisions, policymakers must run a cost-benefit analysis on each move they make, weighing the short-term consequences against the long-term. Experts warn we may not know for years the fallout of deferred procedures, though Sharpless has said the cancellations will likely result in almost 10,000 excess cancer deaths over the next five years, at a conservative estimate.
“We know that these decisions are made by politicians, and politicians often will value the short range over the long range, and I don’t think we can do that when it comes to health outcomes. You have to look at this as over a person’s lifespan,” said Dr. Amesh Adalja, a senior scholar at Johns Hopkins University Center for Health Security, in a recent interview with National Review.
It’s important to remember that “elective procedures” is a bit of a misnomer — while the phrase gives the connotation of face lifts and breast augmentations, elective procedures can be anything from cancer screenings to colonoscopies, heart-valve replacements to chemotherapy, he said.
“What elective really means is that you have some flexibility in scheduling, but not infinite flexibility,” said Adalja, who focuses on pandemic policy and emergency infections. “I think that this is part of the misconception of what it truly means to suspend elective procedures.”
“I think it has to be clear that we don’t want people to postpone any kind of care that is essential to them — and I define essential as you’re turning 50 you need a screening colonoscopy, you need a pap smear, you need a mammogram, your child needs to get their MMR vaccine, you want to start chemotherapy,” he said. “All of those types of things need to be considered as essential and not something that has infinite flexibility in moving.”
In many cases, it’s unclear that any extra beds added by canceling the procedures were even needed.
A McKinsey & Company estimate that New York would need 110,000 hospital beds at the pandemic’s peak led Governor Andrew Cuomo to cancel elective procedures and require hospitals to send COVID-infected patients back to nursing homes to free up bed space, the Daily Caller reported. While even the company’s best-case-scenario estimate was 55,000 required beds, New York used only 18,000 beds at its peak.
Other states, many of which were not even experiencing their own outbreaks, followed New York’s steps in canceling elective procedures.
“What we saw was many governors extrapolate what happened in New York in places where there wasn’t a capacity problem at that time,” Adalja said. “In general when we’re in an infectious-disease emergency, the key is precision public policy, not blanket orders.”
Some doctors are already seeing the fallout. When Dr. Lecia Sequist, a lung-cancer oncologist, tweeted earlier this month about her experience with patients presenting with “worse” lung cancer than she’s used to seeing, other doctors responded citing similar experiences.
“Common theme in my clinic lately: Pt started to have symptoms around the start of COVID, either too scared to seek med attention or advised by MD to delay care, now w/ lung cancer that is much “worse” than I’m used to seeing,” Sequist wrote.
“When I started as faculty in sept 2019, there was a mix of unresectable stage 3s and stage 4s. Now its almost all stage 4s, many too sick to get any treatment,” a thoracic oncologist in Alabama responded.
“Same here in melanoma. Especially complicated because dermatologist offices have been closed for so long so we’re seeing a lot of more advanced disease,” said a melanoma medical oncologist at Memorial Sloan Kettering Cancer Center.
Yet as recently as last month, Mississippi and New Mexico halted elective procedures statewide, and Texas’s governor has temporarily banned hospital-based surgeries in 105 counties and across eleven of the state’s 22 “trauma service areas.”
“I do think that these decisions are best made at a hospital level where the hospital administrators know what their capacity is, what their levels of personal protective equipment are, what their demands are on their mechanical ventilators and on their staffing, and then make those decisions on a case-by-case basis rather than having blanket types of suspensions,” Adalja said.
And it’s not just patients who are suffering: Deferrable procedures make up 51 percent of revenue for a typical hospital, according to an analysis by the health-care consulting firm Advisory Board.
New York City–area hospitals lost 38 percent of their monthly revenue on average early in the pandemic as a result of canceled elective procedures. They have also lost out on revenue because they have not been reimbursed by Medicare and other insurers for the convalescent care they provided for long-term ventilator and other COVID patients with no discharge placement options, according to the Greater New York Hospital Association.
The losses, which occurred while hospitals’ expenses increased, plunged operating margins from a baseline average surplus of 1 percent to a deficit of minus 50 percent, GNYHA found.
“People try to weigh it and figure out whether it was worth it or not,” Roy said of the cancellation of elective procedures and strict stay-at-home orders.
“History will judge whether it was worth it.”