Editor's note: This story was updated on May 10, 2021.

As the Covid-19 pandemic surged over the past year, cancer screening rates plummeted. But now that screening rates are inching up again, cancer specialists say they are seeing patients come in with far more severe disease, Reed Abelson writes for the New York Times.

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Cancer screening rates plummet

According to the Times, several studies indicate that the number of patients screened for or diagnosed with cancer declined during the pandemic's early months.

For instance, one analysis from the Epic Health Research Network found that by June 2020, the screening rates for breast, colon, and cervical cancer were still between 29% and 36% lower than they were before the pandemic hit. Overall, according to the analysis, "[h]undreds of thousands fewer screenings were performed last year than in 2019," the Times reports.

Similarly, a study conducted by Avalere Health for the Community Oncology Alliance looked at Medicare data and found that cancer testing rates dipped when Covid-19 cases spiked in 2020. For example, according to the study, cancer testing levels in November of last year were roughly 25% lower than they were in 2019, while the number of biopsies declined by about 33%.

An increase in advanced cancer diagnoses, providers say

Cancer specialists say it's too early to determine the full effect of these postponed and skipped screenings, but they confirm that at least anecdotally, patients appear to be coming in with more severe cancers, the Times reports.

"There's no question in practice that we are seeing patients with more advanced breast cancer and colorectal cancer," said Lucio N. Gordan, president of the Florida Cancer Specialists & Research Institute.

According to the Times, one such patient, Yvette Lowery, had her annual mammogram in March 2020 canceled amid the pandemic. And even after she discovered a lump under her arm in August, she wasn't able to get an appointment until October—at which point she was diagnosed with Stage 2 breast cancer. She began chemotherapy in November of last year and recently underwent a double mastectomy.

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"I've been seeing a lot of patients at an advanced stage," Kashyap Patel, one of Lowery's providers and CEO at Carolina Blood and Cancer Care Associates. According to Patel, if Lowery's cancer had been spotted in May or June of last year, they could have likely caught it before it spread.

And even among patients who might have otherwise been able to keep their screening appointments, other challenges got in the way, the Times reports. Some, for instance, skipped their routine screenings or ignored symptoms because they were worried about contracting Covid-19 at their providers' facilities or because—if they lost their jobs amid the pandemic—they simply couldn't afford the tests. 

For instance, Sandy Prieto, a librarian in California, didn't go to the doctor in March of last year, when she started getting stomach pains, because she worried she would contract Covid-19. Finally, in May, she went to the ED with severe symptoms, only to learn she had Stage 4 pancreatic cancer. She passed away in September.

"If it wasn't for Covid and we could have gotten her some place earlier, she would still be with us today," Prieto's sister, Carolann Meme, said.

Barbara McAneny, CEO of New Mexico Oncology Hematology Consultants, said that many of her patients are not coming in—even if they have insurance—because they cannot afford the co-payments or deductibles. "We're seeing that, particularly with our…folks who are living on the edge…living paycheck to paycheck," she said.

According to the Times, some of the patients who had to skip or delay testing included people at high risk for cancer because of genetics or because of a previous cancer diagnosis.

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For example, Ritu Salani, director of gynecologic oncology at the UCLA Health Jonsson Comprehensive Cancer Center, said one of her patients who had a high risk of colon cancer skipped her usual screening amid the pandemic, only to learn when she did go to her provider later that she had advanced stage cancer. "It's just a devastating story," Salani said. "Screening tests are really designed when patients aren't feeling bad."

But some health systems were able to counteract at least some of the effects of the pandemic on screening rates, the Times reports. For instance, during the initial stay-at-home orders issued last year, providers at Kaiser Permanente noticed a decline in testing. They "immediately got together" to reach out to patients, according to Tatjana Kolevska, medical director for the Kaiser Permanente National Cancer Excellence Program.

Kaiser Permanente also uses its EHRs to schedule overdue mammography appointments for patients when they schedule other visits, such as scheduling a primary care visit or eye exam. And while Kolevska said she's still waiting on data for the system as a whole, she said she's been encouraged to see her patients get up to date with their mammograms. "All of those things put in place have helped tremendously," she said (Abelson, New York Times, 3/17).