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The impacts of the pandemic have been long-lasting – what has the effect been, and what prompts patients to return.
The COVID-19 pandemic is proving to be a long-lasting issue, posing the question of whether the benefits of preventive screening are worth the risks of infection exposure. Many difficult decisions had to be made quickly early in 2020 when the world was beginning to see the deadly impact of the novel coronavirus. In particular, imaging preventive screenings for breast and lung cancer took an abrupt nose-dive, and the consequences of the delayed and decreased utilization of care, as well as how it has affected radiology, will likely have a long-term effects.
According to a study that analyzed health insurance claims across the United States, there was a regression-adjusted rate per 10,000 persons change of -149.1 percent and -342.1 percent from March and April of 2018 compared to March and April of 2020 for mammograms, respectively1. Many factors contributed to this significant decrease, such as patient fear of infectious exposure, decreased ability to pay for medical care, a shortage of personal protective equipment (PPE), inconsistent guidelines from the Centers for Disease Control & Prevention (CDC), the World Health Organization (WHO), and various state policies that led to loose interpretations of what procedures to postpone or cancel.
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From a study that rated different professions’ risk of COVID-19, radiology technologists and sonographers were two of the highest scorers (84 and 80 out of 100, respectively). In order to mitigate risk to both patients and personnel, the American College of Radiology (ACR) released jointly with American Society of Breast Surgeons recommending to “postpone all breast screening exams (to include screening mammography, ultrasound, and MRI),” as well as discontinuing routine and non-urgent breast health appointments in March 2020.
From these recommendations, there was a subsequent large decline in breast screening. From a survey conducted by ACR and the Radiology Business Management Association, 97.4 percent of 228 radiology practices decreased in imaging volume in March and April of 2020. Elective procedures dropped by more than 90 percent with urgent procedures dropping around 60 percent. Breast imaging was especially hard hit and has been the slowest at recovering. Screening mammography was reduced by as much as 99 percent in calendar weeks 15 and 16. The largest healthcare system in New York reported that mammography decreased 94 percent, MR imaging 74 percent, and ultrasound by 64 percent2.
Radiology practices adapted to these limitations by restructuring reading rooms, setting up home PACS, and increasing usage of telehealth. However, even with these changes, the significant decrease in reading volumes have had devastating financial impacts on radiologists. One survey found that 50 percent of radiology practices had marked reductions in income, research, hours, personal and academic protected time, financial incentives, and retirement allocations. In addition to these tangible effects, there has also been a toll on the mental health of radiologists, with 60 percent rating their anxiety as a 7/10 during the pandemic2.
At this point, it is unclear exactly what mortality cost the pandemic has had due to the lack of breast cancer screening. One model that assumed a 6-month disruption of service estimated the potential excess deaths from breast and colorectal cancer would be an excess of more than 10,000 deaths in the next decade2.There is also the question of how this pandemic will shape the future of teleradiology and how this will continue to change the radiologists' workflow.
There is more concrete evidence about how the decrease in lung cancer screening has affected cancer diagnoses. Mortality from lung cancer has declined significantly in the past decade due to the introduction of annual low-dose CT (LDCT) for high-risk patients. Due to the pandemic – and likely multifactorial reasons discussed previously – cancer diagnoses were decreased across six common malignancies in the United States, and in the Netherlands, it was a 30 percent decrease in all primary cancer diagnoses3. Early in the pandemic, the American College of Chest Physicians recommended delaying screening of new patients and delaying annual LDCT for established patients4.
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In a study of one institution's LDCT database, from January 2012 to July 2020, there were 2,153 unique patients, with a mean number of 54 pack years. Of patients, 4.7 percent were diagnosed with lung cancer. Lung cancer screening was cancelled from March 13, 2020, with phased re-opening from May 5, 2020, and full re-opening on June 1, 2020. Overall, 818 LDCTs were cancelled during this time, and both new (56 down to 14) and routine (146 down to 39) screenings were significantly decreased, with an increase in no-shows (15 percent up to 40 percent). Especially concerning was that once screening resumed, the percentage of patients with lung nodules suspicious for malignancy increased from 8 percent to 29 percent, with a concurrent increase in referrals for intervention by surgery or pulmonology (21.2 percent up to 44 percent)4.
Similar to breast cancer, lung cancer societies, such as the Thoracic Surgery Outcomes Research Network released updated guidelines later during the pandemic which recommended deferring operations for three months in hospitals with resources limited by COVID-19. For hospitals with only a few cases, they recommended limited operations for node positive lung cancer, tumors greater than or equal to 2 cm, or for those who only received neoadjuvant therapy. A study from the United Kingdom estimated that there was a 4.8 percent to 5.3 percent increase in lung cancer mortality due to diagnostic delays4.
From these cases, there is growing evidence that the cancellations and backlog of preventive screening created by the pandemic are demonstrating the expected effect of delayed malignancy diagnoses in later stages. As we are adapting to the multiple surges and ebbs of the coronavirus, it is apparent that we must develop ways to mitigate the risk of COVID-19 exposure, as well as continue screening with safe methods.
Multiple cancer-related societies are lobbying to change guidelines to be more lenient to resume operations2,4. In addition to that, we must make sure that patients feel safe coming back to their appointments. They must be educated that in most cases having a pre-cancer diagnosis does not make them more susceptible to the virus, and that it is safe for them to come with appropriate masking and social distancing. The factors that they have listed as most important to them in resuming elective imaging are how much their clinician encourages them, use of masks by staff, social distancing, short waiting times, and symptom screening on arrival, minimizing trips outside of their house, and most importantly, staff friendliness5. With the continuing roll-out of vaccines and these measures being implemented, hopefully, we can soon stabilize toward a new normal for cancer screening in radiology.
Follow Dr. Makary on Twitter, @MinaMakaryMD.