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COVID-19 Fallout May Lead to More Cancer Deaths

Significant decreases in CT imaging for cancer persisted even after the peak of the COVID-19 pandemic in 2020, delaying diagnosis and treatment and raising the possibility of more advanced cancers and poorer outcomes for patients in the future, according to a study presented at RSNA 2021. Numerous studies have shown COVID-19’s severe impact on US health care, as the pandemic filled hospitals and reduced imaging capacity during its peak from March to early May 2020. Few studies, however, have explored the pandemic’s lingering effects on cancer imaging.

For the new study, researchers from Massachusetts General Hospital and Harvard Medical School in Boston compared cancer-related CT exams during three periods of 2020: the pre-COVID phase (January to mid-March), peak COVID (mid-March to May), and the post-COVID peak (May to mid-November). They looked at CT volume and the type of care being delivered through imaging.

As expected, CT volumes dropped significantly during the COVID peak. CT for cancer screening fell 82%, while CT for initial workup, active cancer, and cancer surveillance also saw significant declines. Volumes for cancer screening and initial workup failed to recover in the post-COVID peak period, remaining down 11.7% and 20%, respectively, from their pre-COVID levels.

“The decline during the COVID peak was expected because of stay-at-home orders and the number of imaging departments that shut down as a precaution,” said study senior author Marc Succi, MD, an emergency radiologist at Massachusetts General Hospital and executive director of the MESH Incubator, an in-house innovation and entrepreneurship center. “Once normal operations resumed, you’d expect that these patients were being imaged in an equitable way, but, in fact, it turns out that they weren’t.”

The persistence of the decline in CTs for cancer screening and initial workup likely suggests that there will be higher numbers of patients with advanced cancers in the future.

“We expect that we’re going to see increased morbidity and mortality, due to the fact that these patients weren’t able to get their routine imaging,” Succi said. “You can also surmise that they probably didn’t have their routine elective follow-up appointments, as well.”

CT imaging declines particularly affected the outpatient setting, as utilization shifted away from large academic centers toward community hospitals and emergency departments (EDs). Cancer-related CTs at the ED actually increased in the post-COVID peak period.

“The ED remains a place in the American health care system where people can get help, no matter the situation,” said study author Ottavia Zattra, a fourth-year medical student at Harvard Medical School. “From a systems perspective, however, the best care in terms of prevention is administered in the outpatient setting.”

The possibility of being exposed to COVID-19 likely made many cancer patients reluctant to go to large hospitals and primary care centers, according to the researchers. As a result, they may have put off a visit until symptoms grew too significant to ignore.

“When initial diagnostic imaging is done in the emergency room, that suggests that people were having symptoms due to cancer for months and months, and they weren’t checking in with their primary care providers,” Zattra said. “Ultimately, the symptoms got so bad they couldn’t handle it at home.”

The study findings underscore the vulnerable position of cancer patients in the pandemic.

“We need better awareness and outreach toward the oncologic patient population,” Succi said. “For example, if a patient is due for a yearly lung cancer screening with a CT scan, we need to make sure they’re aware that they can and should get that screening, regardless of COVID. Delays in screening are inevitably going to lead to delayed diagnoses and increased morbidity.”

The imaging utilization trends support the diversion of more resources to community centers to take care of patients who might be avoiding large academic hospitals. The trends also highlight the importance of a robust ED imaging service with overnight coverage in both academic medical centers and private practices.

“Even the smaller centers should think about having 24/7 ED imaging coverage, to meet the needs of these patients who are being diverted,” Succi said.

The researchers hope to do a follow-up study to track CT imaging volumes through 2021. They also want to look at the role that factors such as race, language, and income have played in access to cancer imaging during the pandemic.

— Source: RSNA

Cancer Patients Overlooked in COVID-19 Vaccine Rollout

Almost two-thirds of US states failed to prioritize cancer patients for COVID-19 vaccinations, despite recommendations from the Centers for Disease Control and Prevention (CDC), according to a study presented at RSNA 2021. Cancer patients are particularly vulnerable to the effects of COVID-19. Both the disease and treatments such as chemotherapy and radiation therapy can leave their immune systems in a weakened state.

Available vaccines are highly effective, but initial supply limitations forced the CDC’s Advisory Committee on Immunization Practices to make difficult patient prioritization decisions. People aged 16 to 64 with high-risk conditions were grouped into the final part of the first phase, along with people aged 65 to 74. However, this group encompassed 129 million people nationally, leading many states to subprioritize.

For the new study, researchers sought to determine the proportion of states that elected to follow CDC recommendations. They identified every state’s COVID vaccination webpage through a keyword-based internet search and set out to identify information about vaccination for cancer patients. While 43 states included cancer among criteria for vaccination, only 17 gave patients with cancer the same immunization priority as patients aged 65 to 74, and a mere eight precisely defined a qualifying cancer diagnosis.

“Although the CDC recommended that all states consider people with significant medical conditions to have equal vaccination priority with people over the age of 65, we found that nearly two-thirds of states did not give equal vaccination priority to patients with cancer,” said study lead author Rahul Prasad, MD, from The Ohio State University Comprehensive Cancer Center in Columbus, Ohio.

Forty-two states did not clearly define the criteria for cancer patients to receive priority vaccination. This lack of clarity is problematic, Prasad noted, due to considerable variation within the cancer patient population.

“You could have someone diagnosed with breast cancer at age 40 who is now 55, in remission, and wondering if they’re eligible,” Prasad said. “On the other side of the spectrum, someone newly diagnosed with low-risk prostate cancer may not be particularly immunocompromised if they haven’t started treatment yet.”

Of the eight states that defined a qualifying cancer diagnosis for vaccine prioritization, six limited it to patients currently receiving treatment.

According to Prasad, the shortfall in the number of states that followed the CDC recommendations is partly due to attempts at streamlining vaccination efforts.

“I don’t think anyone intended to push people to the back of the line,” he said. “The efforts were well intentioned, but what ended up happening was that the CDC governing bodies’ definition of high-risk medical conditions was too broad.”

Early in the fall, the CDC approved a booster shot for seniors and high-risk individuals. Prasad said that these booster shots offer an opportunity to better mitigate disparities in vaccine access.

“It’s especially critical this time around to make sure these most at-risk people are getting their boosters in a timely fashion,” Prasad said.

— Source: RSNA