COVID-19 leads to a decline in screening and testing for cancer,
diabetes and cardiovascular issues. What’s next?
By Mark Thill
COVID-19 kept patients away from their doctor’s offices. When will they return? Will they return? And how will all this affect Repertoire readers?
In May, the Kaiser Foundation Family Poll found that 48% of adults surveyed said they or someone in their household had postponed or skipped medical care due to the coronavirus outbreak. Epic Health Research Network reported that appointments for screening for cervical cancer, colon cancer and breast cancer decreased by 86% to 94% in March 2020 compared to pre-COVID volumes.
Writing in The New York Times in early June, Tomislav Mihaljevic, chief executive and president of the Cleveland Clinic; and Gianrico Farrugia, chief executive and president of the Mayo Clinic, wrote, “In the case of cancer alone, our calculations show we can expect a quarter of a million additional preventable deaths annually if normal care does not resume. Outcomes will be similar for those who forgo treatment for heart attacks and strokes.”
Gastroenterology
“In Colorado, we definitely hit our peak [of COVID-19] in March and early April,” says Christopher Lieu, M.D., associate professor, director of GI medical oncology, and associate director for clinical research at the University of Colorado Anschutz Medical Campus, Division of Medical Oncology. Lieu is a member of the Medical Scientific Advisory Committee of the Colorectal Cancer Alliance.
At the peak of the pandemic, Medical Campus providers saw about a 10% decline in in-person visits and a rapid migration to telehealth. “We did have a drop in our clinical trials volume, though we did continue to enroll people even at its peak,” says Lieu. But patients came “roaring back” in June and July. “Our state did a great job of flattening the curve and getting everybody back on track.”
Consequently, damage to patients’ health was minimized. One- or two-month delays in routine labs or surveillance CT scans for patients with colorectal cancer and no evidence of disease present little risk to the patient, he points out. Stage migration – that is, migration of Stage 1 or 2 cancer to Stage 3 or 4 – is more likely to occur after delays of six months or more.
Cardiology
Seattle was the nation’s first COVID-19 hot spot in February and March, says Eugene Yang, M.D., chair-elect of the American College of Cardiology Prevention of Cardiovascular Disease Council, a cardiologist and professor of medicine at the University of Washington, and medical director of a large multispecialty center at UW Medicine.
Normally, his clinic has about 4,500 outpatient visits a month. During the month of April, that fell to 1,400. A state-mandated stoppage in hospital-based elective procedures had a major impact on cardiology-related procedures.
“At the time, we projected we wouldn’t get back to 100% until fall, but our volumes were restored more quickly than we anticipated,” he says. In fact, the clinic reached that mark in July and was projected at press time to exceed last year’s average in August.
Meanwhile, by the beginning of September, in-person visits to the Texas Heart Institute in Houston had climbed to about 70% of normal, says Emerson Perin, M.D., director of the Center for Clinical Research, director of THI’s Stem Cell Center and medical director of THI.
“Patients have died at home because of reluctance to seek medical care,” he adds. “Those who do reach out for care will likely have some kind of resolution to their issues, although probably not as complete, depending on the severity. Unfortunately, the routine visit as part of preventative medicine probably has sustained the greater impact.”
In fact, because the coronavirus is primarily a vascular, or endothelial, disease, it may have long-term consequences on cardiovascular health, says Perin. “In certain patients, small vessel clotting may cause damage similar to what is seen with heart attacks due to atherosclerosis, that is, the common form of heart disease related to known risk factors such as high cholesterol, high blood pressure, diabetes and smoking. In most cases, they will be treated similarly given the common resultant of damage from lack of blood flow.”
Patients with diabetes
“For some patients, [delayed medical care due to the pandemic] may not make a big difference in the long term, but for others, we believe it will, and there’s growing data to support that,” says Debra Simmons, M.D., professor of medicine at University of Utah and director of clinical affairs at Utah Diabetes and Endocrinology Center. “It will take more time to fully understand.”
Research was unavailable regarding the impact of stay-at-home mandates on people with diabetes, but “anecdotally, we really worry about it,” she says. Published data on COVID-19 and heart disease may offer some clues, as people with diabetes are more likely than others to develop heart disease.
There’s another problem, says Simmons: “People may believe they’re doing fine despite skipping routine appointments with their physician. I think that will have a long-term effect on people with diabetes and other diseases.”
She also worries about the mental health of the population as a whole, because of the coronavirus itself and its economic fallout. Healthcare disparities, racial unrest and other factors all contribute to the stress many people are experiencing. And their return to the doctor depends on more than just their medical condition.
“I think it will have everything to do with the economy. Will people have health insurance, or will they have to pay for the visit out-of-pocket? And if they have a job, will they get paid if they take time off?”
A boost for telemedicine
Physicians who spoke to Repertoire believe that COVID-19 has been a shot in the arm for telemedicine. Less certain is whether the boost will be short-lived or the new normal.
Prior to COVID-19, few if any non-primary-care physicians used telemedicine at University of Washington, says Yang. “But after COVID, we put a huge number of resources into it.” Even though overall patient volumes had dipped, in April, more than 80% of the clinic’s visits were conducted via telehealth, either by phone or video. By July, that percentage had dropped to about 20%.
“There’s agreement on the national level that telemedicine will be embedded in cardiology practices for the long term,” he says. Between a quarter and a fifth of patient visits may ultimately be conducted that way. “In my own practice, I might see patients with stable chronic conditions once a year, and visit with them remotely in between.”
Televisits will never replace face-to-face visits, says Perin. “In-person interactions are far superior to video visits. They seem to be preferred by patients as well.” Rather than relying on telemedicine to streamline physician office operations, clinics should focus on automating processes such as prescription refills, fielding simple questions and triage. “Visits to the cardiologist by patients with complex and life altering heart disease will continue as before.”
Says Lieu, “I think we’ve learned that even in the most challenging circumstances, we can provide oncology care safely. We can continue to enroll people in clinical trials. And in this era of telehealth medicine, we can gather more data without in-person visits.
“We’ve also learned our patients in the cancer community are extraordinarily good at avoiding infection. They have demonstrated they can avoid infection by acting smart.”
Sidebar:
Measuring COVID’s Impact
Key findings of the Kaiser Family Foundation’s Family Poll (Conducted in May):
- Amidst the coronavirus pandemic, Americans are deferring medical care. Nearly half of adults (48%) say they or someone in their household have postponed or skipped medical care due to the coronavirus outbreak. However, as stay-at-home restrictions ease, most (68% of those who delayed care, or 32% of all adults) expect to get the delayed care in the next three months.
- About four in ten U.S. adults (39%) say worry or stress related to coronavirus has had a negative impact on their mental health, including 12% who say it has had a “major” impact. This is down slightly from early April when 45% reported a negative mental health impact. Yet, women continue to be more likely than men to say it is has negatively impacted their mental health (46% vs 33%) and urban (46%) and suburban (38%) residents are more likely than those in rural areas (28%) to say coronavirus has had a negative impact on their mental health. Among adults in households that experienced income or job loss due to the coronavirus outbreak (who make up one-third of adults overall), 46% say the pandemic has had a negative impact on their mental health.
- Three in ten adults (31%) say they have fallen behind in paying bills or had problems affording household expenses like food or health insurance coverage since February due to the coronavirus outbreak. Additionally, one in four Americans (26%) say they or someone in their household have skipped meals or relied on charity or government food programs since February, including 16% who say this was due to the impact of coronavirus on their finances. The share who say they have skipped meals or relied on charity or government food programs due to coronavirus is higher among those in households that have lost a job or income due to coronavirus (30%) and among Black adults (30%) and Latinos (26%).
- As states consider spending cuts to address budget shortfalls caused or exacerbated by the coronavirus pandemic, it appears that many potential cuts will be unpopular among the public. At least three-quarters of adults oppose decreasing spending on K-12 public education (80%), police and safety (75%), and Medicaid (74%). Moreover, majorities oppose cutting spending on social services (60%), higher education (55%), prisons and jails (54%), and environmental protection (53%). Transportation is the only area which garners majority support for state budget cuts. Majorities of Democrats (85%), independents (73%), and Republicans (62%) oppose their state government decreasing spending on Medicaid.
- At a time when many newly unemployed Americans may turn to Medicaid for health insurance coverage, a majority of adults (55%) say the Medicaid program is personally important to them and their families and about one in four adults (23%) who are not currently on Medicaid say it is likely they or a family member will turn to Medicaid for health insurance in the next year. This share rises to 31% among those who lost income or whose spouse lost income due to the coronavirus outbreak. Two-thirds of adults in states that have not expanded Medicaid say their state should expand the program, including seven in ten adults (72%) in those states whose household experienced a job or income loss due to coronavirus.
Source: Kaiser Family Foundation, www.kff.org/report-section/kff-health-tracking-poll-may-2020-health-and-economic-impacts.