The first wave of the COVID-19 pandemic placed significant stress on the already strained U.S. health care system. To ease the pressure, lawmakers, hospital administrators and ultimately clinicians had to prioritize what was considered urgent vs elective care. The rationale behind such decisions was made on many factors including the need to preserve resources and personnel for the incoming surge, but also to ensure the safety of patients, providers and caregivers. The safety issue is especially of concern to cancer patients, who may be immunosuppressed as a result of their ongoing or prior systemic treatments. In that context, many patients with subacute and chronic conditions such as cancer experienced a wide range of delays in their medical care. Specifically, there were delays in cancer screening, cancer diagnosis, and definitive treatment of cancer. Further down the continuum of care, patients with cancer also experienced delays in followup visits and systemic treatments. To help address the confusion, many societies issued guidelines to help triage patients appropriately. Locally here at Brigham and Women’s Hospital/Dana-Farber Cancer Institute, we proposed clinical guidelines that were disseminated on May 1, 2020, roughly 6 weeks after the first elective procedures were ordered to be postponed by state and federal authorities.¹

As mentioned above, while many high-profile publications in lay media issued concerns about the fallout resulting from delayed cancer care, we only recently started to understand the impact of the COVID-19 pandemic on delays in cancer screening tests, cancer diagnoses and cancer procedures.² In a recent publication in JAMA Oncology, we assessed the number of patients undergoing cancer screening tests and ensuing cancer diagnoses during the COVID-19 pandemic at Massachusetts General Brigham (MGB) System whose catchment area includes Massachusetts’ 5 neighboring states.³ We found a dramatic decline in breast, prostate, colon, cervical, and lung cancer screening (−60% to −82%) and cancer diagnoses (−19% to −78%) during the first pandemic peak (March to June 2020).³ Similarly, an analysis of the American Urological Association Quality Registry, a national Qualified Clinical Data Registry reporting on urology patients, found that outpatient visits and surgical procedures decreased up to 59% and 79%, respectively.⁴ Indeed, the number of “missed” cancer diagnoses and treatments will affect millions of people in the U.S. For instance, Chen et al estimated that 1.9 million prostate cancer screenings were missed in the U.S. during the pandemic.² These findings truly emphasize that cancer patients have been disproportionally affected by the pandemic, which we suspect will ultimately result in worse outcomes and deaths due to delays in treatment.⁵ While other diseases can wait, cancer continues to grow and needs timely diagnosis and treatment.

A more recent study by our group published in Cancer Cell looking at cancer screening and diagnosis at MGB after the first wave of the pandemic showed that cancer screening has significantly improved in more recent time periods (September–December 2020).⁶ In fact, prostate cancer screening increased by 24.0% with numbers exceeding those seen before the pandemic.⁶ These findings make sense–health systems and patients have adapted to the post-pandemic world, and efforts to bring patients back to their usual care have been largely successful within our health system. Nevertheless, our experience may not reflect what is happening in the rest of the country. It is important to understand that the population we care for at MGB is not necessarily representative in terms of race, income, education and insurance.

Along those lines, there are growing concerns that the pandemic may exacerbate well-documented racial disparities, and that is true even (especially) for cancer care. Black residents in Michigan were fivefold more likely to be infected with COVID-19 than White residents.⁷ This might be explained by the fact that racial and ethnic minorities are more likely to live in densely populated areas, suffer from higher rates of comorbidities and have less access to care. As such, we assessed whether the pandemic aggravated existing health disparities in different socioeconomic and ethnic groups.⁶ We found that racial and socioeconomic disparities were recorded for mammography and colonoscopy procedures. Given that underserved minorities generally had lower cancer screening rates prior to the pandemic, our recent findings are concerning. Hence, efforts to mitigate these disparities are needed more than ever.

Access to essential care and medical services is a challenge for which we, as health care providers, need to assume full responsibility. To overcome the disparities, institutions and health care providers will need to engage in an inclusive process by enhancing communication and augmenting timely care. Telemedicine could be a potential approach to reach out to underserved populations who often have difficulty accessing care due to availability of transportation or inability to take time off from work. An uptick of telehealth use for outpatient evaluation and management services was seen in urology and other specialties during the first wave of the COVID-19 pandemic, possibly as a result of recent policy changes aiming to broaden coverage for telehealth services.⁸ Other approaches include increased adoption of home screening tests such as the fecal immunochemical test for colon cancer. Therefore, high-risk groups and vulnerable populations need to be identified and prioritized a priori. However, while telemedicine could potentially mitigate disparities in access to care, nonEnglish speakers or minority populations with limited technological literacy may face further discrimination in their care.⁹ Real-time interpreters and technical assistants could make telehealth more inclusive.

The pandemic has significantly impacted patients in need of oncologic care and may disproportionately affect racial and ethnic minorities with cancer. The process of identifying “missed” patients for cancer screening will challenge health care providers for the upcoming years. We need to think “outside the box” about how to improve cancer screening and care, especially when considering that failures in vaccination and the emergence of variants will lead to additional waves of COVID-19.