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COVID-19 Pandemic Affects the Cancer Continuum

Published on: February 11, 2022

ACS studies show how COVID-19 is affecting prevention efforts, cancer screening rates, treatment, quality-of-life, and research. 

COVID-19 took over the world in 2020 but getting reliable data to understand its effect on cancer takes time—usually 2 to 3 years using traditional population-based data sources like state cancer registries.

Until data started becoming available, researchers had to find innovative ways to gather some facts.

These images and text are a sample of American Cancer Society (ACS) studies published in 2021 based on data found in both traditional and less familiar ways. They show the beginnings of how the COVID-19 pandemic is affecting the continuum of cancer care.

Remembering the Start of the COVID-19 Health Care Takeover

In less than 2 months after the United States identified its first cases of COVID-19, there were more than 100,000 cases and 2,000 deaths.

Everyone attempted to prevent the virus from spreading:

  • Most states went into lockdown.
  • Local governments advised people to stay home and away from work, school, restaurants, gyms, family—even doctors’ offices and hospitals.
  • Many doctors’ offices and hospitals completely shut down non-urgent services and elective procedures, and delayed visits for prevention, screening, treatment, and follow-up care. 

Disruptions in health care have affected the full range of cancer care and care for others who may have a higher risk for being hospitalized and dying from coronavirus infection. The pandemic has also increased the risk for people with cancer or with a history of it to have a reduced quality of life due to cancer worry, health anxiety, depression, and inactivity.

COVID-19 Caused Disruptions in Cancer Care

Delay in cancer diagnosis and surgery has been linked with worse health outcomes.

To learn how the pandemic was affecting the number of people being checked or treated for cancer, an ACS research team compared the number of real-time electronic pathology reports in 2020 and 2019. They found a 10% decline in 2020 after the pandemic had started.

“We found declines in records across all cancer sites and ages. That suggests that there were delays in the start of treatment, as well as in evaluation of signs and symptoms, cancer screening, and routine well-child and primary care visits.”

— Robin Yabroff, PhD, MBA, lead study author and ACS Senior Scientific Director, Surveillance Research

See Robin Yabroff's bio 

Kudos to Kentucky for Not Letting COVID-19 Curb Lung Cancer Screening

In most states, the COVID-19 pandemic hasn't helped increase the low lung-cancer screening rates of people eligible for a yearly low-dose computed tomography (LDCT).

Surprisingly, though, when ACS researchers compared screening rates between 2019 and 2020, they found 19 states had improved screening rates—with Kentucky having the most improvement.

"Kentucky's screening implementation efforts led to rates more than 2 times the national average and 4 times that of West Virginia and Arkansas, other high lung-cancer burden states.”

—Robert Smith, PhD, study co-author and ACS Senior Vice President, Cancer Screening

 

See Robert Smith's bio.

ACS Helps Cancer Screenings Catch Up and Tackle Disparities

During the early months of the COVID-19 pandemic, screenings for cancer in the breast, colon and rectum, cervix, and lung have decreased by as much as 90% in the worst periods. Delays have been highest within low-income and rural communities, and for people of color.

With moneys raised through the Crucial Catch: Intercept Cancer campaign, the ACS and the National Football League (NFL) allocated resources to help safely restart cancer screenings in communities with the most need.

Those funds make possible the ACS Community Health Advocates Implementation Nationwide Grants for Empowerment and Equity (CHANGE) grants.

“ACS CHANGE grants are helping health centers create and adopt new processes and protocols to tackle cancer screening backlogs and safely restart cancer screening."

—Korey Hofmann, MPH, ACS Cancer Control Strategic Partnerships Manager

Learn more about Crucial Catch.

Pandemic Reversed Improvements in Breast-Cancer Screening for Women with Low Incomes

Between July 2018 and 2019 BEFORE the pandemic, breast cancer screening rates improved by 18% within 32 community clinics, which largely serve people with low incomes.

But between July 2019 and July 2020, DURING the pandemic, an ACS study showed that breast cancer screening dropped steeply—by 8% in those clinics.

Findings show that if these trends continue, there would be potentially 47,517 FEWER mammograms and 242 missed breast cancer diagnoses in this population.

"People with lower incomes have long-standing barriers to accessing care and are especially vulnerable to healthcare disruptions.”

— Laura Makaroff, DO, senior study author and
ACS Senior Vice President, Prevention & Early Detection

This study was funded by a 2018 ACS CHANGE grant supported by the ACS & National Football League's Crucial Catch: Intercepting Cancer Campaign

Colon Cancer Screening Continues During COVID-19 with At-Home Tests

To help reduce the backlog of cancer screening services due to COVID-19, the ACS led an intervention and study with 22 federally qualified health centers (FQHCs) across 15 US states. These centers provide critical cancer prevention services and treatment to under-resourced rural and urban populations, helping ease and reverse racial and ethnic disparities.

A key finding was that half of the FQHCs in the study were able to continue colon cancer screenings by using at-home stool testing.

“Supplementing existing screening models with self-collected screens may be an important tool to eliminate current screening deficits and prevent future cancers.”

—Marcie Fisher-Borne PhD, MPH, MSW, lead study author and ACS Managing Director, Interventions and Implementations

At-Home HPV Test Could Have Potential During Future Disruptions in Health Care

In the same study of 22 FQHCs, researchers mentioned a promising method that could allow cervical cancer screening to continue throughout pandemic disruptions—HPV self-collection. 

Home HPV tests include a long, cotton swab or brush, a tube, a biohazard bag, and shipping label for mailing to the testing company. Although they can be bought online in the US, they are not approved by the Food and Drug Administration (FDA). Ongoing studies are checking to see if home sampling and mailing leads to accurate results.

“HPV self-collection of cells is currently being done in Australian and the United Kingdom for under-screened populations. Studies show that cells collected at home have a similar detection rate of precancer and cancer as those collected in an office by a health care professional.”

—Marcie Fisher-Borne PhD, MPH, MSW, lead study author,
ACS Managing Director, Interventions and Implementations

This study was funded by a 2020 ACS CHANGE grant supported by the ACS & National Football League's Crucial Catch: Intercepting Cancer Campaign

56% of Cancer Survivors Have Another High-Risk Condition for Severe COVID-19

People with these health conditions have a higher risk of developing severe COVID-19 illness: cancer, chronic obstructive pulmonary disease (COPD), diabetes, heart disease, and obesity.

Unfortunately, cancer survivors are more likely to also have one or more of these other conditions compared to those who haven’t had cancer, which increases their risks of serious COVID-19 even more.

A study of cancer survivors led by an ACS researcher found that:

  • 56% had at least 1 other high-risk condition, including nearly half of even the youngest group, ages 18 to 44.
  • 31% had obesity, heart diseases (25%), diabetes (17%), and COPD (9%).
  • Survivors of cancer in the kidney, liver, or uterus were the most likely to have another high-risk condition.
“The findings highlight the need to protect cancer survivors against COVID-19 transmission and to prioritize survivors in vaccine allocation.”

—Xuesong Han, PhD, senior study author and ACS Scientific Director, Health Services Research

See Xuesong Han's bio.

Certain Factors & Cancer Treatments May INCREASE Risk of Severe COVID-19

Within 30 days after developing COVID-19, a study revealed that 13% to 33% of people with cancer die, compared with 0.5% to 2% in the general population. 

To understand why, a clinical trial studied nearly 5,000 people who had a history of both cancer and COVID-19.

Researchers discovered that the risk for severe COVID-19 as well as the risk of dying within 30 days after a COVID-19 diagnosis was higher in people with cancer, who:

  • Are not able to take care of themselves
  • Have an active and progressing cancer
  • Are older than age 40
  • Recently received chemotherapy 
  • Are male
  • Have a blood cancer
  • Are Black  
  • Also have a lung condition, kidney disease, or diabetes
“We were particularly concerned to find a more than 40% death rate from COVID-19 among people receiving the chemotherapy R-CHOP with the intent to cure non-Hodgkin lymphoma.”

– Dimpy Shah, MD, PhD, study author and ACS grantee from Long School of Medicine - UT Health San Antonio

Listen to a podcast with Dimpy Shah, MD, PhD

See Understanding Death Rate

Certain Cancer Treatments May LOWER Risk of Severe COVID-19

In the same clinical trial of nearly 5,000 people with a history of cancer and COVID-19, researchers found that people receiving certain types of cancer treatment may have less risk of developing severe COVID-19 than the general population.

Treatments NOT associated with higher COVID-19 severity included:

  • Certain combination immunotherapies  given to people with multiple myeloma
  • Immunotherapy in general
  • Targeted therapies in general
  • Endocrine therapies in general (In another study, researchers found that people who had received endocrine therapy had the strongest protection from COVID-19 after receiving 2 vaccinations.)
“This finding is encouraging because more than 40% of people with advanced cancer may be eligible for immunotherapy.”

– Dimpy Shah, MD, PhD, study author and ACS grantee from Long School of Medicine - UT Health San Antonio

People with Blood Cancer May Be Less Protected by COVID-19 Vaccines

COVID-19 vaccines are highly effective in the general population, but what about in people with cancer?

An international study investigated how protected people with a blood cancer or solid tumor were after receiving a first and second dose of Moderna or Pfizer vaccines. They found:

  • A second dose was needed to boost antibody levels in people with either a blood cancer or solid tumor and protection was highest 3 to 4 weeks after that dose.
  • No difference between the 2 vaccine brands’ effectiveness.
  • People with blood cancers were not as protected from COVID-19 vaccination as those with solid tumors were.
“After 2 vaccines, 98% of those with a solid tumor had antibodies against the virus, compared to 77% of those with blood cancers.”

– Dimpy Shah, MD, PhD, lead study author and ACS research grantee from Long School of Medicine-UT Health San Antonio

People Taking Rituximab May Not Be Protected by COVID-19 Vaccines

The same vaccine study of 131 cancer patients found that even after receiving both vaccine doses, the 7 people taking rituximab (Rituxan) in the study were not protected.

Rituximab is one component in R-CHOP therapy, an IV treatment for people with non-Hodgkin lymphoma. It’s also used to treat chronic lymphocytic leukemia (CLL) as well as for people with rheumatoid arthritis.

“The optimal approach for vaccinating and monitoring this subset of patients at high risk for not responding to COVID-19 vaccines remains unclear. Our results stress the importance of identifying these patients at high risk so alternate protection strategy can be developed.”

– Dimpy Shah, MD, PhD, study author and ACS grantee
from Long School of Medicine - UT Health San Antonio

Listen to a podcast with Dimpy Shah, MD, PhD

See Understanding Death Rate

Convalescent Plasma May Fight COVID-19 in People with Blood Cancer

People with blood cancer are more vulnerable to COVID and less protected by vaccines. But help may come from those who have recovered from a COVID-19.

A retrospective study found that convalescent plasma seemed to reduce the 30-day death rate in adults hospitalized with a blood cancer and COVID-19.

Convalescent plasma, also known as “survivor’s plasma,” contains high levels of COVID-19 antibodies, which help fight the virus. This plasma is the liquid part of blood donated from people who have recovered from COVID-19.

Doctors treating people with blood cancers hospitalized for COVID-19 may prescribe convalescent plasma early in the course of the infection.

“If our finding holds up in clinical trials, convalescent plasma would be, to our knowledge, the first COVID-19 intervention with a survival benefit in this high-risk population.”

– Dimpy Shah, MD, PhD, co-leader study author and ACS grantee from Long School of Medicine - UT Health San Antonio

Depression & Anxiety Continued After Initial Lockdown

In June 2020, ACS researchers sent a subset of CPS-3 participants (more than 2,400) a COVID-19 survey. Their goal was to see how the pandemic was affecting mental health.

Participants’ responses suggest that:

  • 42% had mild distress.
  • 10% had moderate-to-severe anxiety or depression, especially when they had a health condition, such as cancer, that increased their risk for severe COVID-19.
  • Females were more likely to have higher distress, especially anxiety.
  • Men were 11 times more likely to be depressed if they were distressed before the pandemic.
“These responses highlight public health priority to identify adaptable strategies for improving mental health during the pandemic.”

 – Corinne Leach, PhD, MPH, MS, lead study author and
ACS Senior Principal Scientist, Behavioral Research

Survivors’ Own Words Showed ACS Researchers the Pandemic’s Impact

One benefit of the ACS study led that used the ACS CAN Survivor Views Panel Study was that it captured participants own words about their worries about treatment and finances early in the US COVID-19 pandemic.

"My surgery is  reconstruction. It’s considered non-essential, but it is essential to me.”

—50-year-old breast cancer survivor

“I have my every-6-month PET scan coming up. . . to make sure I’m still in remission, and I’m very nervous that they will cancel. . . . These scans are the ones I’m scared about but also want done to know how I’m doing.”

–27-year-old female melanoma survivor

The pain is excruciating, and I have to make a choice between pain medication or anti-anxiety medicine since I am not permitted to have both at the same time.”

—54-year-old ovarian cancer survivor

All responders were treated for cancer in the last 5 years and were either ACS volunteers, event participants, or information requestors.

Sitting Time Is Increasing During Pandemic, Even With No Job Changes

Using results from surveys before and after the start of the pandemic, ACS researchers studied the amount of time people spent doing light and moderate-to-vigorous activity, being sedentary, and sleeping each day.

They found that during the pandemic, participants spent:

  • Almost 2 MORE hours a day (1 hour and 44 min) being sedentary—sitting or reclining while awake, such as while watching tv, working at a computer, driving, and eating. Before the pandemic, they spent this time doing light or moderate activity.
  • Hours spent sleeping did not change overall. However, those who were laid off slept 68 minutes more a day.
“Our findings can help inform public health messages and interventions to end these patterns. The need is urgent because the balance of daily physical activity, sedentary time, and sleep are widely recognized as key risk factors for heart disease, cancer, and premature death.”

—Erika Rees-Punia, PhD, MPH, lead study author

 

See Erika Rees-Punia's bio.

Physical Activity During the Pandemic May Help Reduce Depression

One well-established strategy to ease symptoms of anxiety and depression is being physical active.

To examine the potential impact of the COVID-19 pandemic on the relationship between exercise and mental health, ACS researchers looked at survey responses from CPS-3 participants before the pandemic from the 2018 survey and after the start of the pandemic from the COVID-19 survey. 

Researchers found that the risk of having depression INCREASED for those who:

  • Stayed or became physically inactive, compared to those who stayed or became active.
  • Spent more time sitting or reclining (being sedentary) compared with those who were just as sedentary as they were before the pandemic.
  • Increased sedentary time AND stayed or became inactive were 3x more likely to have depression and had more than an 80% chance of anxiety symptoms.
“Finding ways to be physically active during times that feel stressful, tiring, and a little scary—like this pandemic—may be a good way to reduce the risk of depression.”

—Erika Rees-Punia, PhD, MPH, lead study author

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