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Oct 29, 2020

In today’s episode, we hear from Dr. Debra Patt, a breast cancer specialist and the Vice President of Texas Oncology, about an alarming decline in new cancer diagnoses among senior citizens in the United States during the COVID-19 pandemic. Dr. Patt, who is also the editor-in-chief of JCO Clinical Cancer Informatics, discusses a new study that highlights the need to act to protect care now because it could take years for research to reveal the true impact of the pandemic.


ASCO Daily News: Welcome to the ASCO Daily News podcast. I'm Geraldine Carroll. Today I'm speaking with Dr. Debra Patt, a breast cancer specialist in Austin, Texas and the vice president of Texas Oncology. Dr. Patt also serves as editor-in-chief of JCO Clinical Cancer Informatics. She is the lead investigator of a new study about an alarming decline in new cancer diagnoses among senior citizens amid the COVID-19 pandemic (DOI: 10.1200/CCI.20.00134).

Dr. Patt joins me today to warn that this is a critical issue that needs immediate attention. Dr. Patt has received research funding from Merk, Eisai, Seattle Genetics, and Eli Lilly, and serves as medical director of analytics for McKesson Specialty Health. Full disclosures relating to all Daily News podcasts are available on our episode pages. Dr. Patt, welcome to the ASCO Daily News podcast.

Dr. Debra Patt: Thank you, Geraldine, for having me.

ASCO Daily News: So the study we're discussing today is entitled "The Impact of COVID-19 on Cancer Care: How the Pandemic is Delaying Cancer Diagnosis and Treatment for American Seniors." So this study looked at trends in diagnosis and treatment of over six million Medicare beneficiaries. Tell us about your concerns for this vulnerable patient population.

Dr. Debra Patt: Yes, Geraldine. So thank you for heightening awareness of this important issue. I think as we've all observed many changes in medicine that pertain to the COVID-19 pandemic, one of the biggest concerns I have is its impact on cancer care. So we looked at a population of Medicare beneficiaries through a claims database and identifying over 6.2 million Medicare beneficiaries to try to understand how diagnosis and treatment was influenced by the COVID-19 pandemic.

And we observed that screening rates were dramatically down. Surgeries and biopsies were dramatically down. New cancer diagnoses were dramatically down. And therapeutic interventions were dramatically down during that time period of March through July. This is corresponding to the time period, of course, that the United States has been dealing with the COVID-19 pandemic. And it raises a lot of concerns.

ASCO Daily News: Yeah, I'm looking at the numbers in this study. And they're truly staggering. At the peak of the pandemic in April, screening for breast, colon, prostate, and lung cancer were lower by 85%, 75%, 74%, and 56% respectively. This may have repercussions that are not fully understood for decades.

Dr. Debra Patt: You're absolutely correct, Geraldine. I think what I find most concerning is when we look at decreases in cancer screening that we've observed in March, April, May, June, and July that have been as high as 85% for screening mammography in April among Medicare beneficiaries that we have not yet seen a compensation for the delinquency or the gap that we have in screening today.

So all of those patients who, of course, have gotten cancer and have cancer grow during that time period remain undiagnosed. So we've not yet seen a compensatory increase in screening to make up for the gap that exists today.

There's a lot of concern that the natural consequence of delays in screening without a quick uptake to close the gap could translate into a stage migration where patients present with higher stage disease, increasing morbidity and increasing cancer mortality.

In fact, there was a nice study published in Lancet Oncology in August that took information from the UK database, the National Health Service (DOI: 10.1016/S1470-2045(20)30388-0). And they predicted that based on the decreases they were seeing in cancer diagnoses that cancer mortality would increase for colorectal cancer by 15%, for breast cancer by 8% to 9%, and for lung cancer by 5% in the years to come.

ASCO Daily News: Is there anything else that really startled you from this study?

Dr. Debra Patt: I think, Geraldine, the biggest things that concerned me were the trends towards continued delays in cancer diagnosis. So I think cancer treatments follow diagnosis. So if you see delays in diagnosis, you then will see decreases in treatments. And so the fact that they're persistent tells me that this is a problem that will have repercussions that last for many years to come.

Obviously, if you have a delay in a cancer screening where cancer is diagnosed at a more advanced stage, sometimes it conveys additional treatments and an increase in mortality risk. But that actual cancer mortality may not come for 5 to 10 years down the road. And so the ways in which we're diagnosing cancer today or the decline in cancer diagnoses today will likely continue to alter breast cancer, colon cancer, lung cancer mortality for years to come.

ASCO Daily News: Well, for patients and their families, it is just gut-wrenching to know that they will be potentially dealing with a much worse prognosis because of a delayed diagnosis resulting from this pandemic. And this presents a very difficult situation for oncologists as well. Have you encountered patients who were diagnosed late?

Dr. Debra Patt: Many. So in many different ways, what we are observing from this data that we reported is delays in screening and diagnostics. And that's certainly true. And I have observed that in my practice. It's early still to make these observations.

But I have diagnosed patients with aggressive breast cancer who delayed their screening mammogram because of COVID-19 and then presented with a breast mass or got a mammogram six months later and then had a cancer that was more advanced.

The two patients I have in mind then required chemotherapy when, had their cancer been diagnosed much smaller, maybe they would not have required chemotherapy. It also conveys a higher risk of cancer mortality. So those are subtle changes.

But the big changes that we haven't characterized in this study is actually the symptom neglect that we see. There's a real fear particularly among Medicare beneficiaries--and it's been reported in the Medicare beneficiary survey--of Medicare beneficiaries seeking care from their doctors. And as a natural consequence of that, we have observed symptom neglect.

So as I take call on the weekends for all of my partners here in central Texas, I observe patients coming to the hospital after they've had 35 pounds of weight loss or symptoms of dizziness and near syncope for many months. Typically, patients wouldn't allow, if they have access to see a doctor, they wouldn't allow symptoms to progress so severely before they sought medical attention.

But the fear that's inherent in leaving their home during COVID-19 results in a symptom neglect that means that patients present when they may be much worse off. And at that point in time, if you've become malnourished because of a cancer diagnosis, it's very difficult for us to treat the cancer effectively. So I think across the country, we're observing patients presenting with very late stage cancers because of symptom neglect. And that's a unique issue.

So I think that many of the findings from this study in terms of delays in diagnosis you won't see manifest until we are tracking cancer mortality in the next several years. But we are seeing differences on a day-to-day basis in the hospitals for the patients we serve.

ASCO Daily News: So how do you think the oncology care community should address the issue of symptom neglect? And how is the community to manage the backlog within routine diagnostic services?

Dr. Debra Patt: That's a great question, Geraldine. With regards to symptom neglect, we know from the Medicare beneficiaries survey that many Medicare beneficiaries are not seeking health care because of fear because they don't want to leave their homes (Medicare Current Beneficiary Survey COVID-19 Summer 2020 Supplement). And sometimes, they're not seeking health care because their doctor's office is closed, or they have diminished capacity.

So I think that any way that Medicare beneficiaries can feel more comfortable about seeing their doctor or if they have ways that we can increase capacity for those patients that those would be helpful ways to try to get patients in and encourage them to not medically distance.

The screening issue is more difficult because not only do some sites have limited capacity today, but we actually need them to increase the capacity to close the gap, the delta, of the deficiencies that we've had in the previous six months. And that's more challenging.

I think that telemedicine is a really useful service when we can use it. And we really need to get on board and heighten awareness that patients need to get in for their screenings. So that way, centers that do screenings, whether they're radiologic centers or gastroenterologists that are performing colonoscopies, can increase their capacity in a safe way to make sure these patients can get served.

ASCO Daily News: Well, the full range of gaps in cancer screenings and treatment are not yet well-understood or well-documented throughout the United States comprehensively. And looking ahead to a further spike in COVID-19, what interventions will be necessary moving forward?

Dr. Debra Patt: It's a great question, and I think that cancer can't wait. I think cancer screenings, biopsies, and surgeries must press on unless it truly seems unsafe. You can imagine there have been scenarios in the last year where the COVID-19 prevalence is so high, and medical demand exceeds supply of medical professionals.

In those scenarios, I know many governors have issued restrictive orders to try to make sure to protect the health care delivery system. But outside of that true emergency, I think that we need to encourage people to safely get the care that they need--screenings, biopsies, surgeries. It's really important.

And given the current environment--now we're on a national spike again here in October--we need to learn how to safely navigate and live in this environment because it doesn't look like it's a very short-term duration before it turns around. And so we need to make sure that we engage with our doctors who by and large have implemented the Centers for Disease Control and Prevention (CDC) guidelines, are socially distancing and masking, and provide safe ways for patients to get treatment. So I think that we need to encourage patients to participate in screening in that way that is by and large safe.

I think in contrast to what the environment was like in the United States in March, now in doctor's offices, CDC guidelines are widely implemented. By and large, populations are masking. And people can navigate the environment with great safety.

ASCO Daily News: Right. Well, it's very important that you brought these issues to light. Is there anything else that's on your mind today that you'd like to share before we wrap up the podcast?

Dr. Debra Patt: Well, Geraldine, mostly I want to thank you for heightening awareness to this issue. There's not an oncologist in the world that doesn't believe in the words of Benjamin Franklin that, "an ounce of prevention is worth a pound of cure." And our ability to cure cancer is really best when we can prevent it. And that begins with patients seeking care with their doctors and participating in early screening.

So please encourage those around you to make sure that they're getting those preventative services, and then I think that the rest will follow. I think the natural consequence of us not embracing that strategy is that cancer morbidity and mortality will likely be elevated for years to come.

ASCO Daily News: Absolutely. Well, thank you so much, Dr. Patt, for taking the time to discuss the study with us today on the ASCO Daily News podcast.

Dr. Debra Patt: Yes. Thank you so much for your time, Geraldine.

ASCO Daily News: And thanks to our listeners for joining us today. We'd love to hear from you. So please take a moment to rate and review us wherever you get your podcasts.

Disclosures: Dr. Debra Patt

Employment: Texas Oncology, McKesson, MEDNAX (I)

Leadership: McKesson, MEDNAX (I), Texas Oncology

Stock and Other Ownership Interests: MEDNAX (I)

Speakers’ Bureau: Pfizer

Research Funding: Merck (Inst), Eisai (Inst), Seattle Genetics (Inst), Eli Lilly (Inst)

Travel, Accommodations, Expenses: McKesson

Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.