COVID-19 and CANCER
With the spread of coronavirus disease 2019 (COVID-19), countries and states have instituted lockdowns. These decisions have been difficult and are sometimes described as benefiting the public health at the expense of the economy. Fear of contracting the coronavirus in health care settings has dissuaded people from screening, diagnosis, and treatment for non–COVID-19 diseases. The consequences for cancer outcomes, for example, could be substantial. What can be done to minimize this effect?
Cancer is a complex set of diseases whose prognoses are influenced by the timing of diagnosis and intervention. In general, the earlier one receives cancer treatment, the better the results. There already has been a steep drop in cancer diagnoses in the United States since the start of the pandemic, but there is no reason to believe the actual incidence of cancer has dropped. Cancers being missed now will still come to light eventually, but at a later stage (“upstaging”) and with worse prognoses. At many hospitals, so-called “elective” cancer treatments and surgeries have been deprioritized to preserve clinical capacity for COVID-19 patients. For example, some patients are receiving less intense chemotherapy and/or radiotherapy, and in other cases, patients’ operations to remove a newly detected tumor are being delayed. There can be no doubt that the COVID-19 pandemic is causing delayed diagnosis and suboptimal care for people with cancer.
What will be the likely impact of the pandemic on cancer mortality in the United States? Modeling the effect of COVID-19 on cancer screening and treatment for breast and colorectal cancer (which together account for about one-sixth of all cancer deaths) over the next decade suggests almost 10,000 excess deaths from breast and colorectal cancer deaths; that is, a ∼1% increase in deaths from these tumor types during a period when we would expect to see almost 1,000,000 deaths from these two diseases types.* The number of excess deaths per year would peak in the next year or two. This analysis is conservative, as it does not consider other cancer types, it does not account for the additional nonlethal morbidity from upstaging, and it assumes a moderate disruption in care that completely resolves after 6 months. It also does not account for regional variations in the response to the pandemic, and these effects may be less severe in parts of the country with shorter or less severe lockdowns.
Beyond clinical care, the COVID-19 pandemic has caused an unprecedented disruption throughout the cancer research community, shuttering many labs and slowing down cancer clinical trial operations. Many scientists and clinicians are pivoting their cancer research activities to study the impact of SARS-CoV-2 on cancer. The scientific community must ensure that this pause is only temporary, because trials are the only way to make progress in developing new therapies for cancer. Given the long timeline between basic cancer research and changes to cancer care, the effects of pausing research today may lead to slowdowns in cancer progress for many years to come.
Collective action by the clinical and research communities and by governmental agencies can mitigate this potentially substantial impact. The U.S. National Cancer Institute (NCI), for example, has started to address this challenge (see www.cancer.gov). The NCI has worked with the U.S. Food and Drug Administration to increase flexibility and support for clinical trials during the pandemic. For example, allowances have been made to accept “remote” informed consent, and other protocol deviations. In addition, the NCI has announced several new clinical trials and funding opportunities aimed at addressing the relationship between COVID-19 and cancer. Of particular note is the NCI COVID-19 in Cancer Patients Study, a prospective longitudinal study that will collect blood samples, imaging, and other data to understand how COVID-19 affects cancer patients.
Clearly, postponing procedures and deferring care as a result of the pandemic was prudent at one time, but the spread, duration, and future peaks of COVID-19 remain unclear. However, ignoring life-threatening non–COVID-19 conditions such as cancer for too long may turn one public health crisis into many others. Let’s avoid that outcome.
