“How will be certain coming out the pandemic that those who should be a priority for cancer screenings based on risk and need in fact get to the head of the line? And how will we be certain that those who lack voice in the healthcare system are heard and their needs addressed?”
That was the question I asked frequently a year ago as we went into the initial shutdown phase as a result of COVID-19. It was a time when there was fear and a lack of understanding about the pandemic, when resources had to be shifted to acute care, and as a result elective procedures—including cancer screenings—had to be postponed in anticipation of a COVID-related demand surge on medical facilities.
Let’s fast forward to today, and a national cancer conference I watched online the past several days.
One of the sessions was devoted to the discussion of the impact of COVID19 on cancer care, and one focus of the discussion was delays in screening, particularly mammograms. And the participants—who all represented leading national cancer centers—indicated there was a substantial backlog in mammograms. Thousands of women trying to get appointments, and insufficient resources to meet the demand for a number of reasons.
So I asked the question that has concerned me over the past year: What are you doing to prioritize women for mammograms based on their need, as opposed to having the loudest voice in the room?
The answer: nothing. Everyone on the panel said the same thing: routine requests may take months to complete. As to priorities, they rely on clinicians reaching out and asking that a particular patient be moved up on the schedule.
I have to say I wasn’t surprised by the answer, just profoundly disappointed.
Here we are a year later, impacted by a horrendous national and worldwide experience with death, disease and social unrest beyond almost anything what many have previously experienced in our lifetimes, and we are beginning to see a decline in the morbidity and mortality from the SARS CoV-2 virus. Given support from vaccinations and better understanding of the dynamics of COVID19 we are beginning to venture out and about once again.
And in light of that emergence we anticipate that we will be getting back to the business of caring for ourselves, including age, sex and risk appropriate screenings for cancer.
The duration of the impact of the pandemic on cancer screenings for those at average and increased risk of cancer has been far greater than anything we anticipated last March. With everyone doing their part and effective contact tracing put into place, we thought that things would approach a more normal environment in three months, six months max.
That delay likely would not have much impact on cancer detection and cancer care, and in the meantime we needed to understand there could be other options for screening such as home test kits for colorectal cancer, and for women over 50 at average risk for breast cancer perhaps going to an every other year screening schedule instead of what many women believe they need, which is annual screening. Alternative approaches for screening—backed by high quality evidence—could ease some of the anxiety and the burden, while not impacting effectiveness or outcomes.
However that is not what happened: we are now over a year into this pandemic, and people are still scared, especially older folks who benefit most frequently from screening. Screening rates fell dramatically in the early part of the pandemic, then recovered somewhat and are still nowhere near where they have to be.
The fear is that these delays and complacencies—not to mention people falling out of the habit of taking care of their health generally—will lead to a shift in the stage of cancers to later detection, when treatments are more complex and toxic and further resulting in a higher cancer death rate than we have seen previously.
We have been through an incredibly difficult year, not only with the pandemic but with other gut-wrenching issues, including a difficult election and its aftermath and especially with the issues of racism that are confronting us in a way not seen in recent history. And no system is more affected than health care, where health equity and the impact of systemic racism is now moving out of the darkness of quiet ‘respectful”conversation of denial into the daylight of our discourse and awareness.
So here is my bottom line: We need to prioritize those women who are most in need of mammograms (and everyone for their appropriate cancer screenings). Maybe it is risk based on family history, personal experience with breast cancer, or the time from the last study. We need to proactively reach out to those who need to get screened now and get them in the door. Most of all, we need to make certain that EVERY woman is included, without any limiting factor.
There are communities in need who traditionally haven’t been able to advocate within the healthcare system, there are women out there who have lost insurance and are afraid of the cost, there are women who are afraid to come in for a mammogram and need reassurance that safety and concern for their lives and well-being are top priorities.
With all of the changes in care that have resulted from the pandemic—think telemedicine as one example—isn’t it time that we take a look at our lists and determine who really needs priority to get back into the office for screening? Isn’t it time we take to heart the words we utter daily that we care about patient centric care? Isn’t it time we put the patient back into the center of our focus, and make certain that those most in need have the access they deserve, and the priority they deserve?
We have lost valuable time. We need to devote resources and innovation to get back to work and catch up on getting people back to health. We cannot and should not fall back into the bad habits we have experienced in the past.
We owe it to everyone—including underserved communities and those in need, especially in light of the events of the past year—to make certain they are heard, acknowledged, and served equitably. Lives depend on it.