From Diagnostic Imaging
An early analysis shows that low-dose CT screening for lung cancer has still not fully rebounded, leading to later detection of cancers.
The news may not be surprising, but a study published today verifies what many providers in the industry feared would happen during the pandemic – the drop in lung cancer screenings due to canceled or postponed services has led to worse patient outcomes.
Since the start of the pandemic, cross-sectional analyses have revealed a 46-percent plummet in new cancer diagnoses nationwide across six common forms of cancer, including lung cancer. In a study published Dec. 17 in the Journal of the American College of Surgeons, a team of investigators led by University of Cincinnati thoracic surgeon Robert Van Haren, M.D., who is also assistant professor of surgery, concentrated on the impact of not being able to provide low-dose CT (LDCT) screening for at-risk patients during this time.
They found the drop in screenings went beyond the initial phase of the pandemic.
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“When low-dose radiation CT scans were stopped on March 13, 2020, 818 screening visits were canceled [in our institution],” Van Haren said. “We began gradually re-opening on May 5, and, then, fully opened again on June 1. Total monthly CT scans and new patient monthly scans significantly decreased during the COVID-19 period we analyzed, and new patient scans have remained low despite resuming full operations.”
His team retrospectively analyzed screening rates, comparing baseline LDCT screenings conducted in their hospital from January 2017 to February 2020 to those completed during the initial phase of the pandemic – March 2020 to July 30, 2020. Patients included in the study were between ages 55 and 80, and they had smoked at least one pack of cigarettes a day for 30 years or two packs a day for 15 years. All patients also underwent initial lung cancer screening.
Overall, the team discovered that pre-COVID to COVID, the total monthly screenings, as well as new patient screenings, dropped from 146 to 39 and from 56 to 15, respectively.
In addition, the “no-show” rate for screening also grew from 15 percent to 40 percent. Most of these missed appointments – 112 out of 139 during the pandemic – were for annual exams, and the patients who skipped their scans tended to be young, African American women who were smokers, the team said. That this group would forego screening is concerning.
“This aspect of lung cancer screening should be studied further as it could worsen existing disparities in lung cancer survival,” they said. “African Americans already have worse overall survival and are less likely to undergo curative lung resection.”
The most concerning impact of the pandemic-era screening drop, though, was the significant increase Van Haren’s team identified in patients with lung nodules that could be cancerous (Lungs-RADS 4). After screenings re-started, the detection rate for these nodules rose from 8 percent to 29 percent.
“We observed increased lung nodules suspicious for malignancy after screening operations resumed,” the team said. “Patients were more likely referred to tumor board for enlarging nodules, and there was a significant increase in referrals for intervention among tumor board patients in the COVID-19 time period.”
Had routine LDCT screenings proceeded as normal during the pandemic months, Van Haren said, these cancers could have been detected and treated earlier. A backlog for seeing and re-scheduling screenings still exists.
Mitigating risk for these patients is critical, his team added, because reports indicate 13 percent of cancer patients who also have COVID-19 die with lung cancer patients facing particular risks due to smoking rates and underlying pulmonary disease. In fact, 76 percent of patients with thoracic malignancies and COVID-19 end up hospitalized, and 33 percent die, based on existing research. According to data from the United Kingdom, there has been a 4.8-percent to 5.3-percent increase in lung cancer mortality stemming from pandemic-era diagnostic delays.
This lack of rebound is significant on a variety of levels. While similar drops in screening were also seen for breast and colon cancer, the utilization of LDCT is already so low – around 4.5 percent of eligible patients – that this drop-off presents a dire possibility.
“The national utilization of LDCT is low at baseline,” the team said, “so any further decrease has potential negative consequences both in terms of cancer-related mortality and future utilization of lung cancer screening.”
The findings unearthed by Van Haren’s team are vital and significant, said Michigan Medicine providers William Weir, M.D., from the cardiac surgery department, and Andrew C. Chang, M.D., with the section of thoracic surgery, because, as of yet, very little is known about COVID-19’s impact on other health conditions.
“The long-term repercussions of this year’s shutdowns have only begun to emerge,” they wrote, in an accompanying commentary. “Until they are fully known, we would strongly advocate that health systems rapidly resume screening operations, increase community outreach emphasizing patient safety during preventive care, and use extreme caution in limiting or cancelling diagnostic procedures.”
Van Haren agreed, asserting that this study – and using his team’s screening program as a model – provides an early analysis of consequences related to the pandemic.
“Our results provide a framework for future decisions amid the ongoing COVID-19 pandemic,” Van Haren said. “Lung cancer screening operations should be prioritized and continued to prevent negative consequences, such as delay in diagnosis which could lead to increased cancer-specific mortality.”