En español | As the coronavirus has swept through communities across the country, many have shied away from showing up at a hospital or medical center for something like a routine colonoscopy or mammogram.
Back in March, officials at the Centers for Disease Control and Prevention (CDC) and the American Cancer Society specifically encouraged Americans to delay routine cancer screenings in order to protect themselves and their providers from the virus and preserve the supply of personal protective equipment. Many older adults, who are especially susceptible to serious or fatal effects of the virus, continue to follow orders to stay home to stay safe.
As a result, medical billing records show that appointments for mammograms, colonoscopies, Pap smears and other cancer screenings have fallen sharply.
In late April, Komodo Health, a health care technology company, analyzed the billing records of 320 million U.S. patients. Not surprisingly, it found that the steepest declines in cancer screenings have occurred in coronavirus hot spots like New York, Massachusetts and California, although testing is down significantly nationwide.
"We've spent the last 30 years building up a health care system that's designed to screen and treat chronic disease, and then we shut down the whole thing in a matter of days, in some cases,” says Arif Nathoo, Komodo Health cofounder and chief executive. “Diagnostic screenings are down, new diagnoses are down, even monitoring of already diagnosed cancer patients is down. People are more afraid of the virus than they are afraid of cancer."
Kathleen Gundry, director of the Department of Breast Imaging at Grady Memorial Hospital in Atlanta, says her group went from doing a thousand mammograms and other screenings every month to cutting all appointments except for tests to confirm a diagnosis of breast cancer. That's a lot of people to try to fit back into the schedule starting this month, as routine screenings resume.
"This is the problem that everybody is talking about. We can't properly clean the exam rooms and social distance, especially in the waiting areas, without seeing fewer patients per day,” she says.
She's also concerned about protecting her staff. “I'm a radiologist, I'm looking at films. I don't have a ton of interaction with patients, but my technologists are basically giving patients hugs [while positioning them for mammograms]. There's a lot of close contact and a lot of potential exposure for them.”
Even as routine screenings start to resume, Gundry isn't sure how many patients will feel comfortable coming in to Grady, which is a large public hospital that's also treating many COVID-19 patients. “We have already had some diagnostic patients” — those with signs of breast cancer or a previous suspicious mammogram — “refuse to come back for further testing because they don't feel safe,” she says. A second wave of the virus may set screenings back even more.
"There aren't enough technologists in the U.S. to do all these patients and get them caught up,” Gundry says.
When telemedicine can help fill the gap
For other types of routine checks, such as skin cancer screenings, telemedicine has been a boon. Dermatologist Daniela Kroshinsky is director of inpatient dermatology at Massachusetts General Hospital in Boston. Her office closed in March for non-emergency issues and has relied on telehealth to help sort patients into high-risk and low-risk groups.
"For us to bring a patient into the hospital, the risk of the cancer has to be far greater than the risk of catching coronavirus,” Kroshinsky says. “For the most part, teledermatology has been a blessing because so much of what we do is visual.”
Since the office has been closed, patients with lesions consult with a physician via something like video chat, and the doctor makes a decision about whether a biopsy needs to happen right away or whether it can be deferred.
"Even if the spot is suspicious, we're looking at whether it's likely to change or impact a person's overall health in the near term,” she says. “Delaying a lot of things by a few weeks or even months generally won't create a worse outcome. For example, basal cells are slow-growing and typically don't spread to other parts of the body. It's those individuals for whom the lesion would really be problematic that we need to prioritize for biopsy and surgery."
Kroshinsky's dermatology office is working to reschedule patients whose appointments have been canceled or bumped. However, she anticipates that telemedicine will continue to be a big part of her practice's future.
"When we reopen, it's likely going to be a mix of telemedicine and in-person visits because we'll have to implement social distancing and stagger the number of people in the waiting room at any given time,” she says. “It's a way of getting people the care they need while we wait to get back to a full capacity that we had before.”
Doctors grapple with prioritizing patients for screenings
As routine screenings and care begin to ramp up again, many providers are trying to prioritize the highest-risk patients first — those with a family history of cancer, for example. However, some doctors say they don't really have a way to identify which patients ought to be brought in earlier than others.
"The way our electronic medical records are set up, I don't have a way to find those patients in the system,” says Gundry, who notes that it's better for high-risk patients to be a squeaky wheel than patiently wait for a call from the office. “If the patient calls and says, ‘I'm high-risk,’ or the referring provider says they're high-risk, we can get them on the calendar. But otherwise we have no way of identifying them."
For other practices, the biggest challenge isn't fitting in patients or figuring out how to reschedule everyone, it's staying in business.
"If you're not treating COVID patients and you're not performing your usual services, then you're not bringing in any income,” says Carol Huang, a dermatologist in private practice in Queens and Long Island, New York. “And when you do reopen, your cost of running the business is higher because you have to take precautions.”
Huang's dermatology clinic, which stopped seeing patients on March 21 when New York issued a shelter-in-place order, has purchased plexiglass guards, extra personal protective equipment and cleaning supplies, and an ultraviolet C light for disinfecting rooms.
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"Not every provider, especially those that aren't affiliated with a large hospital or academic institution, is going to be able to weather this financially. It could be one or two years before we can get back to our normal case volume,” she says. “If you're a younger doctor who hasn't built up savings, or you're operating on thin margins, your patients may not have a clinic to come back to.”
That could present a huge problem, experts say, since many people already have trouble accessing cancer screenings. A 2015 report from the CDC found that, among those who were in the recommended groups for screenings, about 20 percent of women were not up to date with cervical cancer screening and about 25 percent were not up to date with breast cancer screening. Two in 5 adults were not current with colorectal cancer screening.
"It would be a tragedy to take a step backwards in that way,” Kroshinsky says.