Our leukemia team just cared for a young woman who had gone to a hospital 50 miles from ours because she wasn’t feeling well. She had delayed seeing a doctor for weeks, fearing that emergency rooms and urgent care clinics were akin to Covid hot zones. She didn’t want to catch the coronavirus if she didn’t already have it.
Some of the symptoms she had — fever, cough, fatigue — are also symptoms of having leukemia. They can also be confused with a coronavirus infection. But because of the pandemic, instead of having blood counts drawn, which are the first clue to detecting underlying leukemia, the well-intended emergency room staff tested her for Covid-19 and admitted her to a “Covid rule-out” unit within their hospital.
Under normal circumstances, this woman would have undergone blood tests, which would have shown clear signs of a cancer in her blood. She would then have been admitted immediately to a leukemia specialty unit, where the life-threatening consequences of her cancer, which can double in number in as quickly as two to three days, could be taken care of.
But she came to our attention later, now with a pneumonia and bleeding from her gums, a result of her compromised immune system and low platelet count.
She was admitted to our intensive care unit. And though we scurried to reign in this fast-growing cancer that should have garnered our attention a couple of weeks earlier, it was unfortunately to no avail, and she passed away.
As the death tolls rise to the coronavirus pandemic, those of us who specialize in oncology are bracing for another wave of victims: People not yet diagnosed with cancer.
According to a recent report, cancer screening has plunged since mid-March. At our cancer center, patient volumes are lighter. That in and of itself is not surprising, as the medical field as a whole has worked hard to minimize the numbers of “touches” patients have with our providers, to prevent transmission of the virus from caregiver to patient or vice versa, and also to free up resources for people who have caught the virus. Laboratory tests and scans have been scaled back, routine follow-up visits shifted to a virtual universe or delayed, and some treatments even adjusted to spread out their frequency, as long as it’s safe and medically appropriate for our patients.
We are dealing with cancer, after all, a disease that can be scarier than Covid-19.
A truly scary statistic, though, is that our new patient consults are down by over 40 percent. Most of those referrals come from primary care doctors, many of whom have just handed a patient some of the rottenest news a person can receive: You have cancer.
Why aren’t these cancers being diagnosed?
Cancers can come in two flavors of urgency (acknowledging, of course, that cancer often thumbs its nose at our attempts to define a typical course): faster growing, like the leukemia the woman we saw had, or slower growing.
With a typically slower growing malignancy like breast cancer, and under normal circumstances, it may take weeks for a woman to receive that diagnosis and consider treatment: from the moment she first feels a breast lump while taking a shower; to the time it takes to schedule an appointment with her primary care physician, who confirms that a worrisome lump is present; to the next step of undergoing a mammogram or ultrasound; to scheduling a surgical biopsy; to waiting for the pathology results to return; to finally meeting with an oncologist to discuss medical, radiation, and/or surgical treatments.
Now introduce the abnormal circumstances of the coronavirus pandemic: That first appointment would be virtual. The woman’s doctor may ask her to try to palpate the lump herself and describe it to the doctor, trying to guide the patient through her own exam from the small smartphone screen, as I have tried with my own patients. This is difficult, and an actual visit would probably have to be scheduled anyway, for the primary care doctor to assess the lump. Next, tests that some consider “routine,” like mammograms (which more often are used to screen for breast cancer than to help diagnose it), are also being delayed, as are non-urgent surgeries.
Those weeks to diagnose breast cancer can quickly turn into months.
Other screening tests like colonoscopies to diagnose colon cancer or cervical exams with a PAP smear to identify cervical cancer? Skin checks and biopsies to detect melanoma? They often haven’t been happening at all.
Even with slower-growing cancers, weeks matter, and can transform a cancer that is potentially curable to one that is incurable. For faster-growing cancer, like that of our patient with leukemia, days can make the difference between life and death.
Those of us in oncology fear a second pandemic of “new” cancer diagnoses, which in reality have been brewing for months. And not just new cancers but more advanced cancers. It is entirely possible that, in the latter part of 2020 and into 2021, we will see a shift to higher stages of cancer because of these delays in diagnoses. We may lose our window to intervene early, when cancer is still at an early stage, and eliminate it.
I fear, too, that the latter part of this year will uncover lower success rates at treating these cancers.
As the country ever so gingerly (and sometimes not so gingerly) loosens restrictions on social distancing, and we all look forward eagerly to the simple pleasures of going out to eat at a restaurant, or spending time with friends at a summer barbecue, let me also recommend one other freedom we enjoyed just a few months ago.
Go to see your primary care doctor for your annual mammogram, PAP smear, your colonoscopy, or to get that new swelling, worsening fatigue, or nagging cough checked out.