More than 50 years ago, The National Cancer Act of 1971 launched what became known as the “War on Cancer,” which created great optimism about cancer therapies. Before the pandemic, cancer death rates were trending downward at an encouraging rate; from 1991 to 2017, the US saw cancer deaths decrease by 29%. Increased and earlier screening, coupled with enhanced diagnostic technology and breakthrough advances in personalized, tailored treatment led to more patients understanding their cancer diagnoses sooner and accessing necessary care faster. Despite many recent advances in cutting cancer death rates, the global instability from COVID-19 has resulted in disruption to vital cancer screenings and treatment.
COVID-19 continues to present the US health care system with an unprecedented backlog of screening exams. A recent study in the Journal of the American Medical Association (JAMA), showed that rates for breast, colorectal, and prostate cancer screening declined in spring 2020, but recovered in summer 2020, with a remaining absolute deficit for all 3 cancers. The authors noted regional differences, with the largest decline in the Northeast, as well as socioeconomic differences with the largest decline in the highest socioeconomic status (SES) index quartile. With unclear effects of delayed screening on overall mortality at this early juncture, and the rise of new variants like Omicron, clinicians have begun debates around healthcare utilization and capacity for screening during the pandemic.
Stay-at-home orders and fear of contracting the virus led many people to suspend screenings, defer routine visits, and avoid or delay seeking care. Many also lost their employer-based insurance with rising unemployment, which has a substantial impact on their ability to access healthcare services as well. And without visiting their doctors, people with cancer have not been able to benefit from the incredible progress made in oncology in the last few decades, setting back survival rates and early diagnosis.
On February 9, 2022, the American Association of Cancer Research (AACR) released the AACR Report on the Impact of COVID-19 on Cancer Research and Patient Care. According to findings contained within the report, patients with cancer are not only at an increased risk for developing severe COVID-19, but also face cancer treatment delays and interruptions due to the pandemic, potentially worsening cancer outcomes. The disparities in the uptake of cancer screening among medically underserved populations and with racial and ethnic minorities were heightened by the pandemic. The impact of delayed or missed screenings is already being realized. As an example, the effect of the first 6 months of the COVID-19 pandemic on breast cancer mortality in the US has been estimated to be 0.5 percent higher by 2030 than it would have been in the absence of the pandemic. Because of these concerns, many screening programs have resumed in areas where the infection has been relatively controlled.
The pandemic has resulted in nearly 10 million missed cancer screenings from January to July 2020,3 and in addition, has:
- Impaired referrals for preliminary cancer diagnoses led to an 11% increase in patients diagnosed with inoperable or metastatic cancer from March to December 2020 compared with the same timeframe in 2019
- Caused delays in cancer treatments, including chemotherapy, immunotherapy, radiotherapy, and surgery
- Impacted the mental health of patients, survivors, and caregivers due to social isolation, financial stress, food insecurity, and concerns about timely access to cancer treatments and disease recurrence
- Caused racial and ethnic minorities and other medically underserved populations to shoulder a disproportionate burden of COVID-19, as these populations have been more affected by pandemic-related disruptions to the cancer care continuum
During the pandemic, specific recommendations about cancer screening and diagnostic/surveillance testing were based on the extent of community transmission as well as the availability of resources. In locations with high rates of ongoing viral transmission, any clinic visits that could be postponed without risk to the patient generally were postponed. In areas where the infection had been controlled, screening programs and clinic visits were resumed, with clinicians maintaining full adherence to guidelines for limiting the spread of SARS-CoV-2 infection. Although major organizations, including the National Comprehensive Cancer Network (NCCN) and the American Cancer Society, called for the safe resumption of cancer screening and treatment,  screenings have still not recovered to pre-pandemic levels.
Improving Cancer Care
Despite the many disruptions in cancer care and clinical research caused by the pandemic, the COVID-19 pandemic helped usher in some practices that may lead to future improvements in cancer care for patients. For example, the use of telemedicine jumped 38 times higher in July 2021 than before the pandemic. Initiatives were launched to encourage cancer screenings independent of in-person clinic visits. Telehealth, using electronic medical records to identify patients not up to date with screening, using at-home tests such as fecal immunochemical tests (FIT) for colorectal cancer, and follow up on test results through automated call or direct patient messaging platforms are alternatives to in-person care that can be used to increase screening rates and follow up. 
The COVID-19 pandemic has highlighted the importance of using alternative ways to engage patients to receive recommended screening, which may lead to better access and adoption of cancer screening in the future, and may help alleviate some of the disparities seen today in access to cancer screening.
In the coming year, the medical community will be grappling with the following questions:
- What impacts will delayed screening and the resulting backlog have on mortality?
- What is the health system’s capacity for the backlog of screening needs?
- When should screening be paused for certain cancers during the pandemic to allow for urgent capacity needs?
- How will regional differences in screening delays impact the future of disease burden?
- How can virtual health be leveraged to identify appropriate patients for screening, conduct screening questionnaires, and engage patients to receive their recommended screenings?
A screening backlog will certainly impact biopharmaceutical manufacturers through delayed treatment and the need for more advanced disease treatments. Some considerations for biopharmaceutical manufacturers in support of cancer screening programs and in the management of patients with cancer may consist of:
- Support of telehealth visits, which were widely used for the first time during the pandemic and were associated with better screening rates. Telehealth has a measurable positive effect on whether patients get their cancer screenings. This suggests a potential benefit of telehealth: while the COVID-19 pandemic led to broad cancellations of nonemergency in-person health care appointments, telehealth appointments might have enabled individuals to still receive medical consultation and advice, as well as conduct general screening questionnaires to see if they qualify for additional screening tests, or plan for rescheduling screening tests that were missed
- Work in conjunction with national and regional cancer societies to establish guidelines and design screening questionnaires that can be utilized in training programs for less specialized staff such as general practitioners (GP), midwives, or nurses to provide cancer screenings, or that could be delivered in a virtual manner
- Support the provision of patient outreach services to enhance access to health services and improve overall retention at the national level
- Support policymakers in the establishment of a flexible outreach system into the community as a preparation for future pandemics
- Support the development of public health messaging to accurately convey the risk of severe illness due to COVID-19 versus the risk of not seeking healthcare advice if patients are symptomatic, and provide evidence-based information for clinicians to balance the risks for patients against the benefits of medical procedures including cancer screenings during the pandemic
- Support the development of cancer screening education apps via smartphones or tablet devices to educate the population about cancer screening
- Support the development of dedicated cancer awareness programs via a wide range of media channels in order to reach broad target groups, including patients most vulnerable to cancer. A media-led education intervention could be used to enhance the awareness of the public and their attendance of screening tests
- Support the development and utilization of patient self-sampling programs, such as that employed for colorectal cancer,  for other cancers, including HPV testing for cervical cancer. Self-sampling is believed to be equivalent to clinician sampling and can be taught by simple graphics or animated video presentation
- Support programs that address social determinants of health and the disparities that exist in access to cancer screenings
 American Cancer Society. Facts & Figures 2020 Reports Largest One-year Drop in Cancer Mortality. January 8, 2020. Accessed February 25, 2022. https://www.cancer.org/latest-news/facts-and-figures-2020.html
 Chen RC, Haynes K, Du S, Barron J, Katz AJ. Association of cancer screening deficit in the United States with the COVID-19 pandemic. JAMA Oncol. 2021;7(6):878-884. doi: 10.1001/jamaoncol.2021.0884
 American Association for Cancer Research. AACR report on the impact of COVID-19 on cancer research and patient care. February 9, 2022. Accessed February 25, 2022. https://www.aacr.org/wp-content/uploads/2022/02/AACR_C19CR_2022.pdf
 Alagoz O, Lowry KP, Kurian AW, et al. Impact of the COVID-19 pandemic on breast cancer mortality in the US: estimates from collaborative simulation modeling. J Natl Cancer Inst. 2021;113(11):1484. doi: 10.1093/jnci/djab097
 National Comprehensive Cancer Network. Major US cancer centers and organizations endorse goal of resuming cancer screening and treatment during the COVID-19 pandemic. January 28, 2021. Accessed February 28, 2022. https://www.nccn.org/docs/default-source/covid-19/resume-screening/nccn-acs-resume_cancer_screening_treatment_letter.pdf?sfvrsn=2c66b924_2
 Patel S, Issaka RB, Chen E, Somsouk M. Colorectal cancer screening and COVID-19. Am J Gastroenterol. 2021 Feb;116(2):433-434. doi: 10.14309/ajg.0000000000000970
 Kaiser Permanente. Exploring the promise of at-home cervical cancer screening. January 7, 2022. Accessed February 28, 2022. https://about.kaiserpermanente.org/our-story/our-care/exploring-the-promise-of-at-home-cervical-cancer-screening
Featured image: Despair patient after diagnosis, Photo courtesy: © 2016 – 2022 Fotolia / Adobe. used with permission.