Although much remains unknown about the impact of COVID-19 on people with cancer, the impact on screening is becoming clearer.
A growing body of data estimates the pandemic resulted in twenty-two million missed or cancelled cancer screenings in the United States in just a 4-month period in 2020.
This has led to an increase in the diagnosis of later-stage cancer cases that typically require more complex care.
A study from American Cancer Society — performed within thirty-two community health centres that serve lower-income populations — showed that screening mammograms dropped by 8% among women aged 50 to 74 years in the first 2 years of the pandemic. Researchers concluded this reduction in screening could lead to 47,517 fewer mammograms and 242 missed breast cancer diagnoses.
In another analysis, investigators from Harvard School of Public Health estimated there would be a 10% to 14% increase in cancer cases diagnosed in 2021 and 2022, with a higher percentage being advanced-stage cancers.
Investment in radiation therapy
Investments in radiation therapy (RT) may be especially necessary in the months and years ahead as this wave of later-stage cancer diagnoses exacerbates the pre-existing gap in access to RT that existed prior to the pandemic.
Despite its key role in improving survival and quality of life, millions of people worldwide lack access to radiation therapy, as low- and middle-income countries have 80% of the global cancer burden but have access to only 32% of global radiation therapy resources.
It also is estimated that although 50% to 60% of all patients with cancer require radiotherapy, 40% to 60% of them lack access to it.
Even within developed economies, access may vary based on geography or socioeconomic status, with innovative radiation care more readily available in large cities with academic centres dedicated to cancer care and research than in rural community hospitals.
In addition to palliation of metastatic symptoms, RT is widely used for brain metastases, and there are developing data supporting the use of RT for delaying progression and improving OS among patients with low-volume metastatic disease in multiple cancer types.
The phase 2 SABR-COMET study assessed stereotactic ablative RT to treat metastases among patients with multiple cancer types. Most study participants had lung, breast, colorectal or prostate cancers. Results showed an OS benefit with the addition of metastasis-directed RT to systemic therapy.
An ongoing trial at Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital is evaluating high-field magnetic resonance-guided RT (MRgRT) for treating oligometastatic disease among patients with primary prostate, renal cell, or colorectal cancers, as well as melanoma.
More equitable access
In preparing for the potential wave of patients with late-stage cancer due to pandemic-related screening delays, clinicians and care centres may position themselves to provide broader and more equitable access to critical cancer therapies, including RT.
Genesis Care — a leading global oncology provider with more than two hundred radiotherapy treatment centres across four countries — is leveraging its RT capabilities to prepare for a potential increase in the number of patients with late-stage cancers.
Several of the strategies it is pursuing may provide a roadmap that other cancer care centres may consider as part of their own initiative-taking initiatives to prepare for this looming surge.
A key objective is to formulate and implement strategies to support remote centres in developed and developing countries with highly technical services for treatment planning performed remotely, which reduces the cost of having these centres open.
Another is preparing for an increase in the demand for functional imaging (e.g., PET), which can detect metastatic disease more accurately and support optimized treatment decision-making.
Addressing the increased demand for PET imaging includes building capabilities with molecularly targeted PET imaging, including prostate-specific membrane antigen PET tracers that are FDA-approved or pending FDA approval for use among men with metastatic prostate cancer.
Another important strategy for addressing the historic gaps in RT access and the growing need for RT services is investing in and using multiple advanced cancer care technologies that help optimize each patient’s treatment based on his or her specific needs.
High-field MR-Linac systems can allow RT to be used in cancers that are not amenable to more traditional forms of beam radiation therapy; may support hypofractionated regimens that significantly reduce treatment time; and allow automated, real-time adaptive therapy that can improve patient outcomes while also streamlining clinical workflows.
Ensuring access to high-field MRgRT is essential for improving health equity and optimizing the safety and efficacy of RT in a growing number of cancer indications.
Brachytherapy is another RT approach that may have utility in treating advanced primary cancers and metastatic lesions. Innovative technologies and applicators make it easier than ever to administer brachytherapy efficiently, safely and effectively with fewer manual steps.
Investing in advanced brachytherapy systems will be important for increasing capacity and efficiency of care delivery, both of which are essential for ensuring that brachytherapy services are available to as many patients as possible.
Optimizing multimodal care
Optimizing care for patients with advanced cancers also requires supporting and enhancing collaboration among the radiation, medical and surgical oncology communities to ensure coordinated patient care.
Multimodal therapy is a pillar of cancer care and is increasingly used in later-stage disease as evolving treatment regimens integrate multiple strategies. Optimizing multimodal care requires close and effective communication and coordination among medical, radiation, and surgical oncologists, as well as oncology nursing and supportive services staff.
COVID has made it more challenging to create a multidisciplinary and collaborative environment, especially given the need to adhere to HIPAA requirements when using videoconferencing strategies. However, a potential positive aspect of the pandemic is the accelerated development and deployment of HIPAA-compliant technology-based collaboration platforms.
Use of these platforms played a key role in providing patients with access to care providers over the past 2 years, but they can also be implemented to facilitate collaboration and data sharing among care teams. This may allow more team members to participate more frequently than might have been possible when attending in person was the only option, especially if team members work in multiple locations.
Finally, meeting current RT demand requires providing additional capacity to enhance resilience as well as a commitment across the RT and medical education communities to increase the number of radiation oncology professionals who are trained in the newest technologies and latest insights into cancer care.
Solutions such as global ground rounds can help connect physicians from across the globe with expert committees to guide evidence-based practice and online learning practicums for technically complex or new procedures.
Additionally, lessons learned from the past 2 years of making cancer care available in extremely difficult settings should be incorporated into routine policy and practice to improve and expand access to high-quality RT and effective patient and provider support resources.
The capacity and resilience we build now can improve care today while preparing us to face the challenges of tomorrow.
Atun R, et al. Lancet Oncol. 2015;doi:10.1016/S1470-2045(15)00222-3.
Fedewa SA, et al. Cancer. 2021; doi:10.1002/cncr.33859.
Palma DA, et al. J Clin Oncol. 2020; doi:10.1200/JCO.20.00818.
Printz C, et al. Cancer. 2020;doi:10.1002/cncr.33128.
Scherer L. Cancer trends: How has the COVID-19 pandemic affected cancer screening? Everyday Health. Published May 14, 2021. Accessed April 11, 2022.
Ward ZJ, et al. Lancet Oncol. 2021; doi:10.1016/S1470-2045(21)00426-5.