How exactly did radiology departments cope, and how might patients be affected by screening delays? In a session moderated by ECR president Prof. Dr. Regina Beets-Tan and Prof. Dr. Michael H. Fuchsjäger, chair of the European Society of Breast Imaging, five experts (four European and one American) outlined how their institutions dealt with breast and colorectal cancer screening during COVID and offered advice on how to provide effective screening going forward.
Dealing with delays
Dr. Ruud M. Pijnappel, PhD, of the University Medical Center Utrecht described how, during the peak of the COVID pandemic, the center delayed surveillance following a breast cancer diagnosis from three to 12 months in women with a low risk of recurrence and established that women at average breast cancer risk could delay screening mammography by three, six, or 12 months if they had been undergoing regular biennial screening.
Pijnappel reported that most of the medical center's breast cancer screening programs reopened between mid-May and June 2020, although capacity remains lower than it was before the pandemic due to social distancing, equipment cleaning requirements, decreased screening exam attendance rates, and staff illness.
"Backlog is an issue," Pijnappel said.
He warned that breast cancer screening delays due to COVID will likely have negative effects on patient outcomes in the coming months, particularly due to shifts in the stage of diagnosis from lower stages to more advanced, as well as an increase in interval cancers. Pijnappel cited grim statistics from the following three modeling studies:
- An Australian study that suggested a six-month delay in cancer screening could shift cancers from stage 1 to stage 2 by 5%, and a 12-month delay could reduce five-year survival from 91.4% to 89.5%.
- A Dutch study that suggested a screening delay of six months could result in an additional two breast cancer deaths per 100,000 women or 186 extra deaths over a decade.
- An Italian study that suggested a three-month breast cancer screening delay could translate to 10,000 women not diagnosed, while a six-month delay could result in 16,000 women not being diagnosed.
"We need to continue to monitor and model the adverse effects of delays in screening rounds to pressure policymakers to provide additional [screening] resources," Pijnappel concluded.
Dr. Monika Ferlitsch of Medizinische Universität in Vienna presented data in a similar vein, noting that during the pandemic's peak, there was a three-month suspension of colorectal cancer screening in many European countries. Ferlitsch referred to research indicating that moderate screening delays (seven to 12 months) could boost the incidence of advanced colorectal cancer from 26% to 29% and that a long delay (more than 12 months) could increase the incidence by 33%.
Ferlitsch urged her clinician peers to prioritize patients by colorectal cancer screening history and to explore using molecular markers to predict disease risk. She further cautioned that asymptomatic screening -- and even imaging -- could begin to take a back seat when it comes to colorectal cancer screening.
"Prepare for a future in which the role of colonoscopy in screening will shift increasingly toward diagnosis, therapy, and surveillance and away from asymptomatic screening," she said.
To close the session, Beets-Tan invited panelists to offer a key piece of wisdom for going forward in a pandemic-prone world. The group's basic message? No matter what, don't stop screening.
"We must not stop screening programs during any other COVID wave," Fuchsjäger said. "We have safety and security measures in place, and we have to communicate to our patients that they benefit from attending screening programs, even at pandemic high points."
Dr. Geerard Beets of the Netherlands Cancer Institute in Amsterdam agreed. "The pandemic has helped cancer screening to become better and smarter."
Since we now have vaccines, women should be encouraged to attend regular breast cancer screening, panelist Prof. Dr. Boris Brkljačić of the University of Zagreb in Croatia said. "[For better or worse,} the COVID pandemic has shown the importance of screening," he noted.
The fact is, cancer screening is one of radiology's strengths, according to Dr. Greg Sorensen, president of DeepHealth, the AI division of RadNet. "Screening is one way our specialty can have the greatest impact," he said. "To be proponents for screening is the best thing we can do for our patients."
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