As it became clear in March that the coronavirus was tearing through the U.S., federal health officials and cancer societies urged Americans to delay their routine mammograms and colonoscopies. The public has heeded those recommendations — and that’s helped lead to an apocalyptic drop in cancer screenings, according to a white paper released Monday by the electronic medical records vendor Epic.

Appointments for screenings for cancers of the cervix, colon, and breast were down between 86% and 94% in March, compared to average volumes in the three years before the first Covid-19 case was confirmed in the U.S., the Epic data show.

The paper provides only a snapshot of the overall picture — the company’s records cover just a fraction of all cancer screenings — but they help reveal the magnitude of the gaps in care resulting from the pandemic. Although there is debate about whether certain preventive cancer screenings actually save lives, many researchers fear that deadly cancers could go undetected if screening appointments that would have normally happened in recent weeks are not soon rescheduled.

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Epic Cancer Screenings in U.S.
Epic

The data suggest there is reason to be concerned that cancer screenings may not rebound even as some states begin to reopen their economies. The Epic researchers found an elevated rate of cancellations of cancer screening appointments even in the days before mid-March, when counties began issuing stay-at-home orders and the American Cancer Society and the Centers for Disease Control and Prevention recommended that people delay non-urgent outpatient care.

“We’re also fairly convinced that even once they lift the lockdowns, we’ll still see the concerned patients a little bit more reluctant to go in,” Epic President Carl Dvorak told STAT. “Truthfully, it doesn’t take much to talk a person out of going in for a colonoscopy.”

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Epic looked at data from 2.7 million patients in the U.S. whose records showed that they had at least one screening for cervical, breast, or colon cancer between 2017 and 2019. The data cover 190 hospitals spread across 39 health systems in 23 states.

Although there’s always seasonal variability in how many people go in for cancer screenings — appointments generally spike after Breast Cancer Awareness Month in October — the Epic researchers found that the plunge during the pandemic period went well beyond what could be expected under normal variation.

Breast and cervical cancer screenings fell by 94% in March compared to the 2017-2019 averages, while colon cancer screenings dropped by 86%, the researchers found. Dvorak, who commissioned the research, said he was “shocked” by the scale of that drop-off.

The Epic numbers follow a similar data release last week from the San Francisco-based health tech company Komodo Health, which analyzed the billing records of 320 million patients in the U.S. Komodo found that screening for cervical cancer was down 68% from March 19 to April 20, compared to the previous 11 weeks and a comparable period last year. Tests for cholesterol, diabetes, and active and recurrent cancers were down, too, with the sharpest declines in Covid-19 hotspots like New York and Massachusetts.

Cancer screenings generally take place at doctor’s offices and at diagnostic centers run by larger health systems. There’s been variability in how these facilities have responded to the pandemic: Some have closed their doors altogether, while others have stayed open for emergencies or maintained a skeleton crew of staff.

Epic did not draw any conclusions in its research about why a small fraction of screenings continued in recent weeks, Dvorak said. It’s possible, though, that some of those may have represented people who were especially worried about their cancer risk, such as a woman who found a large lump in her breast, or people who were less concerned about getting infected with the virus by going into the clinic.

As doctor’s offices and health systems begin to go back to relatively normal operations, Dvorak said he hopes that the research can help Epic’s customers develop a strategy for booking people who may have delayed recommended cancer screenings, such as by prioritizing calls to people at high risk of cancer due to past irregular screenings or a family history.

Epic doesn’t have any immediate plans to try to publish its findings on a preprint server or in a medical journal, but Dvorak said the company hopes to partner with its health system customers so they can do research on health outcomes associated with Epic’s data.

Dvorak said his team also plans to mine Epic’s data to see if it substantiates anecdotes that the company has been hearing from its customers, such as reports that brain surgeries have declined or that there’ve been more emergency amputations for people with diabetes.

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