Ruminations: COVID-19 vs Cancer

"I do believe that patients with cancer in Canada -- are being rendered fatal, terminal or incurable, as a result of what's happened."
"It has absolutely had an impact. I've seen it with my own eyes. It's extremely stressful."
Dr.Neil Fleshner, chair, urology, University of Toronto

"Where this gets us is another pandemic."
"When we do catch these people, when we do screen them and get them through diagnosis, it won't be early any more, it will be more advanced cases of cancer."
Dr.Eva Villalba, executive director, Quebec Cancer Coalition

"Clearly, it's something that may have consequences."
"What we really see is that the screening leads to earlier diagnosis, and it will also lead to earlier management of breast cancer."
Dr.Joseph Ragaz, medical oncologist, breast-cancer expert, University of British Columbia

An infusion drug to treat cancer is administered to a cancer patient via intravenous drip. Canadian oncologists worry the pandemic has led to cancer going undiagnosed and untreated. (Gerry Broome/The Associated Press)

Over four thousand people who would under other circumstances have been diagnosed with a malignancy during the first wave of COVID-19 went undiagnosed, according to the Quebec Ministry of Health. Thousands of Canadians had no access to proactive cancer screening or diagnoses, or chose not to present at hospitals or doctors' offices for fear of contracting the SARS-CoV-2 virus throughout the course of 2020, giving many doctors reason to fear a surge in advanced tumours and deaths, as a result.

Proactive screening of patients without symptoms, and diagnosis of people suspected of having cancer dropped abysmally in the initial months of the onset of the coronavirus. A particularly dramatic change was seen with prostate cancer, when 60 percent fewer biopsies were performed last March and August in Ontario. Currently numbers of tests have been re-established to reflect normal levels. Which still leaves hundreds of thousands fewer mammograms, pap smears and colorectal cancer screens taking place last year in comparison to the year before.

A matter of great concern to Dr.Fleshner who feels that though the missed screening may prove to have less short-term impact than delayed surgeries, his experience of encountering more patients with advanced, harder-to-treat disease gives him great unease. This, at a time when the grave situation unfolding with the presence of COVID's phase three driven by the far more infectious U.K. variant has led the medical community to talk of triaging, to assess who among the gravely ill COVID-19 patients will be prioritized for limited critical-care resources.

Mammograms are one of several screening tests for cancer that were put on hold during the first wave of the COVID-19 pandemic. (Enrique Castro-Mendivil/Reuters)

Yet, as far as Dr.Fleshner is concerned, a form of triaging has already been in place in the health care system. And it is patients with cancer and those among other non-coronavirus patients that the brunt of that prioritizing has taken place. These are horrendously difficult decisions to make, since making every effort conceivable to attempt to control the pandemic is an absolute requirement.

According to Dr.Villalba, over 8,000 Quebecers have been undiagnosed over the past year. The province's Health Ministry's January report detailed the pandemic's impact on cancer care, such that based on the reduced number of biopsy and other pathology reports an estimated 4,119 new cancers were undiagnosed that would have been discovered earlier, under normal circumstances. All of which added to the situation of hundreds of thousands of elective operations having been shelved in the face of panic over hospital space and treatment for COVID.

According to British Columbia's Provincial Health Services Authority there was a 20 percent decrease in new cancer diagnoses in the first months of the pandemic.The province has now approached pre-COVID levels with the number of screening mammograms performed in February roughly similar as in February of 2019. Dr.Ragaz of UBC is of the opinion that many missed tumours would be slow-growing, that some of the impact of lost screening is to be rectified through 'catch-up' procedures.

In a colonoscopy, a doctor inserts a small camera into a patient's large intestine and checks for possible tumours. Shifting medical resources to deal with the COVID-19 pandemic has made it harder to screen for colorectal and other cancers in Quebec. Experts worry a wave of advanced cases could hit in coming months. (Jean-Paul Pelissier/Reuters)

The consensus of opinion of the situation is not totally unanimous, however. There are skeptics and one such who does not support the efficacy of mass screening, like Dr.Steven Narod a breast cancer expert at University of Toronto. "I can pretty much promise you there will be no difference", he asserted, pointing out that mass cancer screening programs detect so few serious malignancies there is likely to be minimal if any impact from the coronavirus complications.

The pandemic "gives us a really interesting opportunity to evaluate (screening)", he said in the face of the reality that about 0.5 percent of screening mammograms finds a tumour of any size. There is, in fact, no end in sight for the near future of these medical interruptions with ongoing disruptions. Ontario is once again scaling back elective surgeries, despite that huge numbers have already been delayed.

215,000 fewer cancer and other operations, not including heart or transplant surgeries, have been carried out in Ontario since the pandemic arrived, compared to the same period a year earlier. Resections, removal of tissue, and biopsies to diagnose cancer dropped by about 20 percent between March and August in Ontario, while prostate biopsies saw the steepest decline, at 60 percent.