Crucial early cancer diagnoses being missed amid COVID-19 pandemic priorities

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Fei-Fei Liu knows they’re out there: The missing cancer patients.

As the head of the radiation medicine program at Toronto’s Princess Margaret Cancer Centre, she has watched in alarm as the number of newly diagnosed patients seeking her department’s help has dropped in the midst of the coronavirus pandemic.

From April to September of this year, the radiation program received 3,855 referrals, down from 4,653 in the same period last year. Dr. Liu doesn’t think fewer people are getting cancer. She thinks fewer cancers are being found early, when treatment is likeliest to succeed.

“There are about 800 patients out there that we don’t know about,” Dr. Liu says. “This really worries us.”

Oncologists across the country share Dr. Liu’s concern. Cancer screening was one of the first things to go when provincial governments partly shut down their health care systems during the first wave. The number of mammograms for breast cancer, fecal tests for colon cancer and Pap tests for cervical cancer plummeted through the spring.

At the same time, many Canadian family doctors and other primary-care providers shifted to virtual care to help curb transmission of COVID-19. Patients with new and unexplained symptoms either couldn’t get in-person appointments, or chose to avoid physicians' offices and emergency departments for fear of the virus.

As a result, cancer diagnoses and new referrals for chemotherapy and radiation are down in much of the country.

In Alberta, the number of cancers diagnosed between March and September is 23-per-cent lower than the same period last year, according to Alberta Health Services. The chief medical officer of British Columbia’s cancer agency says new diagnoses have dropped in his province by about 20 per cent. At Princess Margaret, the largest cancer centre in Canada, referrals for chemotherapy for breast and gastrointestinal cancers over the summer were down 38 per cent and 40 per cent, respectively, from last summer.

At Montreal’s McGill University Health Centre, “there was a drop in just about everything” in April, May and June, according to Armen Aprikian, the medical director of oncology.

“When we talk second wave, I’m thinking second wave of cancer,” he says, “because the last six months was an anomaly.”

The second wave that Dr. Aprikian dreads is one in which a glut of patients whose malignancies went undetected in the spring pour into cancer centres with advanced disease – at the same time hospitals are fighting a resurgence of the virus. The number of Canadians in hospital with COVID-19 has nearly quadrupled since mid-September to 1,168 as of Thursday.

Dr. Aprikian and other oncologists say they don’t yet have the data to determine whether Canada’s pandemic measures caused more cancers to be discovered late. They also say it’s too early to predict how the pandemic will affect cancer survival rates.

But what they’re finding on the front lines has them nervous. Many patients, “are presenting at a more advanced disease stage than I’m used to seeing,” said Antoine Eskander, a head and neck surgical oncologist at Toronto’s Sunnybrook Health Sciences Centre.

Dr. Eskander is working on several research projects about the pandemic’s impact on cancer care with ICES, formerly known as the Institute for Clinical Evaluative Sciences, where he’s an adjunct scientist. “But I can tell you that for every cancer doctor this is so obvious to them that we don’t even need a study to show us this,” he says.

One of those obvious examples could be Bill Gardner, an Ottawa child psychologist and mental-health researcher who was diagnosed with throat cancer in July.

Mr. Gardner, 67, started having trouble swallowing in January. The problem grew serious enough that he broached it with his family doctor in March. By that point, the office had gone virtual, meaning Mr. Gardner’s doctor couldn’t look down his throat or feel his neck. His doctor suggested a video fluoroscopy, but Mr. Gardner couldn’t even secure an appointment for the real-time swallowing exam before he started coughing up blood in early July.

He went to the emergency department where a doctor examined him in-person for the first time since his swallowing troubles began. “The first attending [physician] that I saw looked at my throat, felt my throat and said, ‘We need to get your image,’ ” Mr. Gardner says. “But his facial expression said everything.” A CT scan that night found a mass in Mr. Gardner’s oropharynx, the middle part of his throat. It was metastatic cancer, and it had already spread to his lymph nodes.

Mr. Gardner, who is recovering from radiation and has a good prognosis, says he understands why players at every level of the health care system chose to ramp down routine care in the face of a frightening new virus.

“But those choices probably had a cost in terms of the health and well-being of those of us who have other diseases,” he says.

Political and health care leaders have said throughout the pandemic that when it comes to non-COVID care, surgery and treatment for cancer takes priority. That has mostly been true for patients who knew they had cancer before the arrival of COVID-19.

In Ontario, for example, the number of cancer operations has dropped, but not by as much as other operations. Oncology operations are down 19 per cent since the pandemic began compared with March to October, 2019, while adult and pediatric operations are down 51 per cent and 57 per cent, respectively (excluding cardiac and transplant procedures).

“We saw wait times for cancer surgery decrease because more elective surgeries weren’t happening,” says Kim Chi, BC Cancer’s chief medical officer. “Some [oncology] patients were getting their surgery even faster than in pre-COVID times.”

Cancer patients whose treatments have continued have been hurt by the pandemic in more subtle ways.

Diane Van Keulen, a 60-year-old former teacher and horseback riding instructor with Stage 4 lung cancer, went from seeing her oncologist every three weeks at a hospital in Newmarket, north of Toronto, to seeing him primarily by phone. “It’s not the same,” Ms. Van Keulen says. “He had to rely completely on me to be able to give him valid information … and I was getting progressively more ill on the chemo treatments.”

Harder than not seeing her oncologist face-to-face was not being allowed to bring her partner or eldest daughter to appointments, Ms. Van Keulen says. Cancer centres have mostly barred visitors to reduce the risk of the virus finding its way inside and infecting immunocompromised patients.

Amit Oza, head of medical oncology and hematology at Princess Margaret, says it has been heartbreaking to deliver bad news to patients who are alone, with the loved ones who would have been holding their hands on the phone instead.

“Many of us, unfortunately, have shed tears,” Dr. Oza says. “In 30 years of working as a medical oncologist, the challenges that we’ve faced in the last six months have been the toughest ever, in terms of supporting a patient.”

Even triumphs can’t be celebrated normally. On Wednesday, Ms. Van Keulen received the first good news in her nearly two-year battle against lung cancer. Her tumours had shrunk dramatically, thanks to an experimental drug.

With both of them clad in masks, Ms. Van Keulen told the oncologist whose advocacy had helped give her a future, ‘I wish I could give you a hug.’ "

He replied, “Yes, I wish I could too.”

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