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From the Editor

Cancer Prevention During the COVID-19 Pandemic

Debra Lyon
ONF 2020, 47(5), 491-492 DOI: 10.1188/20.ONF.491-492

The COVID-19 pandemic continues, now disproportionately affecting the richest and best-resourced country in the world. Although the death rates per affected individual have decreased from the initial wave in New York City, the United States is in the unfathomable situation of having more than 50,000 new cases per day, and the case numbers are increasing. The pandemic is now expected to remain a vexing health problem for months and perhaps years to come, and the implications for health promotion and disease prevention have taken on new importance given the need for ongoing attention to acute and long-term issues. However, the health-promoting behaviors of many Americans have changed during the pandemic, setting up risk for additional collateral losses, such as from an increase in cancer diagnoses.

The COVID-19 pandemic continues, now disproportionately affecting the richest and best-resourced country in the world. Although the death rates per affected individual have decreased from the initial wave in New York City, the United States is in the unfathomable situation of having more than 50,000 new cases per day, and the case numbers are increasing. The pandemic is now expected to remain a vexing health problem for months and perhaps years to come, and the implications for health promotion and disease prevention have taken on new importance given the need for ongoing attention to acute and long-term issues. However, the health-promoting behaviors of many Americans have changed during the pandemic, setting up risk for additional collateral losses, such as from an increase in cancer diagnoses.

In the initial phases of the pandemic in the United States, most hospitals stopped elective surgeries and other nonurgent care. Not surprisingly, the volume of screening appointments dramatically decreased in March 2020 by 86%–94% as compared to mean monthly volumes from prior years (Epic Health Research Network, 2020). This trend continues as the pandemic has progressed: data from March 15 to June 16 show that 285,000 breast, 95,000 colon, and 40,000 cervical examinations were missed, which represent deficits of 63%, 64%, and 67%, respectively, relative to the number of screenings in a prior year (Epic Health Research Network, 2020). In a model from the United Kingdom of avoidable cancer deaths related to delay in diagnosis from deferred diagnostic workup for four tumor types (breast, lung, colorectal, and esophageal), it is estimated that a total of 3,291 to 3,620 additional cancer deaths will occur in the next five years, and the additional years of life lost is estimated to be between 59,203 and 63,229 years (Maringe et al., 2020; Wise, 2020).

To prevent the unintended consequences of increased future cancer deaths related to screening delays, cancer prevention and control issues are emerging as major foci for oncology clinicians and researchers (American Cancer Society, 2020). Until vaccines and/or curative treatments are developed and validated for COVID-19, tailored strategies need to be initiated for cancer prevention, control, and screening, and diagnostic testing must be considered within the context of a pandemic (Marron et al., 2020). One method that has emerged for mitigating risk and providing continuity is an increased focus on virtual strategies for access to health care. Policy changes in insurance coverage were made early in the pandemic. Medicare granted payment parity between telehealth and in-person clinical care, and Medicaid began to reimburse for telehealth visits outside of limited usage prior to the pandemic. Many insurance companies soon followed this practice. Although telemedicine had been used for urgent care and chronic disease management, it may also provide a larger role in mobilizing cancer screening and assessment. Prior to the pandemic, telehealth was used to provide outreach to rural and underserved communities to decrease the limited access that people have to cancer preventive care. However, access issues may still be problematic and further contribute to health disparities. eHealth, including mobile applications, have been developed to support lifestyle modification, wellness activities, and medication adherence (Sirintrapun & Lopez, 2018).

Other risks to consider in the cancer prevention and control research domain are the social, psychological, and physical health changes related to increased home confinement and disruption in daily life. Many lifestyle habits, including changes in dietary intake and physical activity, lack of gym attendance, and constrained energy output due to home confinement, may contribute to increased weight gain and consequent obesity for some. Undernutrition may also be problematic because of the unavailability of fresh fruits and vegetables due to lack of access to groceries or financial consequences related to under- or unemployment. The pandemic has differentially affected racial and ethnic minorities (Dyer, 2020), particularly Black and Hispanic individuals, those with public-facing employment, and those living in congregate spaces. Our research must continue to address these important issues, moving past examining risks and toward developing strategies for harm reduction and health promotion within the context of known barriers, as well as toward attainment of optimal outcomes across individuals and communities at high risk. Because many of these issues are known to contribute to increased cancer risks, research is needed to explore opportunities for health promotion within the context of a pandemic, perhaps with known strategies for health promotion used in dealing with natural disasters such as hurricanes or other disruptive conditions.

Although there are multiple health challenges associated with the COVID-19 pandemic, there are a few notable positive aspects: rapid health system changes, including the more rapid evaluation of diagnostic tests and vaccines; the transition to compensated virtual care for most counseling and education visits; and broadened access to home services. For nurse scientists and clinicians, the COVID-19 pandemic portends a timely opportunity to reimagine cancer prevention and control, reducing the boundaries of hospital-focused health care and creating systems for health promotion that are more accessible. Research will need to examine whether, in the short term, individuals and families come back into the primary healthcare setting for routine preventive care and, if current trends persist, strategies for increasing recommended screenings are needed, perhaps including more home-based strategies. In the long term, there are many avenues for enhancing cancer prevention and diagnosis at the individual, community, and national levels. It is up to us to begin focusing on clinical care and research programs centered on health promotion under conditions of long-term disruption, including environmental, social, and economic factors that matter.

About the Author(s)

Debra Lyon, RN, PhD, FNP-BC, FAAN, is the executive associate dean and Kirbo Endowed Chair in the College of Nursing at the University of Florida in Gainesville. Lyon can be reached at ONFEditor@ons.org.

 

References 

American Cancer Society. (2020). Cancer screening during the COVID-19 pandemic. https://www.cancer.org/healthy/find-cancer-early/cancer-screening-guidel...

Dyer, O. (2020). Covid-19: Black people and other minorities are hardest hit in US. BMJ, 369, m1483. https://doi.org/10.1136/bmj.m1483

Epic Health Research Network. (2020). Preventive cancer screenings during COVID-19 pandemic. https://www.ehrn.org/wp-content/uploads/Preventive-Cancer-Screenings-dur...

Maringe, C., Spicer, J., Morris, M., Purushotham, A., Nolte, E., Sullivan, R., . . . Aggarwal, A. (2020). The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: A national population-based modeling study. Lancet Oncology. https://doi.org/10.1016/S1470-2045(20)30388-0

Marron, J.M., Joffe, S., Jagsi, R., Spence, R.A., & Hlubocky, F.J. (2020). Ethics and resource scarcity: ASCO recommendations for the oncology community during the COVID-19 pandemic. Journal of Clinical Oncology, 38(19), 2201–2205. https://doi.org/10.1200/JCO.20.00960

Sirintrapun, S.J., & Lopez, A.M. (2018). Telemedicine in cancer care. American Society of Clinical Oncology Educational Book, 38, 540-545. https://doi.org/10.1200/EDBK_200141

Wise, J. (2020). Covid-19: Cancer mortality could rise at least 20% because of pandemic, study finds. BMJ, 369, m1735. https://doi.org/10.1136/bmj.m1735