Cancer disparities in the COVID‐19 era

Necessary decisions in response to the COVID‐19 pandemic are having unintended consequences for both patients and providers. While emergency care was largely preserved, elective diagnostic and surgical services have been temporarily inaccessible for many parts of the country. Patients who would otherwise seek evaluation for routine or nonurgent care are unable to do so.

Health care systems and providers have suffered significant losses as a result of reduced volumes and many essential hospitals are at risk of closing in the near future. ¹ In an effort to recover, hospitals are gradually restarting elective surgeries and diagnostic procedures as COVID‐19 cases decrease in their region. The assumption is that volume will return by simply re‐opening the doors.

This will not be the case. In the immediate future, concern regarding COVID‐19 exposure may prevent patients from seeking care even when available. Cardiologists have seen a significant reduction in emergency cardiac procedures and more patients are presenting later in the course of their acute coronary syndrome than before COVID‐19. ² Patients with underlying malignancy who develop breast lumps, melena, abdominal pain, and other ominous symptoms can be expected to make the same decisions in the coming months. Existing studies have shown that delays from diagnosis to surgery adversely affect overall survival for cancer patients, ³ and it is only natural to assume that delays in diagnosis will do the same.

The COVID‐19 pandemic has magnified existing gaps in our health care system. Socioeconomic disparities have long been described in various aspects of medicine, especially within the cancer care continuum. ⁴ Characteristics of low socioeconomic status include low income, limited education, unemployment, and inadequate health insurance. These patients have less access to cancer screening and other preventative services and are more likely to present with advanced‐stage disease and comorbid conditions. They are also less likely to receive guideline‐appropriate surgery and other therapies. As a result, cancer survival is more accurately predicted by a patient's zip code than their genetic code.

The ripple effects of COVID‐19 will limit access to health care even when concerns regarding infectious risk have subsided. As this is written, over 30 million people have filed for jobless benefits, and economists are expecting the unemployment rate to reach its highest point in close to a century. Before COVID‐19, the majority of Americans were covered by employer‐based health insurance and greater than 27 million were uninsured. ⁵ As a result of economic contraction and historic unemployment, it is likely that these numbers will shift and millions of citizens will become under‐ or uninsured. Moreover, many patients who maintain health insurance coverage will suffer financial constraints that directly impact their health as they choose between preventative care and food on the table.

This combination of factors will dramatically increase the segment of our population at‐risk for disparities in cancer diagnosis and treatment. Now, more than ever, it is the responsibility of health care providers to find innovative ways to bridge these gaps. Patients need more help accessing potentially life‐saving treatment and hospitals will need to regenerate their business. There are many potential interventions, and a detailed review is beyond the scope of this article, but we will briefly outline some areas where impact and cost‐effectiveness might be maximized.

Telehealth has been a growing field for several years, and the COVID‐19 pandemic has forced major insurers to now reimburse for these services. Providers should consider using this opportunity to build their telehealth infrastructure in ways that accommodate patients with travel restrictions as a result of infectious, economic, or other considerations. These platforms provide a safe and cost‐effective way to evaluate and communicate with patients.

Cancer screening mechanisms will need to be adjusted. Costs associated with screening, such as copays and transportation, can be barriers to access. Investing in the theoretical risk of developing cancer is a difficult value judgment for patients struggling with more tangible economic concerns. Removing these barriers may ultimately be beneficial and cost‐effective in the long run. Providers should also be innovative in delivering cancer screening programs that better accommodate patients. Successful programs have been described utilizing methods such as portable mammography or in‐home fecal occult blood testing. Creativity will be necessary to address these challenges.

Finally, education and outreach should be coupled to the above initiatives. If patients are not participating in primary and other health care services in conventional ways, then health care systems must adapt and find new opportunities to connect with patients. This relationship is crucial to identifying malignancies early when treatment may be more successful.

The COVID‐19 pandemic has already presented dramatic challenges to our health care system and society as a whole, and the fallout will likely continue for months to years. Socioeconomic disparities in cancer care are old problems, but the current pandemic has amplified these issues. It is the responsibility of health care systems to take a more active role in cancer prevention, diagnosis, and management in ways that benefit our most vulnerable citizens in these difficult times.