Long-Term Repercussions of Postponing Care Due to COVID-19

Individuals who catch COVID-19 might not be the only ones suffering lasting health consequences. Sheer fear of SARS-CoV-2 has caused patients to cancel or delay needed cancer screenings, diagnostic tests, wellness exams, elective surgeries, and immunizations.

The fall-out from skipped care can be quick, even deadly.

That was already clear last March and April when the pandemic first led to regional and national stay-at-home measures, says Stephen Hunger, MD, chief of oncology at The Children’s Hospital of Philadelphia (CHOP) and co-author of a study reported in Pediatric Blood Cancer Journal.¹

“Early in the pandemic, people were very afraid to leave the house for fear of catching COVID-19, and they did not go to the doctor, emergency room or hospital as they would [normally] have,” he says.

Before the first COVID-19 case in Pennsylvania was reported on March 6, 2020, new leukemia diagnoses were made every 2.96 days at CHOP.¹ The span of time between seeing patients for new leukemia diagnoses then jumped almost 12-fold to 35 days, Dr Hunger says.

But cancer did not take a vacation. Two patients were admitted on consecutive days to CHOP’s pediatric intensive care unit (PICU) after going into cardiac arrest at smaller hospitals. Both children were diagnosed with advanced stages of B-cell lymphoma.

That same month, Lucile Packard Children’s Hospital in Stanford, California also reported a similar cluster with 3 patients requiring prolonged PICU care upon diagnosis of lymphoma or leukemia. Over 75% of new leukemia or lymphoma diagnoses required PICU care, compared with a historic monthly average of 12% during the 2018 to 2019 season.¹

All of the 3 children were SARS-CoV-2 negative. Nonetheless, they required emergent life-saving measures, such as resuscitation following cardiac arrest, intubation, or pericardiocentesis. Unfortunately, 2 children died within days of arrival.

“They all were critically ill,” Dr Hunger says. “And our colleagues across the country saw some of these same things.”

As for adults, “the rate of cancer screening procedures here and nationally took a really hard hit,” says Mothaffar Rimawi, MD, executive medical director of the Dan L. Duncan Comprehensive Cancer Center at Baylor College of Medicine in Houston, Texas.

After COVID-19 was viewed as a national emergency last March and April, preventive mammograms, colonoscopies, cervical, and prostate exams plummeted.

At the Dan L. Duncan Comprehensive Cancer Center, as well as at public hospitals in the surrounding Harris County Health System, preventive screenings fell to 10% of prepandemic levels. While the cancer center’s screening numbers returned to 90% of prepandemic levels by January 2021, “we still have ground to make up,” says Dr Rimawi.

Nationally, a review of 306 hospitals across 28 states showed that colonoscopies plunged 86% and breast and cervical exams fell 94% compared to levels seen from January to April, 2017 to 2019, as published by the Epic Health Research Network. By June 2020, weekly rates remained 29 to 36% of expected totals.²

In a national survey of 1337 people across the United States, 544 respondents (41%) said they skipped doses of prescription medications, preventive medical care, and elective procedures from March through mid-July, 2020. Of these, 307 respondents (29%) did so in fear of COVID-19. Another 75 respondents (7%) did so due to financial struggle caused by the pandemic.³

“Delayed screenings can lead to worse outcomes and more aggressive treatment, adding to the toxicity of care and cost to the patient,” Dr Rimawi says. “It will take us years to fully measure the negative impact the pandemic has had on colon, breast, and prostate cancer.”

Nor has the pandemic slowed cardiovascular disease, diabetes, or childhood disease, says Dean Winslow, MD, professor of medicine at Stanford University and an infectious diseases specialist at Stanford Health Care and the Veterans Affairs Palo Alto Health Care System. “That’s why it’s so important people do whatever they can to maintain routine care.”

But not everyone has a choice. “Right now, hospitals throughout most of the nation, and particularly in California, are bursting at the seams caring for COVID-19, so we’ve delayed elective procedures and diagnostic tests,” Dr Winslow says.

Elsewhere, he notes, clinics and labs have tapered their service to limit exposure in waiting and exam rooms, thus addressing the safety issues that have kept people away.

Dr Rimawi suggests talking with patients to individualize concerns about screenings. “If a woman is 45, completely healthy, and has a strong family history of breast cancer, the benefit of screening is high,” he says. In contrast, women over age 70 with multiple risk factors for COVID-19 may be better served if they wait a few months until the surge subsides.

Annual wellness visits can be done via telemedicine or delayed up to a year for healthy individuals. And routine eye exams can be delayed 6 months, says Nasia Safdar, medical director of Infection Control at the University of Wisconsin Health.

Lower Rates of Routine Immunizations in Pediatrics

The result of fewer pediatric in-office visits is likely fewer immunizations, in particular those for childhood diseases such as polio; measles, mumps and rubella; and diphtheria, tetanus and acellular pertussis.⁴

Blue Cross Blue Shield reports a 26% drop from 2019 to 2020 in vaccinations for those diseases, equivalent to an estimated 9 million fewer shots nationally. In a Blue Cross Blue Shield survey of 2000 parents prior to September 2020, 40% cited COVID-19 concerns as the cause of missed appointments and vaccinations.⁴

In prior generations, these ailments were disabling or deadly. Doctors are concerned that they could be so again as the gap between vaccinations and herd immunity grow larger.

“Telemedicine has been extremely helpful but has limitations,” Dr Hunger says. “You cannot examine a patient, listen to their lungs, check vital signs, and observe pallor or a swollen liver as you can in person.”

One child with leukemia arrived at CHOP after multiple telehealth exams elsewhere. “By then he had overwhelming sepsis that progressed to cardiac arrest and brain death.”

Role of Telemedicine During COVID-19 and Beyond

In general, telemedicine is better suited to counseling, coaching, and follow-ups for chronic conditions, such as hypertension and diabetes.

“Even then, it should be individualized. Patients who are diabetic need to come in for blood work and eye exams. And a new diagnosis of HIV should be addressed face-to-face,” says Dr Safdar. “If the patient has had HIV for some time and it’s fully controlled, telemedicine is fine.”

Reassuring patients they will not catch COVID-19 at physician’s offices and hospitals is vital to resuming essential medical care, Dr Winslow says.

“It’s important for people to know there have not been large outbreaks traced to doctors’ offices.”

To minimize the risk of COVID-19, clinics can have parking lot check-ins, allowing patients to go directly to designated exam rooms, says the American College of Physicians. HIPAA-compliant texting apps and patient portals (Doctible, UpDox, Jellyfish, Luma Health, Rhinogram) enable patients to alert doctors’ practices upon arrival with greater ease.⁵

Staff can use these apps and portals ahead of appointments to contact patients and update their medical history and medication lists. This helps patients practice using the technology in advance. So does giving step-by-step instructions on websites, Dr Hunger says.

Ideally, COVID-19 patients can be treated in separate offices or buildings. If not, consider parking lot visits, the American College of Physicians suggests.

If a patient is at high-risk from COVID-19, they should be treated at the beginning or at the end of the day when there are fewer patients, says David M Aronoff, MD, fellow at the Infectious Diseases Society of America and professor and director of the division of infectious diseases at Vanderbilt University Medical Center.

References

1. Ding YY, Ramakrishna S, Long AH, et al, Delayed cancer diagnoses and high mortality in children during the COVID-19 pandemic, Pediatr Blood Cancer. 2020;67(9):e28427. doi:10.1002/pbc.28427

2. Mast C, Munoz del Rio A. Delayed screenings—A second look. Epic Health Research Network. https://ehrn.org/articles/delayed-cancer-screenings-a-second-look. Published July 17, 2020. Accessed February 4, 2021.

3. Anderson KE, McGinty EE, Presskreischer R, Barry CL. Reports of forgone medical care among US adults during the initial phase of the COVID-19 Pandemic. JAMA Network Open. Published online January 21, 2021. doi.10.1001/jamanetwork.2020.34882

4. Missing vaccinations during COVID-19 puts our children and communities at risk. Blue Cross Blue Shield. https://www.bcbs.com/the-health-of-america/infographics/missing-vaccinations-during-covid-19-puts-our-children-and-communities-at-risk. Published online November 18, 2020. Accessed February 4, 2021.

5. COVID-19 Practice Management Issues. American College of Physicians. https://www.acponline.org/practice-resources/covid-19-practice-management-resources/covid-19-practice-management-issues. Published February 1, 2021. Accessed February 4, 2021.