Columbus Monthly Special Section: Keeping Up with Cancer

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Keeping Up With Cancer The coronavirus pandemic caused many to delay their cancer screenings, which could lead to worse outcomes for those affected.

By Peter Tonguette

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Keeping Up With Cancer The coronavirus pandemic caused many to delay their cancer screenings, which could lead to worse outcomes for those affected.

photo: getty images

By Peter Tonguette

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Columbus Monthly MARCH 2021

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During the early days of the coronavirus pandemic, many public health officials expressed their fears about the possibility of a so-called twin pandemic: If COVID-19 and the yearly influenza strains ran rampant in the population concurrently, health systems might not be able to withstand the strain.

Fortunately, thanks to the same measures used to mitigate the coronavirus, this year’s influenza season has been unusually mild.

Yet last year’s lockdowns, combined with nagging fears in the general public about entering health care facilities, have raised red flags about an altogether different sort of twin pandemic: As some individuals are missing or delaying cancer screenings recommended based on their age, sex or risk factors, health care professionals worry about an increase in overall cancer diagnoses as well as diagnoses made later in the progression of a given cancer.

“The pandemic has definitely affected a lot of the screenings this past year,” says Dr. Emily B. Saul, an oncologist with Columbus Oncology & Hematology Associates.

“We are seeing, unfortunately, an increase in higher stages of cancer due to delay of screening.”

Screenings can capture signs of a wide range of cancers before they are able to progress to more serious disease—but only if those screenings actually take place.

“It is really important to remind people of getting their screening test,” Saul says. “The cure rate is definitely affected by the stage at diagnosis. The outcomes are much better [when cancers are caught earlier]. We aim to cure for most malignancies, so the earlier we can detect something, the better chance that we’re able to cure someone of their cancer.”

Dr. Darrell Gray, a gastroenterologist and deputy director of the Center for Cancer Health Equity at the Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, has seen both anecdotal and data-based evidence that the pandemic has led to fewer screenings for colon cancer.

“Early in the pandemic, we really just shut a lot of the operations down,” Gray says.

“But even later, after the operations got back closer to normal, we noticed that patients just felt apprehensive about walking back into the health care center.”

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cancer: Average-risk males and females should undergo once-per-decade colonoscopies—in which a tiny camera gives physicians a view of the entirety of the colon—at age 50.

It’s worth noting, however, that the American Cancer Society, recognizing increased incidence among younger adults (including “Black Panther” film actor Chadwick Boseman, who recently died of colon cancer at just 43 years old).

“Most recently ... the United States Preventive Services Taskforce [USPSTF] issued a draft recommendation that is in agreement with that,” Gray says. “At this time, most insurers for average-risk population are still only covering starting at age 50.” Other health care bodies have for some time recommended that Black people begin screenings at 45 due to elevated rates of colon cancer in the population. “I have not had much pushback from insurers, and when I have, I have shown them those guidelines” for Black patients, Gray says.

Family history of colon cancer places an individual in a high-risk category: More frequent screenings are called for if colon cancer has been found in a single firstdegree relative, such as a parent, or multiple second-degree relatives, such as grandparents. “If someone has a first-degree relative who has been diagnosed less than or equal to 60 years of age, we recommend that they start at age 40, or 10 years younger than the age at which [the relative was] diagnosed,” Gray says.

Colonoscopies are considered the gold standard among screenings for colon cancer, but Gray points out that they are not the only option for those uneasy about entering a health care facility during the pandemic.

“There are stool-based tests that don’t require having transportation, that don’t require people leaving their home,” says Gray, who points to the convenience and cost savings of such at-home tests (which would have to be done much more frequently than colonoscopies). “For us, we want our patients to get the best test that they will complete appropriately,” Gray says.

Lung cancer screenings are targeted to individuals based on both age and behavior: Smokers of both sexes between 55 and 77 years old are eligible for the annual screening if their personal history of tobacco use qualifies them.

“You have to have what we call a 30-packyear smoking history—you either smoke one pack a day for 30 years, two packs for 15 years, et cetera,” says Dr. Michael Wert, a pulmonologist who directs the OSUCCC –

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James lung cancer screening program. “You have to either currently be smoking or have quit within the past 15 years.”

The screening process itself is minimally invasive and low-risk in terms of potential COVID-19 exposure. “It involves a very brief, face-to-face encounter ... then you get a CT scan and then you go home and get a phone call,” Wert says. “It’s about as risk-free as a cancer screening can be, honestly. It’s a highreward and basically no-risk proposition.”

If current or former smokers participate in the screening regimen, the chances of physicians spotting an early-stage cancer are

greatly increased. “Once people go through the screening process, we’re starting to find a lot more Stage 1 cancers,” Wert says. “It’s isolated to one single spot in the lung, and if you find a cancer there, you have multiple options—and a lot of times, you can actually be cured by cutting the cancer out.”

Those eligible should continue the annual screenings until they have exceeded age 77 or they have dropped their smoking habit for more than 15 years.

Physicians combatting cervical cancer have two main weapons in their arsenal: prevention and screening. In the former

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category, a vaccine exists to ameliorate the effects of the human papillomavirus (HPV), a sexually transmitted infection occurring in men and women alike that can lead to cervical cancer.

“The HPV vaccination is a preventative technique,” says Dr. David Cohn, the chief medical officer at OSUCCC – James. “The hope is that if you can block the effects of the virus ... you can prevent the cells of the cervix turning precancerous and cancerous.”

Vaccines should be given to all people between the ages of 9 and 26, although a physician can administer the vaccine to those as old as 45. “The immune system certainly declines after the age of 26 ... but it doesn’t go to zero so that there is no benefit,” Cohn says.

Females who have been vaccinated should still receive cervical cancer screenings, for which two procedures exist: a conventional Pap test in which cells are collected and scrutinized for abnormalities and an HPV test in which the cells are looked at for the presence of the infection.

“You have two different opportunities to detect this continuum,” Cohn says. “One is if there are abnormal cells—the virus has infected the cells and the cells have turned precancerous already. We know at that point in time that a precancerous cell, which is detected by a Pap test, needs some type of an intervention to keep it from turning into cancer.”

The HPV test, by contrast, targets the HPV infection itself. “If infection is something that is necessary for the cells to turn precancerous, then if you detect the HPV infection, that can also be a time to intervene,” Cohn says.

Females should get Pap tests every three years beginning at age 21, but if both screenings are conducted during a single office visit, the gap widens to every five years. “If you do both of them together, you are looking at two different points on that continuum,” Cohn says.

Regardless, testing ends at age 65.

Prostate cancer screening guidelines have long been hazier, but some clarity began to emerge when the USPSTF issued a recommendation statement in 2018: Screenings meant to detect prostate-specific antigen

(PSA) in the blood can be advisable for males between the ages of 55 and 69. An approach targeted to the patient should be adopted, as the risks of the invasive screening—such as a biopsy being taken on the basis of a false positive—are not negligible.

For males outside this age range, the USPSTF does not recommend PSA screenings.

Females with an average risk of developing breast cancer are advised to begin the annual screenings at age 40; some OB-GYNs recommend an initial mammogram five years earlier, at age 35, but Dr. Shilpa Padia, a breast surgeon at the Mount Carmel Medical Group, says that she considers a screening at that age to be optional.

“If people feel compelled to get mammograms at 35 as a baseline, I think that’s completely fine,” Padia says. “In terms of starting routinely on an annual basis, 40 would be the recommendation for the average-risk woman.”

High-risk factors—such as having had a mammogram resulting in a biopsy that shows high-risk cells, a family history of breast cancer, or knowledge of a genetic mutation—can

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lead to annual mammograms being done in conjunction with annual MRIs. “Every January, you get your mammogram, and then every July, you get the MRI,” Padia says.

“There is some sort of imaging happening every six months.” Such risk factors could also lead to mammograms and MRIs starting before age 35.

Less clearly established is the age when women should stop getting mammograms.

Although guidelines suggest that age 75 could be a cut-off point, Padia says that the most common time when women get breast cancer is in their 60s and 70s. “Cutting off screening mammograms at the middle of your 70s is kind of cutting off a time when it’s most likely to happen,” says Padia; on the other hand, “if a malignancy were to be identified, it was probably going to be a less-aggressive form” that would not be that woman’s eventual cause of death.

A complete picture of a patient’s health is necessary to ascertain whether continuing mammograms is advisable past 75. “Age is important, but it’s just a number,” says Padia, noting that she has seen women in their 50s with compromised health and women in their 80s with good health prospects.

Padia says that, in addition to screenings by their health care providers, women should practice “breast self-awareness,” or monthly self-exams. “Make sure at least once a month you’re looking in the mirror and ensuring that your right breast looks the same as it did last month, and the left one does as well,” Padia says. Dimpling or other cosmetic changes should be brought to your doctor’s attention.

Skin cancer also offers patients the chance to monitor themselves in conjunction with annual screenings by medical professionals. Individuals should be attuned to changes on portions of their skin that are visible to them, but a full examination of the surface of the body should be done by a dermatologist on an annual basis to catch irregularities in locations that are difficult to see, such as the back or the scalp.

No matter which category for cancer screenings someone falls into, the experts say that resuming regular screenings is of the utmost importance.

“If you put off screenings by a month or two or three or six, it’s very unlikely that there’s going to be any negative outcome related to that decision,” Cohn says. “But if it’s one, two, three or six years, that’s when you’re going to start to see a major difference in the rates of cancer deaths rising substantially.”

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