Cancer surgeons in Ontario are reporting a sharp rise in the number of people coming to hospital with advanced cancers, an unintended consequence of the sudden shutdown of non-urgent health-care services during the spring wave of COVID-19.
In mid-March, the number of people getting routine cancer screening plummeted after the province halted its screening programs for breast, cervical and colorectal cancers.
Physicians say they’ve seen a corresponding drop in patients going for diagnostic imaging tests and that some patients are deferring care, over fears of contracting the coronavirus in hospitals or doctors’ offices.
Now, seven months into the pandemic, experts warn too many cancers are not being caught at their earliest stages, as patients arrive in hospital with more severe symptoms and advanced stages of disease. In turn, this leads to patients requiring more intensive surgery and longer hospital stays, and potentially seeing poorer long-term prognoses.
“I’m worried for people,” said Dr. Frances Wright, the Temerty Chair of Breast Surgery at Sunnybrook Health Sciences Centre. “It’s upsetting as a cancer-care provider.
“Over the years we’ve made huge strides in reducing the mortality and morbidity for cancer, and this is a step backwards.”
Surgeons and physicians are seeing this stark trend even as they work through the backlog of cancer surgeries that accumulated after operating rooms were shut to elective procedures in mid-March.
While hospitals prioritized surgery for the most advanced cancers, many surgical programs for weeks functioned well below capacity as part of a provincial plan to clear beds and free up resources in preparation for a surge of COVID-19 cases.
Hospitals began to slowly ramp up surgical cases in late May after the province loosened restrictions, with patients triaged on a case-by-case basis.
Dr. Jonathan Irish, provincial head of the Surgical Oncology Program at Ontario Health (the new provincial superagency that now includes Cancer Care Ontario), told the Star “there has been a gradual reduction in the backlog” of cancer surgeries.
According to provincial data provided to the Star, 19 per cent fewer adult cancer surgeries have been performed during the pandemic compared to the same period in 2019.
Data from the provincial Wait Time Information System shows 29,341 adult cancer surgeries were performed between March 17 and Oct. 20 in 2019, dropping to 23,629 surgeries during the same 218-day period in 2020.
“Throughout the pandemic, surgeons and other health providers have been attempting to prioritize patients that are more time-urgent,” Irish said, noting wait lists for hip and joint and cataract surgeries, for example, are much longer than for cancer surgeries.
Provincial wait-list data shows 51 per cent fewer adult surgeries (excluding cancer, cardiac and transplant surgeries) have been completed between March 17 and Oct. 20 in 2019 compared to that period this year.
“Don’t get me wrong, if you’re using a cane or wheelchair while awaiting your hip replacement, that’s of course important,” Irish said. “But I think we all appreciate the fact that we’re trying to prioritize patients where survival may be impacted over quality of life. That’s critical.”
In the spring, the province postponed its routine screening programs for breast, cervical and colorectal cancers as part of the move to preserve health resources and curb virus spread by limiting the number of people coming to hospital.
Between March 15 and May 31, screenings for all three cancers plunged compared to the same period in 2019. According to data shared by Ontario Health, there was a 97 per cent decrease in screening mammograms (4,065 from 158,967), an 88 per cent decrease in Pap tests (26,269 from 219,079) and a 73 per cent decrease in fecal tests (38,000 from 141,251) in provincial programs.
Routine cancer screening has largely resumed but the programs are not back to pre-pandemic levels.
Data from Ontario Health for the month of August shows 65 per cent of expected mammograms were done as part of the Ontario Breast Screening Program, falling to 37,364 tests from 57,463 during August 2019. About 60 per cent of diagnostic Pap tests were done as part of the Ontario Cervical Screening Program and 28 per cent of fecal tests for ColonCancerCheck, when comparing August 2019 and August 2020, data shows.
Irish, who is also a cancer surgeon at Toronto’s University Health Network, said there is a growing backlog of cancer patients in the “diagnostic pathway” from primary care through to CT and MRI imaging to a cancer specialist.
“Anecdotally, we are seeing more advanced cancers as patients finally present to their surgical specialist,” he said, noting that usually means patients will require a bigger operation and longer hospital stay and are more likely to need radiation and chemotherapy and other multidisciplinary care. “So the impact to the entire system is significant.”
In a statement to the Star, a spokesperson for Ontario Health said the province is investing $283.7 million to “assist the health system’s ongoing efforts to reduce surgery backlogs by supporting extended hours for additional priority surgeries and diagnostic imaging.”
The spokesperson also said the province will support more surgeries by “adding 139 critical care beds and 1,349 hospital beds in hospitals and alternate health facilities.”
Dr. Roberta Minna, corporate chief of surgery at William Osler Health System, said her team has been keeping up with cancer surgeries by triaging cases and moving surgeons among its three hospitals as time slots opened up.
As well, operating room hours have been extended into the night for elective surgeries, well past the typical closing time of 3:30 p.m., and opened on weekends to sustain cancer surgeries, Minna said.
Osler, which includes Brampton Civic Hospital, Etobicoke General Hospital and Peel Memorial Centre for Integrated Health and Wellness, did 5,029 cancer surgeries in its last fiscal year, April 1, 2019 to March 31, 2020. In the spring, during the provincial shutdown, Osler went down to about 18 per cent of its usual surgical volume, Minna said.
Rather than a backlog in cancer surgeries, Minna’s current worry is the sizable drop in patients getting diagnostic testing and screening to catch early cancers. At Osler, for example, the number of patients getting mammograms has fallen and the surgical team is seeing more patients presenting with later stages of colon cancer, she said.
“We are going to see some collateral damage in the next year or two related to these cancers.”
Minna said there are several reasons why people are being diagnosed with later cancers. It can be harder for patients to see their primary care provider for an appointment that might trigger a specialist referral; provincial routine screening programs that catch the earliest signs of disease were halted for months; and patients are avoiding the health-care system over fears of getting COVID-19.
“I would urge (people) to continue with their routine screening and not be afraid of getting COVID in the hospital,” she said.
At Unity Health Toronto, gastroenterologist Dr. Sam Elfassy said he is seeing a higher concentration of very sick patients coming to his clinic at St. Joseph’s Health Centre.
“When we’re doing procedures, the frequency of seeing cancers in very advanced diagnosis … I’ve never seen that many in my career in such a short amount of time.”
Elfassy said many of his patients say they are too nervous to come for the procedure — even though the referring physician has identified their case as urgent — for fear of the virus. While he does his best to explain that hospitals are taking extraordinary measures to be safe, Elfassy said some patients still want to defer their colonoscopies or endoscopies.
In November, Unity will open its endoscopy clinics on Saturdays — for the first time — to reduce the backlog of procedures from the spring and keep up with new referrals, said Elfassy, noting the clinics are operating at about 90 per cent capacity.
While the initial backlog of surgeries and procedures has so far taken precedence, Elfassy said he is just as worried about the next wave of people, those who have postponed regular checkups and screening tests.
“The risk of deferring their care, and not having their symptoms investigated or having their screening tests done, far outweighs any risk of coming into the hospital.”
Dr. Samantha Hill, president of the Ontario Medical Association, said while the province has provided additional funding to hospitals, more support needs to flow to primary care providers to help them see more patients in person.
Among the challenges, Hill said family physicians cannot get through as many procedures a day during the pandemic. In addition to doffing and donning personal protective equipment, it takes longer to see patients because offices must space out appointments to prevent crowded waiting rooms and to properly clean exam rooms, she said.
According to OHIP billings, screenings for colon cancer dropped from an average of 210,000 a year to roughly 60,000 so far in 2020, Hill said. Similarly, screening for cervical cancer has fallen from just over 200,000 a year to 80,000 this year.
“These tests are performed by general practitioners. These aren’t things that require you going into a hospital. So it speaks to the challenges that our community infrastructure is facing.”
At Sunnybrook’s Louise Temerty Breast Cancer Centre, Wright said the backlog of patients requiring surgery from the spring shutdown was largely cleared by August.
Two months later, the concern is that the number of people diagnosed with breast cancer is down this year, a similar trend observed across the province, said Wright, a professor at the University of Toronto.
“My guess is it’s because we haven’t been screening women,” she said, adding those who have been diagnosed are presenting to her clinic with more advanced disease and with a physical finding of breast cancer, “either a mass in their breast or lymph node involvement.”
The breast screening program is designed to pick up breast cancers at the earliest stage, often before they are palpable, said Wright.
While Sunnybrook’s high-risk breast cancer screening program restarted about a month ago, Wright said the province’s routine mammography screening is about six months behind.
“We’ve got these missing patients with early cancers. We know they are there and we should be seeing them.”
This content was originally published here.