Rae Woods (00:03):
From Advisory Board, we're bringing you A Radio Advisory. My name is Rachel Woods. You can call me Rae. During the peak of the pandemic, an estimated 9.4 million cancer screenings were missed, which we know led to delays in cancer diagnoses. And now, health leaders are left wondering what impact this might have on patient outcomes, not to mention the larger impact on healthcare business. We're still learning about the pandemic's impact on cancer. So to find out more, I brought two Advisory Board experts, Ashley Riley and Lauren Woodrow. Ashley, Lauren, welcome to Radio Advisory.

Ashley Riley (00:46):
Thank you. Excited to be here.

Lauren Woodrow (00:48):
Yeah, thanks for having us.

Rae Woods (00:50):
Only took me two and a half years to get representatives from our specialty care research stream on the podcast. No pressure for the two of you, but I'm expecting some really high quality conversation about the state of oncology care.

Ashley Riley (01:04):
We will try to bring our A game.

Rae Woods (01:23):
I want to start this conversation by backing up to the beginning of the pandemic, so I'm trying to remember how it felt in spring, early summer of 2020. I'm remembering, basically, being afraid of everything, right? We were washing our groceries. We weren't getting together in-person for, basically, any reason. Everything went virtual, including weddings, birthday parties, and the like, and that meant a lot of folks weren't actually going to the doctor. But tell me, what did that actually mean in terms of cancer care?

Lauren Woodrow (01:55):
Health systems all but shut down their cancer screening services. They were worried about exposing patients to COVID. They were worried about exposing their own staff, and they had to see fewer patients because of new social distancing, cleaning protocols, things we hadn't had to do in the past. Many clinical leaders had to make real trade-offs about staffing. They had to redeploy resources to fight the COVID-19 surge, which contributed to millions of patients missing their cancer screenings.

Rae Woods (02:26):
And that caused kind of its own set of fears, not just about what the COVID pandemic would mean for healthcare, but what these missed screenings would mean for the state of everyone's health.

Lauren Woodrow (02:39):
I mean, there was. And there still is a lot of concern that missed screenings would lead to delayed diagnoses, which would lead to more patients being diagnosed with late stage cancers, which would ultimately lead to more cancer deaths.

Rae Woods (02:55):
I don't want to minimize the very human impact that you just shared, Lauren, but we are in the business of studying healthcare. This is a healthcare business podcast. What kinds of larger consequences could the industry see here?

Ashley Riley (03:10):
I'm not sure honestly how much most healthcare leaders were thinking beyond that human impact, really to those business implications, but I think two big ones stood out to me. One being changes to treatment patterns, and then the second being higher costs. So advanced cancers typically require more complex and more extensive treatment than early stage cancers, which can lead to increased cancer costs, which probably isn't super surprising. So for example, one analysis that we looked at found that Medicare spends almost $80,000 more for a stage IV colorectal cancer patient, compared to a stage I colorectal cancer patient, right?

Ashley Riley (03:44):
So this is bad news for payers, it's bad news for patients, and even providers who are participating in value-based payment models, right? So pretty much bad news across the board. This could also mean, though, that certain stakeholders are going to have to make more investments in things like more subspecialized physicians, for example, to manage those additionally complex patients and treatments. More and more support services and support staff, maybe, to manage the additional side effects that are associated with the more complex and extensive treatments, or even just infrastructure necessary to provide those more complex treatments.

Rae Woods (04:17):
When I have conversations with health leaders, they bring up these exact implications. You're right that they weren't doing it in, necessarily, let's say May of 2020, but as time has gone on, they're thinking more and more about these larger business implications. And by the way, I'm not talking to oncology leaders like the two of you are. I'm talking about any C-suite leader in the payer landscape, provider, life sciences. They will bring this up. And they brought it up because at the time, at the start of the pandemic, we had this hypothesis about how the missed cancer screenings would affect the whole industry. Two and a half years later, was our hypothesis actually correct?

Lauren Woodrow (04:56):
Yes and no, so let me break that down. We predicted delayed diagnoses and we have seen data showing that there were fewer new cancer diagnoses during the peak of the pandemic than expected, so meaning there definitely was a delay in some patients getting diagnosed. I saw a study that between March and May of 2020, so peak toilet paper shortage, there was a 36% decline in monthly average of new breast cancer diagnoses in the US.

Rae Woods (05:29):
I don't want to be crass here, but did those delays actually, ultimately impact mortality?

Lauren Woodrow (05:34):
Yeah. I want to be careful with my words here because, obviously, cancer is incredibly scary and painful diagnosis, but in most cases, cancer is a long battle, meaning that there is sometimes a long time between diagnosis and death. I say that because even though it's been more than two years, we're still making predictions. The National Cancer Institute predicts that all those missed screenings will lead to 2,500 additional breast cancer deaths and 5,000 additional colorectal cancer deaths in the US. But that's still a hypothesis, and those predictions are over the next decade.

Rae Woods (06:15):
So you can't actually give me a definitive answer.

Lauren Woodrow (06:17):
I can. It's still too early to say whether missed screenings and delayed diagnoses have actually resulted in an increase in the number of cancer deaths.

Rae Woods (06:27):
What about late stage cancer diagnosis? That's another big concern that I've heard.

Ashley Riley (06:32):
Yeah. I think that's, honestly, the one I've heard most about. I've been talking to cancer program leaders. We can't say for sure with the impact on late stage cancer diagnoses has been either, but we do have a little bit more to go off here. So anecdotally, we've heard from several providers that they've started to see more advanced stage cancer diagnoses among their individual patient cohorts. More recently, we've also seen a few quantitative data points to support this. So for example, data from a sample of 400 oncologists across the US showed that there was a 1% to 2% increase in patients diagnosed with metastatic or advanced breast, lungs, cervical, and colorectal cancers in 2020 compared to pre-pandemic. But on the flip side, in that same study, they found that patients diagnosed with metastatic prostate cancer declined by 1% during 2020, so not totally consistent across the board. Another study from 21st Century Oncology, and they have 300 locations across the US, so pretty big practice network, they showed a 50% increase in breast cancer patients that were diagnosed with advanced cancer during the peak of the pandemic, compared to pre-pandemic.

Rae Woods (07:33):
Wait a minute, wait a minute, wait a minute. 50% increase and 1% to 2% increase are not even remotely close to each other.

Ashley Riley (07:41):
Yeah. It is all over the board, right? And the third one I saw was someplace in the middle around 16 to 20, or something like that. So the estimates are really all over the place, which honestly gives me some concerns about the reliability of the data, right, and how much stock we should actually put in it right now. So not only is it all over the place, these data points aren't nationally representative, and it's data from a relatively short time period, right? So they're not long term studies, which tend to be the gold standards within cancer. So like Lauren, I can't give a definitive answer, but I know I'm not ready to say, for sure, that missed screenings have caused an uptick in late stage cancer diagnoses overall. I think we really need to see more data, and I'm looking at you, healthcare leaders, to collect and publish that data.

Rae Woods (08:25):
I am not surprised that as researchers, you have come to this conversation with a lot of data to back up our hypotheses, and the fact that we're still not ready to put a line in the sand about what this means. But I have to believe that our listeners are probably thinking about individual stories that they've heard, whether it's from their organization, or from their friends, or from their family that say that these missed screenings have had a real impact on people.

Ashley Riley (08:53):
Yeah. We've definitely heard a lot of those stories as well, and they are heartbreaking for sure. And it's one of the reasons that oncology leaders have spent their careers pushing for more cancer screenings and more efforts to reduce disparities in screening as well, even before the pandemic. We know that screening can save lives, so it is really critical, still. Even though if we don't know the true impact of the missed screenings, it's still important to get patients back in to receive their recommended screenings, right? That should be a top priority for all oncology stakeholders.

Rae Woods (09:21):
So at this point, we've talked about the past. We talked about the millions of missed cancer screenings that happened in the beginning of the pandemic. We've also talked about the fact that the future is still relatively unknown. We're still making hypotheses, we're still putting out predictions. Now, I want to focus on the present. Have cancer screenings rebounded from that really dramatic drop in the peak of the pandemic, or is there still concern about actually getting those patients back?

Ashley Riley (09:49):
Yeah, so we've done a good job in that we are nowhere near the kind of dip that we saw in the spring of 2020, in terms of the number of screenings. But when we look at the data, and we actually had our internal data team at Advisory Board run a Medicare claims data analysis for us for mammograms and colonoscopy volumes ... Keep an eye out for a blog about this data soon. Couldn't help during shameless plug. But in that analysis, we saw that screening volumes are still lower than they were in 2019 before the pandemic, in the 2021 data that we looked at.

Rae Woods (10:18):
Wait, we're not back to 2019 levels, but shouldn't they be higher than 2019 levels, right, if nine-plus-million people missed their screenings, wouldn't we expect screening volumes to go up before maybe leveling off somewhere?

Ashley Riley (10:31):
Yeah, that's exactly right. At a minimum, we'd expect them to be at the same level as 2019, but we actually should be expecting them to reach higher levels, at least for a short period of time, to account for that backlog of missed greetings in the peak of the pandemic.

Rae Woods (11:29):
Let me actually push back on myself, maybe, a little bit, if you'll allow me. The baseline that we're working with is 2019, right? Pre-pandemic levels. I hear that we're not back at that baseline and that there maybe should have been an increase before leveling off, but I wonder if 2019 is the right baseline at all, right? Could this be an appropriate course correction? I hear a lot about overdiagnosis being a problem in cancer. Is 2019 even the right baseline for us to operate on?

Ashley Riley (12:17):
Yeah, so just for our listeners, overdiagnosis is basically when you find cancers that would never have progressed to the point where they would cause symptoms or premature death. And we honestly don't know if 2019 is the right baseline for us to be using as a comparison against, right? Because frankly, we don't know how many patients screened in 2019 were overdiagnosed and historically, we haven't had good data on this. Although, I did see a really interesting new study, that was published back in April, that said that one in seven breast cancer cases were overdiagnosed, so starting to see some new data. Prior to that, it was kind of all over the place, honestly, in terms of what the actual impact of overdiagnosis was, or the prevalence of it.

Ashley Riley (12:54):
But if we go based on that breast cancer study, it could mean that more than 10% of patients who missed screenings during the peak of the pandemic might have been overdiagnosed anyway, so no amount of delay in their diagnosis would result in late stage cancer or an increased risk of death. And in fact, not getting diagnosed actually could have prevented them from getting unnecessary treatment, which we would call overtreatment, that would've potentially decreased their quality of life and, of course, generated unnecessary healthcare costs to both the patients and the broader healthcare system.

Rae Woods (13:23):
Help me square this overdiagnosis kind of question mark that we have. Because on the one hand we see volumes lower than they probably should be, right, especially if we're encountering the backlog. But there are also open questions, at least at a national level, about how we deal with cancer screenings and the potential problem of overdiagnosis. I'm feeling this kind of push-pull. Where do you want our listeners to land?

Ashley Riley (13:47):
So if missed screenings and delayed diagnosis result in less of an increase in late stage cancers or less fewer deaths than predicted, that could corroborate those new study findings, that overdiagnosis is a problem, and really help us to further quantify how much of a problem it is.

Rae Woods (14:01):
Right.

Ashley Riley (14:02):
And then that could ultimately mean that maybe we should be aiming for lower screening rates to avoid overdiagnosis. But I want to underscore that this isn't for you, or me, or individual providers even to decide.

Rae Woods (14:12):
Right.

Ashley Riley (14:13):
This is really something that we need to look at as a country and kind of codify through revisions to our national cancer screening guidelines. And until this happens, we do still need to focus on getting patients back in for screening as soon as possible, even though there is that possibility of overdiagnosis.

Rae Woods (14:27):
And why aren't they coming back for screening? Is it still fear? Are they still afraid of, I don't know, COVID?

Ashley Riley (14:34):
So for some people there might be that lingering hesitancy to return to healthcare facilities for fear of getting COVID. But honestly, people are traveling again. They're having weddings, they're going to the movie theaters again.

Rae Woods (14:45):
That's right.

Ashley Riley (14:45):
So they're not that afraid, right? I think it's unlikely that fear is the sole reason that screening rates haven't recovered. Another piece of it, though, is that having had screenings shut down, even for that short period of time during the peak of their pandemic, may have inadvertently messaged to patients that screenings are nonessential, so patients aren't prioritizing them. And we already had enough trouble convincing patients that screenings were important before the pandemic.

Rae Woods (15:09):
That's right.

Ashley Riley (15:10):
The other kind of factors in why we aren't seeing screening rates rebound could be, honestly, just the age old challenges we've had getting people in for screening, right? So not just helping them to see it as a priority, but also things like barriers to access, or lack of awareness of screening recommendations, and there are lots of conflicting recommendations out there. Fear of getting a cancer diagnosis, which is pretty scary. Distrust of providers, cost concerns, and just general lack of convenience, right? So the impact of these challenges, they haven't gone away. They're just amplified right now because there are just a larger number of people that are overdue for screenings than there normally are. And this also raises capacity constraints for providers in terms of getting patients back in, right? So some patients might be trying to reschedule their missed screenings, but unable to get an appointment for six months due to the backlog that providers are working through.

Rae Woods (15:59):
That's a lot of challenges to overcome. And like you said, some of these are longstanding issues that have only gotten worse. How do you recommend our listeners actually get people to come back for their cancer screenings?

Ashley Riley (16:12):
So honestly, oncology leaders have always had to be pretty creative to get people to come to their screenings. They're also going to have to get extra scrappy and think even further outside the box. A couple cool things I've seen, one is at-home screening tests. And this is not a new idea, but I've seen a lot of recent articles kind of proposing that this might be the answer, kind of ramping up on these, specifically for colorectal cancer. But basically, it makes it so patients can do screening at their own homes and just mail it in. Makes it, obviously, much easier, less uncomfortable than a colonoscopy for patients. Another really cool innovation that I've seen in the screening space is the new liquid biopsy screening tests. So they've recently become commercially available and we've seen, for example, Providence Health System. They've become the first health system to announce a partnership with a biotech company called GRAIL to integrate their multi-cancer screening tests into the clinical setting.

Rae Woods (17:02):
Oh, wow.

Ashley Riley (17:03):
Yeah, it's pretty cool. The test allows patients to be screened for more than 50 cancers, where you can only screen for four to six cancers now. So that includes many cancers that we could never screen for before anyway, and it's just with a small blood sample. There are lots of things that remove some of those barriers to entry, to screening, that we're really encouraging providers to investigate and think about implementing.

Rae Woods (17:26):
I'm going to resist the urge to make a Theranos joke when you said just a small blood sample.

Ashley Riley (17:32):
Yep!

Rae Woods (17:33):
We've been talking a lot about oncology leaders. You just mentioned a couple of providers, but my guess is that missed cancer screenings aren't just a provider problem. Am I right?

Lauren Woodrow (17:45):
You're definitely right. Missed screenings are going to have implications for all healthcare stakeholders. So for example, diagnostic companies will almost certainly see increased demand for their services.

Rae Woods (17:58):
Like the ones that Ashley just mentioned.

Lauren Woodrow (18:00):
Right, to work through that screening backlog. And if missed screenings result in more advanced diagnoses and deaths, pharmaceutical, medical technology companies, they may see more demand for certain treatment shifts, but it's difficult to predict how much this would affect their portfolios and finances.

Rae Woods (18:17):
Right.

Ashley Riley (18:18):
On the other side, if we think about health plans, if missed greetings actually result in more advanced diagnoses, health plans are likely going to see an increase in cancer costs in the near term. It's also possible, though, that health plans could see a decrease in costs if the missed screenings reduces overdiagnosis, like we talked about earlier, and subsequently, costly overtreatment.

Lauren Woodrow (18:36):
Right, and digital health companies can play a central role in assessing the true impact of missed screenings. They can create tools to collect, analyze, aggregate that data that we've been asking for on diagnosis rates and stage treatment patterns, and patient outcomes. And again, if missed screens result in more advanced diagnoses, then those digital health platforms, that support treatment planning and care coordination will be even more critical to help ensure effective and cost-efficient management of patients with more complex care needs.

Ashley Riley (19:09):
And I've said this before, so I don't want to sound like a broken record, but of course, all stakeholders have a role to play in getting patients back in for screenings. That is everyone's responsibility, not just providers.

Rae Woods (19:19):
I'm reflecting on all of the things that the both of you just said, and a lot of the impacts you mentioned are, frankly, still based in the unknown. These hypotheses, these predictions that we're making about what all those missed screenings are going to mean for the business of healthcare. So as researchers, what are you watching for next that might tell us the way the dominoes are going to fall?

Lauren Woodrow (19:42):
Right. We're looking and watching so many things. Honestly, we have more questions than we have answers at this point, so a couple of those questions. When will we have collected enough data to understand the true downstream impact of missed screenings during the pandemic? How did the number of missed cancer screenings and, thus, the potential downstream impact on advanced cancer and deaths vary by patient populations? So by cancer type, by demographics, or by the severity of the pandemic in different communities. How many patients' diagnoses were delayed long enough to have an impact on whether they were diagnosed with late stage cancer instead of early stage cancer? For example, I saw a study of colorectal cancer found screening needs to be delayed at least seven months, while another found that it needs to be at least 16 months to actually have an impact on whether the cancer was advanced.

Ashley Riley (20:34):
One of the questions that I have is how will the increasing number of treatment options for late stage cancers affect how much of an impact more late stage diagnoses will actually have on mortality, or treatment patterns and costs? One of the other questions that I'm thinking about is how will the long-term health effects of having COVID-19, which we are still figuring out, impact mortality for patients?

Rae Woods (20:54):
Well Ashley, Lauren, when it comes to the state of oncology, what is the one thing that you want our listeners to take away?

Ashley Riley (21:01):
So I think the questions that Lauren mentioned, and others like them, are going to need to be answered before we can actually, confidently predict the full impact of missed screenings during the pandemic on cancer care and on patient outcomes. And until then, unfortunately, it's going to be pretty difficult for oncology leaders to effectively plan for the future, so it's going to be critical that they're regularly iterating on their plans as we learn new information about the impact of missed cancer screenings during the pandemic, we're also going to need them to really do their part, to collect and share the necessary data to answer these outstanding questions as quickly as possible.

Lauren Woodrow (21:33):
And you've heard it once, I'm going to say it again. You need to get patients back in for screening. That is the highest priority. And to do that, it's going to be critical for all oncology stakeholders to work together and do their part to collect and share the necessary data to answer these questions as quickly as possible.

Rae Woods (21:53):
Well Lauren, Ashley, thanks for coming on Radio Advisory.

Lauren Woodrow (21:58):
Thanks for having us, Rae.

Ashley Riley (21:59):
Thanks for having us. Hopefully we did you proud as the first oncology folks on the podcast.

Lauren Woodrow (22:05):
Yeah. Two years in the making.

Rae Woods (22:07):
Proud and only moderately afraid about the future, which I'll take as a win. When it comes to the impact that COVID has had on cancer and, frankly, on our health at large, I know it can be frustrating that we still have more questions than answers. But that's exactly why Advisory Board exists, because we have a team that's going to be going through every single one of those questions that we still have, and trying to understand how it impacts all healthcare stakeholders. Because remember, as always, we're here to help.