Preventive Screenings in Lung Cancer, Sleep Medicine Decrease During COVID-19

Along with a wide range of elective medical services affected by the coronavirus 2019 (COVID-19) crisis, pulmonary screenings decreased substantially, especially in the early months of the pandemic. In a recent survey of sleep medicine providers from 297 centers across the United States, for example, 93.6% of respondents indicated that all or nearly all in-laboratory sleep testing had initially ceased because of COVID-19.¹

Lung Cancer Screenings During COVID-19

A drop in the number of screenings for lung cancer has also been reported, as well as for other types of cancer. This reduction could lead to increased mortality in patients with lung cancer, as low-dose computed tomographic (CT) screening has been found to reduce mortality by at least 20% among high-risk patients.^2-3 Results from a modeling study published in August 2020 in the Lancet Oncology estimated that lung cancer deaths could increase between 4.8% and 5.3% compared with pre-pandemic rates.⁴

In research described in the Journal of the American College of Surgeons published in December 2020, Robert M. Van Haren, MD, MsPH, assistant professor of surgery in the division of thoracic surgery at the University of Cincinnati Medical Center in Ohio and colleagues examined COVID-19-related screening differences in their low-dose CT program.² They suspended services on March 13, 2020, resulting in 818 canceled screening visits.

Van Haren et al compared the monthly mean number of low-dose CT screenings that occurred during a baseline period before COVID-19 (January 2017 to February 2020) to those that occurred during the first several months of the pandemic (March 2020 to July 2020). The results showed a significant reduction in both total monthly mean (±SD) screenings (146±31 vs 39±40; P <.01) and new patient monthly screenings (56±14 vs 15±17; P <.01) between baseline and the COVID-19 period.² Although screenings gradually resumed beginning May 5, 2020, with a full re-opening on June 1, 2020, new patient monthly screenings remained low, and there was a significant increase in “no-shows” compared with baseline (from 15% to 40%; P <.04).²

“We believe that our new patient screenings remain low due in part to decreased referrals from primary care physicians, which is likely related to patients in general being less likely to visit primary care physicians due to concerns regarding COVID-19,” Dr Van Haren stated in an interview. “The higher no-show rate probably reflects patient fears about coming into the hospital.”

The patients who were most likely to no-show for their screening appointment were women, Black patients, current smokers, and patients of younger ages. Dr Van Haren et al noted the potential risk for increasing existing disparities in lung cancer survival among Black patients, who, historically have had higher mortality and lower rates of curative lung resection.⁵ This issue warrants additional investigation.  

The findings further revealed that once services resumed, 29% of patients screened once services had nodules suspicious for malignancy, compared with 8% of patients at baseline (P <.01), and the number of referrals to thoracic surgery or interventional pulmonology increased from 21.2% at baseline to 44.0% in the COVID-19 period (P =.04) among tumor board patients.²

“Our results demonstrate the importance of continuing cancer screening operations, such as lung cancer screening programs, during this pandemic,” said Dr Van Haren. “We have made operational changes to ensure that screening is safe at our institution, and we’ve made an emphasis to educate patients that lung cancer screening can still be performed safely.”

In addition, the pandemic has illuminated the need to refine selection criteria for low-dose CT screening and to improve risk stratification of pulmonary nodules identified on screening. “These improvements could help prioritize which LDCTs are performed, which would help reduce risk of exposure during current and future pandemics,” wrote Dr Van Haren et al.²

Sleep Medicine and Elective Pulmonary Services

In November 2020, a task force that included volunteers from the Association of Pulmonary, Critical Care, and Sleep Division Directors and the American Thoracic Society published a report offering guidance on resuming elective services in various pulmonary and sleep medicine settings when appropriate. The recommendations were created by discussion and consensus among all members of the task force.⁶

In line with guidance from the Centers for Disease Control and the Centers for Medicare and Medicaid Services, the panel recommended that elective services may resume only when there is a 14-day downward trajectory in the community new case rate. They described alternate calculation methods that can be used in the context of large day-to-day variation in case rates.⁶

Facilities should also have a mitigation strategy consisting of “patient prioritization, screening, diagnostic testing, physical distancing, infection control, and follow-up surveillance,” according to the paper.⁶ The authors noted that each institution’s mitigation strategies will vary based on community prevalence of COVID-19, and they recommended frequent reassessment and revision of protocols as needed.

“The goals are to protect patients and staff from exposure to the virus, account for limitations in staff, equipment, and space that are essential for the care of patients with COVID-19, and provide access to care for patients with acute and chronic conditions,” they wrote.⁶

Disclosure: Dr Van Haren is a paid consultant to Intuitive Surgical, Inc.

References

1. Johnson KG, Sullivan SS, Nti A, Rastegar V, Gurubhagavatula I. The impact of the COVID-19 pandemic on sleep medicine practices. J Clin Sleep Med. 2021;17(1):79-87. doi:10.5664/jcsm.8830

2. Van Haren RM, Delman AM, Turner KM, et al. Impact of the COVID-19 pandemic on lung cancer screening program and subsequent lung cancer. J Am Coll Surg. Published online December 17, 2020. doi:10.1016/j.jamcollsurg.2020.12.00

3. de Koning HJ, van der Aalst CM, de Jong PA, et al. Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020;382(6):503-513. doi:10.1056/NEJMoa1911793

4. Maringe C, Spicer J, Morris M, et al. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study. Lancet Oncol. 2020;21(8):1023-1034. doi:10.1016/S1470-2045(20)30388-0

5. Ezer N, Mhango G, Bagiella E, Goodman E, Flores R, Wisnivesky JP. Racial disparities in resection of early stage non-small cell lung cancer: variability among surgeons. Med Care. 2020;58(4):392-398. doi:10.1097/MLR.0000000000001280

6. Wilson KC, Kaminsky DA, Michaud G, et al. Restoring pulmonary and sleep services as the COVID-19 pandemic lessens. From an Association of Pulmonary, Critical Care, and Sleep Division Directors and American Thoracic Society-coordinated task force. Ann Am Thorac Soc. 2020;17(11):1343-1351. doi:10.1513/AnnalsATS.202005-514ST