It’s well known that cancer screenings can help identify cancer early, allowing for earlier treatment and a decreased risk of dying of late-stage disease. However, the COVID-19 pandemic led to a drastic dip in cancer screening and prevention efforts, and the long-term impacts could be quite substantial. But according to Andi Dwyer, program director of the Colorado Cancer Screening Program at CU Anschutz, co-chair of the AONN+ Community Outreach, Prevention, & Early Detection Committee, and vice chair of the National Navigation Roundtable, navigators can play a vital role in reigniting cancer screening efforts in the United States and getting early detection back on track.
“Cancer screening can have an amazing impact, but getting people to do it is sometimes challenging,” she said at the AONN+ Virtual Midyear Conference.
As was the case with many other professions, the pandemic highlighted the vulnerability of navigators as a workforce, she said. As a result of economic issues within hospitals and reduced navigation hours, preventive cancer screenings began to take a back seat. But the pandemic also highlighted the crucial role of navigation in facilitating preventive cancer screenings, and putting forth the necessary resources to sustain it will be vital moving forward, she added.
Importance of Cancer Screening
People with a higher risk for certain cancers include older individuals, people with a family history or personal history of cancer, and people who are exposed to tobacco smoke, certain chemicals, and other cancer-causing agents.
The United States Preventive Services Task Force strongly recommends screening for breast, cervical, colorectal, and lung cancers among people of average risk for these cancers, although other important screening tests to keep in mind at annual wellness exams include those for ovarian, pancreatic, prostate, thyroid, and skin cancers. Importantly, she noted, most of these tests are covered by insurance as part of the Affordable Care Act.
“Education and awareness from the navigation and outreach standpoint can be substantial,” she said. “If we could use these guidelines and recommendations—and if people would hear them—we could dramatically decrease cancer incidence and mortality in our country.”
In large part due to successful cancer screening efforts, cancer death rates in the United States dropped almost 30% between 1999 and 2019. However, the impact of the COVID-19 pandemic on cancer screenings was in no way insignificant. “2020 really did make an impact,” said Ms Dwyer. “But I think there are great data to show that if we get back in the groove, we might be able to make up for some lost time.”
The Role of Patient Navigation in Cancer Screening
Patient navigators play a crucial role in guiding patients through the healthcare system, helping them to overcome barriers and obtain the care they need. Patient navigation in cancer screening has been shown to improve health outcomes and satisfaction, reduce overall healthcare costs, and benefit the most vulnerable populations.
“We see the best uptake of preventive screening work when we see navigators who are really matched with the populations that they’re serving,” she said. “At the cornerstone of that is aptitude for working with people, even if there’s not always a strong healthcare background, but having cultural competence and connectivity with the population is key.”
Navigators help to bridge gaps in care, provide a line of communication between the patient and the provider, and aid in the uptick of cancer prevention and detection, often through staying informed on who is eligible for cancer screening, and keeping patients apprised of that knowledge.
“When we first started our statewide program for colorectal cancer screening almost 15 years ago, primary care docs were questioning the role of the navigator,” she said. “Now, if I tried to take navigation away from those teams, the primary care docs would probably be the first to come after me because the navigators are such a great asset to preventive screening.”
What Happened to Screenings in 2020?
In the wake of COVID-19, elective medical procedures were banned, so nonemergency screening procedures came to a halt. These governmental restrictions led to a decrease in screening rates and referrals, as well as insurance and financial changes (ie, patients losing insurance coverage through their employers). But, as we all know, cancer did not come to a halt.
“If navigators are not integrated into the team, we will not be able to bridge the gap that was presented to us because of the elective procedure ban,” she said.
According to Ned Sharpless, MD, director of the National Cancer Institute, postponing care “was prudent at one time” because of the risks of COVID-19 exposure, but the impact of delayed cancer screening and treatment due to the pandemic could translate to nearly 10,000 excess deaths (from breast and colon cancers alone) over the next decade. However, not everyone diagnosed with cancer will die of it, and estimates for missed or delayed cancer diagnoses due to reductions in cancer screening and monitoring are much higher than estimates for excess deaths alone.
Further exacerbating the problem is “pandemic behaviors,” not only limited to putting off healthcare, but also increased drinking and smoking (often due to stress and idle time), and sedentary behaviors.
But according to Otis Brawley, MD, a Johns Hopkins University professor and former chief medical officer of the American Cancer Society, there is some good news: a short-term delay may not hurt mortality too much if screening resumes quickly. “But the time is now,” Ms Dwyer emphasized. “We have to strike while the iron is hot.”
Patient Navigation Needed More Than Ever
According to Ms Dwyer, navigators can use a proactive approach, encouraging patients to return to screening by providing direct communication and guidance as well as continued follow-up.
“If we lost people before the pandemic in terms of preventive care, navigators can find out where they are now, also reminding them that they are a trusted and reliable extension of the healthcare team,” she said.
During the pandemic, many navigators became accustomed to providing care through telehealth and were often well informed of their patients’ fears and concerns (when many were afraid to leave the house). Because of this, navigators are in a unique position to open up discussions with patients about fears of exposure to COVID-19 versus getting important preventive screenings. However, it’s important to note that certain precautions should now be taken when conducting cancer screenings: patients should be prescreened for COVID-related symptoms before cancer screening appointments, scheduling of appointments should allow for physical distancing between patients, face coverings should be worn when appropriate, etc.
According to Ms Dwyer, all of these new precautionary measures, when combined with barriers, misinformation, and fear, can be overwhelming for both patients and navigators. But, she added, patient navigation is a must, especially as Americans attempt to return to some semblance of normalcy. Navigation provides a safety net for the most vulnerable populations and is a proven method to increase cancer screening rates, she said. Navigators are some of the most vital providers not only when it comes to patients overcoming the barriers to screening but also ensuring that they adhere to regular screenings. And according to Ms Dwyer, aligning national partnerships with state and local efforts will be crucial to sustaining navigation and community health work after the pandemic.
“Although I was really concerned about what was happening with our workforce at the beginning of the pandemic, I think people heard our battle cry about the necessity of navigation, and we’re starting to see a call for community health work and navigation in regard to vaccine uptake, vaccine hesitancy, and health literacy,” she said. “Getting preventive screening rates back up is going to be harder than ever, but I think we’re up to it, and I think we can definitely do it.”