In Austria, from the first COVID-19 outbreak in February 2020 until now, the Austrian healthcare system had to face considerable difficulties. During the first lockdown from March 16th to April 30st 2020, social distancing measures were applied not only for the private and commercial sector, but also for the medical services. Routine checkups and gynecological screening examinations such as the annual PAP smear and the biennial mammography have been mostly postponed. In this period, a strong decline in newly diagnosed gynaecological and breast cancers was observed in Austria, as previously reported by our study group . The aim of the present work was to follow up this phenomenon throughout the year 2020 from a tertiary centre’s perspective.
In the current study, we found a strong decline of newly diagnosed gynecological and breast cancer cases in 2020 as compared to 2019. This decrease was mainly due to a lower cancer detection rate at our department during the two lockdown periods (March 16th, 2020 – April 30st, 2020 and November 3rd, 2020 – December 31st, 2020) as compared to the same period in 2019.
In order to guarantee adequate patient care, considerable efforts have been made during the first lockdown to facilitate gynecological screening examinations with a minimized risk of a hospital acquired infection: COVID-19 symptom screening by questionnaires, temperature measurements, mandatory facemasks and optimized patients waiting time. By 14th of June, these actions were expanded by COVID-19 screening of every admitted patient. Therefore, although rising infection rates were experienced during fall and winter, screening examinations and outpatient care were guaranteed. However, as our study shows, even with optimized pandemic management, a strong decline in newly diagnosed cancers was still observed throughout the year 2020 as compared to 2019.
In the group of breast cancer, a strong decline of cancer detection rate was observed during both lockdown periods. In between the lockdowns, cases of newly diagnosed breast cancer increased and even reached a higher number as compared to 2019. We suppose that patients who missed screening examinations during the first lockdown, tended to catch up their appointment as soon as the pandemic situation looked stabilized. Significantly more patients with tumor specific symptoms presented directly at our department or were referred by their gynecologist due to these symptoms. This observation indicates that tumor specific symptoms forced patients to consult a doctor, while non-symptomatic cancer cases in patients who missed the routine mammography remained undetected. The observed tumor stage shift towards higher stage at diagnosis might also be explained by postponed mammography during the first lockdown. However, further studies on larger population are needed to prove this assumption. Moreover, there was an increasing trend towards neoadjuvant chemotherapy and a reduction in primary surgical cases during the lockdown periods. This might be explained by advanced tumor stage and the attempt to increase the overall hospitals’ bed capacity.
A decrease of 45% of newly diagnosed gynecological cancers was observed as compared to 2019. In particular, non-symptomatic tumors such as cervical cancer was underdetected in 2020, as annual PAP test was postponed during the first lockdown period. In the same time, tumor patients with tumor-specific symptoms such as postmenopausal bleeding or abdominal pain, less frequently consulted their specialist and presented themselves directly at our department.
Our observations are in line with several studies on the impact of the COVID-19 pandemic on cancer detection rate and management of oncological diseases. In accordance with our results, a strong decline in newly diagnosed cancers was observed in breast, colorectal, lung and prostate cancer in the USA and across Europe [4, 5, 6, 7]. Recommendations on cancer management during the pandemic include the implementation of telemedicine for the outpatient treatment of cancer survivors to minimize face-to-face appointments . Oncological surgery, chemotherapy and radiotherapy should be continued based on priorities, while surgeries due to benign diseases should be postponed .
Treatment delays in potentially curable disease could lead to inferior outcomes and have impact on the overall survival of our patients, with the risk of missing the optimal treatment window. As the COVID-19 pandemic will be a challenge for some time to come, new strategies in patient care are needed to minimize the risk of infection. New strategies may include telemedicine or self-sampling HPV test, which detects viral nucleic acid rather than morphological changes and thus does not rely on healthcare practitioners visualizing the cervix , and thereby provide early diagnosis and improved treatment options for our patients. Most importantly, awareness must be raised for the importance of screening examinations to avoid any further shift in tumor stages at the time of diagnosis.
The major limitations of the current study are its relatively small sample size of only 889 patients and its single center observational character. Despite these limitations, we were able to demonstrate that the COVID-19 pandemic led to a strong decline in the detection rate of newly diagnosed gynecological and breast cancers, which is in accordance with the findings of other subspecialities.