Yuri Fesko, MD, a board-certified oncologist, assistant consulting professor in the Department of Medicine at the Duke University School of Medicine, and and Vice President of Medical Affairs and Medical Oncology for Quest Diagnostics.
The COVID-19 pandemic itself was bad enough, but it had a negative effect that few anticipated: more cases of advanced cancer.
That’s because during the pandemic many people couldn’t visit their primary care physicians for so-called elective procedures. As a result, they weren’t routinely screened for breast, prostate, colon, lung, or other deadly cancers; weren’t referred to oncologists because of suspicious findings; and weren’t scheduled for further diagnostic tests.
A new study from researchers at the American Cancer Society, published in the Aug. 24, 2023, issue of Lancet Oncology, tells the sad story: After the initial shutdowns in March 2020, monthly cancer diagnoses plummeted by 50 percent, from 70,000 to 35,000. But overall in 2020, the risk of being diagnosed with advanced stage 4 cancer—when undiagnosed cancer has spread (metastasized) beyond its original location to distant sites in the body—rose by 26 percent. Stage 4 cancer is far more deadly than stage 1 cancer. For example, the five-year survival rate for stage 1 lung cancer is 56 percent, but for stage 4 lung cancer, it’s 5 percent. That trend of more advanced cancer continues, according to Hannah Hazard-Jenkins, MD, director of the West Virginia University Cancer Institute.
“In the breast cancer world, last year , we had a profound amount of advanced disease—numbers of advanced disease I haven’t seen in 15 years,” she told STAT magazine.
Four cancers account for 50 percent of all new diagnoses in the United States: prostate (15 percent), breast (15 percent), lung (12 percent), and colorectal (8 percent). Here are important ways to catch those cancers early.
It’s difficult for a man to know what to do about the early detection of prostate cancer. In most cases, it is a slow-growing disease that is not life-threatening, but it also kills 50,000 men yearly.
The main screening tool is the prostate-specific antigen (PSA) test. But there’s a reason why the U.S. Preventive Task Force (USPSTF)—a widely respected consortium of scientists that evaluates preventive services used to recommend against prostate cancer screening. Now it recommends that men ages 55 to 69 engage in a shared decision-making process with their doctors about the pros and cons of screening.
Research shows that it requires 1,000 men to have a PSA test in order to prevent one death from prostate cancer. But of those 1,000 men, between 150 to 200 will have a worrisome PSA test (a level higher than 4) that will lead to a biopsy of the prostate—an invasive procedure that can cause blood in the urine, infections, and a high rate of hospitalization in the month after the procedure.
Of those biopsied, 30 to 100 will be treated for prostate cancer, and between one-third to one-half of those men will become impotent. Another 20 to 30 percent will become incontinent.
The overdiagnosis, overtreatment, and treatment complications should lead you and your doctor to carefully consider the risks and benefits of PSA testing, says the USPSTF.
The USPSTF also recommends no PSA testing for men 70 and older because the chance of dying from prostate cancer is lower than the chance of dying from another cause.
The problem is, with fewer men receiving PSA tests, there is now an increasing incidence of metastatic prostate cancers, with the rate doubling from 2011 to 2023, according to a new report from the American Cancer Society.
Fortunately, there are several newer types of blood tests (such as the 4kScore, Prostate Health Index and IsoPSA) that are used to augment PSA. A study published in Urology Practice showed that these tests can reduce recommendations for biopsies by 55 percent.
These testes are included in the guidelines from the National Comprehensive Cancer Network (NCCN), an alliance of 33 leading cancer centers. If you have a high PSA, ask your doctor about this test.
The USPSTF recommends every-other-year mammograms for women ages 50 to 74. However, they give the relatively low grade of “C” to starting mammography in women younger than 50, saying it leads to many false positives and unnecessary biopsies, while preventing a relatively small number of deaths. On the other hand, the American Cancer Society says women ages 40 to 44 should have the option to start yearly mammograms, women ages 45 to 54 should get yearly mammograms, and women ages 55 and older can switch to a mammogram every other year.
But there’s one thing that most of the top experts on breast cancer agree on: If a mammogram shows dense breasts—more fibrous tissue and glands than fat, which occurs in nearly half of women over age 40—a women should consider further testing to detect a possible cancer. That’s because dense breasts make it much harder to see cancer on a mammogram. Plus, dense breasts are themselves a risk factor for breast cancer.
The test recommended by most breast imaging experts, a 3D mammogram (digital breast tomosynthesis), produces more visual clarity, reduces the likelihood of a false positive result (leading to an unnecessary biopsy), and better identifies the size and growth of a possible tumor. If you have dense breasts, your future mammograms should be 3D, if available.
You should also talk with your doctor about whether or not you need more tests, including genetic testing, which depends on your level of risk, taking into account risk factors like dense breasts, the BRCA gene, a family history of breast cancer, and obesity after menopause. You can calculate your risk level at https://bcrisktool.cancer.gov.
If you’re at high risk, you should have a yearly breast MRI in addition to your mammogram.
If you have dense breasts and you’re not at high risk, talk to your health care professional about screening tests in addition to a 3D mammogram, like a breast MRI or ultrasound. If you’ve had breast cancer, you should have a yearly mammogram and breast MRI—especially if you have dense breasts or were diagnosed before age 50.
About 80 to 90 percent of people who develop lung cancer are smokers or former smokers. The best way to detect their cancer early is with yearly low-dose computed tomography (LDCT) screening. The USPSTF added this screening to their recommendations in 2021. The problem is that only 5 to 6 percent of the people who should be getting LDCT screening are actually getting it. You should definitely get the screening if you meet these criteria:
The earlier lung cancer is detected, the greater the chance of successfully fighting the disease and adding years to your life.
Colorectal cancer—the second-biggest cancer killer in the United States—is being detected more commonly in people under age 50. In fact, people born in 1990 have double the risk of colorectal cancer as people born in 1950. No one knows the reason why, but it’s probably environmental factors like obesity, sedentary lifestyle, or a diet low in fruits and vegetables and high in processed meats.
A study in the Journal of the National Cancer Institute found that people under age 55 are nearly 60 percent more likely to be diagnosed with stage 4 colorectal cancer than older adults. In response, both the American Cancer Society and the USPSTF now recommend that colorectal cancer screenings begin at age 45, which is five years earlier than their previous recommendations.
You can screen for colorectal cancer with a stool-based test, such as a fecal immunochemical test (FIT), or a colonoscopy. If a stool-based test is positive, you need a colonoscopy.
After your first test, you should get a screen once every five to 10 years, depending on your level of risk. Talk to your doctor about your risk level. If you have a higher-than-average level of risk, talk to your doctor about whether you should get a screen every five years. If precancerous polyps are detected and removed during a colonoscopy, you need a screen every five years. You may not need any more testing after you turn 75 or 80.