Long term trends at a comprehensive cancer center during the COVID‐19 pandemic

Abstract Background As the ongoing public health crisis from Coronavirus Disease 2019 (COVID‐19) pandemic puts strains on current models of cancer care, many health care centers had to adapt to minimize the risk of exposure and infection. The effects of the COVID‐19 pandemic in a comprehensive cancer center were determined. Aims To measure the impact of the COVID‐19 pandemic on care delivery at a comprehensive cancer center. Methods The number of on‐site and telehealth visits (TH) were obtained from scheduling software. Multiple factors including total visits, telehealth visits, screenings for cancer diagnosis, and cancer treatments were tracked from 2 years before the pandemic onset through 2022. The length of stay (LOS) and Case Mix Index (CMI) were calculated using hospital database. Results In the third quarter of FY 2020, telehealth visits (TH) represented a fifth of total patient encounters. Cancer treatments, such as chemotherapy, radiation therapy, and surgery, decreased during the pandemic with number of surgeries being most affected (23% decrease in 2020 compared to the previous fiscal year). The average length of stay (LOS) was also longer with less discharges per given time during the pandemic. The increased LOS was related to increased severity of patient illnesses since CMI was higher. Screening mammograms decreased to a nadir of 58% in 2021 as compared to those screened in pre‐pandemic fiscal years. Conclusion The COVID‐19 pandemic impacted many aspects of care, such as treatment and screenings. Many of these factors had to be postponed due to the fear of acquiring COVID‐19 and access to care. The findings presented implicate that the delays and changes in cancer care during the pandemic resulted in less screening and treatment of more advanced disease.


| INTRODUCTION
In late 2019, China had reported rapidly emerging clusters of pneumonia cases caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), prompting the World Health Organization to declare Coronavirus disease (COVID-19) a global pandemic. 1 Before the distribution of COVID-19 vaccinations became commonplace, great effort and focus was placed on preventing the spread of infection, especially in the context of treating cancer patients. The Center of Disease Control issued mandates urging mask wearing and the practice of social distancing to deter the spread of infection. Likewise, the practice of telehealth, defined as the interactions among patients and providers through telephone, e-mail, video chats, and the Internet, became an increasingly popular route of communication. 2 Many patients avoided hospitals and healthcare settings where many cases were documented, thus risking delayed detection of cancer diagnoses and treatment. This general avoidance of healthcare ultimately places patients at a greater risk for receiving an overall poorer prognosis due to the likeliness of them presenting with a more advanced cancer stage. 3 Even when the severity of the pandemic lessened did the utilization of cancer care still lag behind pre-pandemic states, and the lasting impact of cancer progression, morbidity, and mortality remains unclear. 4 While the associated risks stemming from a worldwide pandemic are still being evaluated, we sought to further elucidate how the COVID-19 pandemic affected cancer screening and treatment at a comprehensive cancer center in southeast Michigan.

| MATERIALS AND METHODS
During the COVID-19 pandemic, the total visits and telehealth visits (TH) in a comprehensive cancer center clinic were measured. A visit was a TH if video conferencing or audio call were used to complete and document a patient interaction. The number of on-site and telehealth visits were obtained using the scheduling software. The number of radiology visits, discharges, screening mammograms, surgical cases, chemotherapy, and radiation treatments during this timeframe were also measured.
The length of stay (LOS) was calculated by total hospital days divided by the number of discharges for the time period. The Case Mix Index (CMI) is a measure to determine the complexity and severity of patient illnesses that is weighted for each type of discharge. July-September). The primary outcome measured in this study is the impact of the COVID-19 pandemic on healthcare volumes with a secondary outcome measured as the effect of the pandemic on the number of breast cancer screenings performed.

| RESULTS
In the beginning months of the pandemic, cases and deaths from COVID-19 began to skyrocket, prompting the Karmanos Cancer Center to allow only essential visits, such as cancer treatments and diagnosis. 6 Many other visits, such as those for cancer surveillance, had to be delayed or converted to telehealth to reduce the risk of viral trans-  (Table 1). In FY 2021 and FY 2022, the total number of visits and telehealth visits remained steady ( Table 1).
The pandemic effects on cancer treatments were compared to pre-pandemic levels.

| DISCUSSION
With the COVID-19 pandemic came many concerns regarding its impact on patients with cancer. This concern stems from the fact that many cancer patients delayed consultations for initial diagnosis and treatment, perhaps due to reluctance from many primary care services to make referrals during the height of the pandemic. 7 These findings are reflected in the decrease in the number of new patients during FY 2020 compared to FY 2017-19 at this cancer center (Figure 4). The COVID-19 pandemic also evoked a substantial amount of fear and anxiety in patients that lead them to delay treatment, which jeopardized adherence to therapy. 8 Based off these findings, it may be inferred that delays in care could lead to worse outcomes in terms of mortality and treatment options, especially in a complex patient population where timing of treatment is of utmost importance.
To balance on-time care with the risk of exposure to COVID-19, many institutions established the use of telehealth medicine, which consisted of nearly one fifth of total clinic visits at the Karmanos Cancer Center at the pandemic onset ( Figure 1). Its main purpose was to provide a feasible alternative to reduce chances for contact and spread of the virus, and its use in the cancer care setting allowed for surveillance and follow-up in this population. 9 At the height of the pandemic in FY 2020-Q3, the surge in telehealth visits as compared to the lowest-recorded total number of visits should be attributed to the fact that many healthcare encounters were not conducted in person due to the risk of infection. The decline in telehealth usage, however, in subsequent years compared to when it was first introduced may be attributed to it not having yet entered a mature phase of integration into cancer care. 10 Even so, the use of telehealth medicine was adopted into an even more integral role in the cancer care journey in many institutions given its many advantages, such as cost savings, decreased travel time, and easy access. 11 This is perhaps why, even if there was an appreciable decline in the percentage of telehealth encounters that made up total clinic visits at the Karmanos Center, many institutions still offered this alternative platform to continue giving much needed healthcare to their patients.
Given the significance of increased mortality associated with cancer and COVID-19 infection and the consequence of delayed cancer diagnosis, screenings for breast cancer malignancies should have theoretically increased, but its exact opposite was observed ( Figure 4).

| CONCLUSION
The COVID-19 pandemic impacted many aspects of care, such as treatment and screenings. Many of these factors had to be postponed due to the fear of acquiring COVID-19 and access to care. The findings presented implicate that the delays and changes in cancer care during the pandemic resulted in less screening and treatment of more advanced disease.

AUTHOR CONTRIBUTIONS
All authors had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analy-