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France – Faced with the consequences of two complaints a few months later, authorities and health professionals are working to limit the impact of the health crisis on cancer screening and treatment. Three of them take stock of the delays associated with the first hospitalization and detail the strategies put in place to minimize or even make up for any new delays in terms of access to care and in particular for screening tests.
Exams and treatments: strategies for prioritizing them
Studies follow that leave no room for doubt about the impact of diagnostic delays in terms of future mortality (see box at the end of the article). A fatality? Not if we are to believe the Dr Jean-Baptiste Méric, director of public health and assistance at the INCa, says “we have the means to avoid these delays.”
These strategies are currently being developed in France as part of the “Cancer and covid-19” steering group created on 5 May. Led by the National Cancer Institute, it brings together ARS cancer representatives, oncology networks, hospital federations, health insurers, and also brings together study societies and regional cancer screening coordination centers.
“This has enabled recommendations to be established and disseminated to the entire industry, so as to convey good practices and prioritize testing and treatment to those who need it most quickly,” explains Dr. Méric.
Therefore, colonoscopies will be performed as a priority for patients who have had a positive immunoassay. Those who need to take this exam as part of a follow-up can wait a few more days or weeks. While a surgical deprogramming tool has been published, some institutions have nevertheless been authorized to treat cancer patients on an exceptional basis. “There are also delays for interventions that do not address a prognostic problem, such as breast reconstructions or ostomy closures, but” we are in the process of establishing a recovery for these activities after the second birth. », Explains Dr. Méric.
ways was to avoid these delays.
Projections: interruptions but the possibility of recovery
Regarding screening, however, significant delays are observed in France.
According to Dr Méric, there was a significant drop in screenings during the first brief confinement for some regions, up to 90% for colorectal cancer, then an increase in June and almost a return to normal in July, but no further, which means that there are “people who have not returned to treatment. It is important to say that there is no risk, that screening is possible, that we can also do a teleconsultation to find out if we are eligible without traveling. “
It is important to say that there is no risk, that screening is possible.
For its part, the regional center for the coordination of cancer screening of Nouvelle-Aquitaine (CRCDC-NA) made its calculations: “the first confinement caused the cancellation and postponement of 27% of mammograms, or 47,650 examinations fewer and also a decrease of 16%, or 37,311 fewer tests for colorectal cancer screening ”. “The first confinement led to a sudden interruption of activities. Our center has suspended the sending of invitations to screenings * and its second mammogram readings for ten days, time to comply “, specifies the Dr Denis Smith, president of CRCDC-NA.
Note that the other centers have been out of business for a shorter or longer period, depending on the region.
Sending invitations: take into account postal delays
Stopping the sending of invitations also responded to the imperative “not to confront users with paradoxical injunctions, while some radiology practices had also stopped their activities,” adds Dr. Smith.
Epi-flagship, an organization created at the end of 2018 by ANSM and Cnam to carry out pharmaco-epidemiological studies based on information from the National Health Data System (SNDS), recorded a 62% drop in product deliveries. preparation for colonoscopy during the 8 weeks of the first birth and the first week after delivery compared to the same period in 2018 and 2019.
62% decrease in the delivery of colonoscopy prep products during the 8 weeks of first delivery.
The disorganization of the postal services has also contributed to the delays in the delivery of invitations, but also in the return of stool samples for immunological screening tests for colorectal cancer. However, to be legible, samples must be processed within five days of collection.
On another aspect of prevention, the Dr Catherine Nogues, oncogeneticist, head of the cancer prevention and monitoring department at the Paoli-Calmettes Institute of Marseille, indicates for oncogenetic consultations and therefore for the identification of high-risk people, observed from the end of the first birth a return to normal activities, but no rebound effect, which implies that a number of people did not come to consult.
An uneven situation from one center to another
While the entire industry is now able to receive patients, screen, perform necessary care and treatment again, “some operating rooms remain closed when ICU staff have been assigned to Covid services,” reports Dr. Denis Smith. .
“This is not the case with specialized centers for the fight against cancer, which for the most part are not confronted with these staff transfers”, describes Dr. Nogues. However, “the follow-up of people at very high risk of cancer was as delayed as the others during the first crisis.
Most of the services in oncology centers had set aside cancer screening for both breast and colon, in order not to run the risk of putting Covid-19 patients in contact with cancer patients. risk of developing severe forms. Preventive surgeries for breast and ovarian cancer have also been postponed. But the situation lasts and now we see things differently. Specific screening or prevention measures must be resumed.
For their part, the screening coordination centers, in collaboration with their Regional Health Agency (ARS), adapt the sending of the invitations according to the regional health context and the availability of professionals and health facilities in the region, indicates INCa in a question and answer updated on November 9th.
Screening: saute users
During this re-containment, all screening activities were continued, but “we still feel that people aren’t making appointments,” notes Dr. Smith. This is why the health authorities are multiplying the messages. Professional organizations such as the French breast and radiology societies have therefore committed to resume breast cancer screening and diagnosis from 11 May. This November 16, the Ministry of Health, Health Insurance and Public Health France relaunched the media campaign, already broadcast in May, on the theme “Coronavirus, during the epidemic, continues to seek cures” which expressly mentions do not postpone exams prescribed.
We get the feeling once again that people aren’t making appointments.
To keep users coming back, Cnam has also reduced the time that elapses between the first invitations to screenings and the reminders sent to people who have not replied to the first email. It was also already experimenting, prior to the Covid-19 epidemic, strategies to send immunoassay kits directly home, in order to increase the efficiency of organized screening for colorectal cancer, which reaches around 30% of participation.
“Interested people should not hesitate to contact us, to contact the service that follows them or the regional network for the monitoring of genetically predisposed people. Exaggerated fears should not be maintained for a few weeks late on a screening, but if people identified as “high risk” were already late in their follow-up, they can be prioritized. For their part, doctors shouldn’t hesitate to have an additional clinical breast exam, while waiting for their patient to perform MRI and mammography. This also applies to all women waiting for their mammogram appointment. It would be a shame to lose a palpable tumor … “, for his part, points out Dr. Catherine Nogues.
If people identified as “high risk” were already late in follow-up, we can give them priority Dr Catherine Nogues
Consequences on mortality
A recent study conducted in the UK and published in The Lancet Oncology predicts that for four common types of cancer (breast, bowel, lung and esophageal cancer), diagnostic delays due to the Covid-19 pandemic will result in approximately 3,500 preventable cancer deaths, which is equivalent to 60,000 years of life lost, given the relatively young age of many cancer patients [1].
The Canadian and British researchers conducted a meta-analysis on the consequences of delays between diagnosis and initiation of treatment. They collected data from 34 studies published between January 1, 2000 and April 10, 2020 – thus regardless of the covid-19 pandemic – related to 17 indications, and comprising a total of nearly 1.3 million patients.[2]. Their results show that a four-week delay in this time between diagnosis and initiation of treatment has a significant impact in terms of mortality for seven cancers studied (bladder, breast, colon, rectum, lung, cervix). . uterus, head and neck). Thus, for any four-week increase between diagnosis and treatment, the increased risk of mortality will rise to 6-8% before surgery, range from 1 to 28% while awaiting systemic treatment, and between 9 and 23% for radiotherapy.
* for organized screening for breast, colorectal and cervical cancer.
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