Cancer Prevention in a Postpandemic World: A One-Stop-Shop Approach

Abstract

Cancer is currently the second leading cause of death in the U.S. and is expected to claim approximately 600,000 lives in 2021.1American Cancer SocietyCancer facts & figures 2021. American Cancer Society, Atlanta, GA2021https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdfGoogle Scholar In an effort to promote the early detection and prevention of cancer, the U.S. Preventive Services Task Force recommends regular screening for many cancers, including breast, cervical, lung, and colorectal cancers.2U.S. Preventive Services Task Force. A and B recommendations.https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-b-recommendations. Accessed April 2, 2022.Google ScholarThere is considerable concern that a national increase in cancer morbidity and mortality rates will be observed after the novel coronavirus disease 2019 (COVID-19) pandemic. In the late spring of 2020, the National Cancer Institute Director, Norman E. Sharpless, warned that “ignoring life-threatening non–COVID-19 conditions such as cancer for too long may turn one public health crisis into many others.”3Sharpless NE. COVID-19 and cancer.Science. 2020; 368: 1290https://doi.org/10.1126/science.abd3377Crossref PubMed Scopus (195) Google Scholar To that end, a recent systematic review reported that during the pandemic and related stay-at-home orders, cancer screening rates and cancer diagnoses have declined significantly.4Alkatout I Biebl M Momenimovahed Z et al.Has COVID-19 affected cancer screening programs? A systematic review.Front Oncol. 2021; 11675038https://doi.org/10.3389/fonc.2021.675038Crossref Scopus (31) Google Scholar In fact, an analysis of >2.5 million patients found that cancer screening rates for colorectal, breast, and cervical cancer fell between 86% and 94% early in the pandemic.5Epic Health Research NetworkDelayed cancer screenings. Epic Health Research Network, Verona, WIMay 4, 2020https://ehrn.org/articles/delays-in-preventive-cancer-screenings-during-covid-19-pandemic/Google Scholar Although signs of recovery in cancer screening rates have been seen,6Labaki C Bakouny Z Schmidt A et al.Recovery of cancer screening tests and possible associated disparities after the first peak of the COVID-19 pandemic.Cancer Cell. 2021; 39: 1042-1044https://doi.org/10.1016/j.ccell.2021.06.019Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar challenges remain. A recent study found that as of March 2021, breast cancer, colon cancer, and cervical cancer screening remained lower than historical averages.7Mast C Muñoz del Río A Heist T Cancer screenings are still lagging. Epic Health Research Network, Verona, WIJune 9, 2021https://epicresearch.org/articles/cancer-screenings-are-still-laggingGoogle Scholar These disruptions in cancer screening efforts may result in increased late-stage cancer diagnoses and ultimately increased cancer-related deaths, for years to come.4Alkatout I Biebl M Momenimovahed Z et al.Has COVID-19 affected cancer screening programs? A systematic review.Front Oncol. 2021; 11675038https://doi.org/10.3389/fonc.2021.675038Crossref Scopus (31) Google ScholarThere is also concern that cancer inequities will be exacerbated because of the pandemic. The COVID-19 pandemic has cast a spotlight on flaws in the healthcare system that disproportionally impact those that are systematically marginalized.8Risk of severe illness or death from COVID-19. Centers for Disease Control and Prevention.https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/disparities-illness.html. Updated December 10, 2020. Accessed September 22, 2021.Google Scholar Indeed, some emerging disparities in cancer screening rates during the pandemic have already been identified in the literature.6Labaki C Bakouny Z Schmidt A et al.Recovery of cancer screening tests and possible associated disparities after the first peak of the COVID-19 pandemic.Cancer Cell. 2021; 39: 1042-1044https://doi.org/10.1016/j.ccell.2021.06.019Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar,9Amram O Robison J Amiri S Pflugeisen B Roll J Monsivais P. Socioeconomic and racial inequities in breast cancer screening during the COVID-19 pandemic in Washington State.JAMA Netw Open. 2021; 4e2110946https://doi.org/10.1001/jamanetworkopen.2021.10946Crossref Scopus (21) Google Scholar,10Holcombe RF Tom J Morimoto M et al.Effect of COVID-19-related reductions in cancer screening in Native Hawaiians and across urban and rural communities in Hawaii.J Clin Oncol. 2021; 39: 109https://doi.org/10.1200/JCO.2020.39.28_suppl.109Crossref Google ScholarAs the U.S. begins to plan for a postpandemic era, cancer screening must be prioritized with an eye on equity. A return to normal would mean continuing to operate under a flawed system that creates and maintains health inequities. This moment in time presents an opportunity and perhaps an obligation to build a more equitable healthcare system that prioritizes prevention and equity. With regard to cancer, the authors encourage healthcare systems and healthcare professionals to reimagine cancer prevention and control.Toward that end, it is proposed that cancer screening efforts be prioritized and streamlined. Currently, most cancer screening efforts are siloed on the basis of the targeted cancer site. Most patients are required to make multiple appointments and navigate separate healthcare systems to be screened for breast, cervical, colorectal, skin, prostate, and lung cancers. This complex and fragmented model of care is particularly problematic because decades of research suggest that some barriers to cancer screenings include patient time/burden, limited health literacy, and lack of transportation.11Muthukrishnan M Arnold LD James AS. Patients’ self-reported barriers to colon cancer screening in federally qualified health center settings.Prev Med Rep. 2019; 15100896https://doi.org/10.1016/j.pmedr.2019.100896Crossref Scopus (38) Google Scholar, 12Honein-AbouHaidar GN Kastner M Vuong V et al.Systematic review and meta-study synthesis of qualitative studies evaluating facilitators and barriers to participation in colorectal cancer screening.Cancer Epidemiol Biomarkers Prev. 2016; 25: 907-917https://doi.org/10.1158/1055-9965.EPI-15-0990Crossref PubMed Scopus (123) Google Scholar, 13Bruce KH Schwei RJ Park LS Jacobs EA. Barriers and facilitators to preventive cancer screening in Limited English Proficient (LEP) patients: physicians’ perspectives.Commun Med. 2014; 11: 235-247https://doi.org/10.1558/cam.v11i3.24051Crossref Scopus (5) Google ScholarAs it stands, many cancer screening research and programmatic efforts focus on patient education, outreach, and navigation. The authors maintain that patient-centered initiatives are necessary yet insufficient. To substantially and sustainably increase cancer screening uptake, it is essential to also implement system-level change. A one-stop-shop approach to cancer screening can help to eliminate organizational and system-level barriers to cancer screening. The one-stop-shop model of care would streamline all aspects of the cancer screening process, including education/outreach, risk assessment, screening tests, results, and follow-up. In this model of care, members of the healthcare team would reach out to patients due or overdue for cancer screening to conduct a comprehensive cancer risk assessment. A member of the healthcare team would then carefully review the results of the assessment with the patients and provide them with the appropriate cancer screening referrals and education. Patients would then be offered the option to complete all of their recommended cancer screening tests either at home (e.g., fecal immunochemical test [FIT], FIT-DNA) or in a same-day clinic. However, in cases where the patient is referred for a colonoscopy, they will likely need to make an additional appointment. After the screening test(s) are completed, a member of the healthcare team would follow-up with the patients to provide them with the results of their tests and make appropriate follow-up recommendations. Patient navigators and care coordinators would be leveraged to help link patients to follow-up care and coordinate future screenings to ensure that they are screened for each cancer in a timely and appropriate way. A similar model of care has been implemented in Israel and has been proven feasible.14Sella T Boursi B Gat-Charlap A et al.One stop screening for multiple cancers: the experience of an integrated cancer prevention center.Eur J Intern Med. 2013; 24: 245-249https://doi.org/10.1016/j.ejim.2012.12.012Abstract Full Text Full Text PDF PubMed Scopus (7) Google ScholarOf importance, offering patients the option to complete all of their recommended cancer screenings within 1 (or a maximum of 2) visits would require careful coordination with local resources. Although many cancer screening tests can be completed at home (e.g., FIT, FIT-DNA) or in a clinic (e.g., Pap test, prostate-specific antigen test), there are other tests that require a radiologic procedure (e.g., low-dose computed tomography, mammography). As such, clinics will need to coordinate with local hospitals or mobile clinics to provide all the necessary cancer screening tests in a centralized and convenient location. Mobile clinics may be particularly useful for those who are geographically isolated and live far from hospitals and radiology centers. The authors acknowledge that system-level changes can require institutional investment, complex coordination between various specialties, and considerable workflow reorganization. However, they believe that it is the responsibility of the institutions and healthcare professionals to assume this burden to help pave the path to cancer prevention, particularly for the most at-risk and vulnerable patients.The authors hypothesize that this one-stop-shop approach to cancer screening could significantly improve cancer screening uptake. The potential benefits of the one-stop-shop model of care are twofold. First, it would likely improve continuity of care by streamlining all aspects of cancer screening efforts. The American Academy of Family Physicians states that continuity of care “reduces fragmentation of care and thus improves patient safety and quality of care.”15American Academy of Family Physicians. Continuity of care, definition of. https://www.aafp.org/about/policies/all/continuity-of-care-definition.html. Accessed April 2, 2022.Google Scholar Extensive research shows that sustained continuity of care is related to improved health outcomes and patient satisfaction.16Cabana MD Jee SH. Does continuity of care improve patient outcomes?.J Fam Pract. 2004; 53 (, PMID: 15581440.): 974-980PubMed Google Scholar The second expected benefit is that patients who are due or overdue for multiple screenings will have the option to complete all of those screenings within 1 (or a maximum of 2) visits. Research shows that compliance with 1 cancer screening is often correlated with compliance with other cancer screenings.17Lemon S Zapka J Puleo E Luckmann R Chasan-Taber L. Colorectal cancer screening participation: comparisons with mammography and prostate-specific antigen screening.Am J Public Health. 2001; 91: 1264-1272https://doi.org/10.2105/AJPH.91.8.1264Crossref PubMed Scopus (137) Google Scholar,18Sinicrope PS Goode EL Limburg PJ et al.A population-based study of prevalence and adherence trends in average risk colorectal cancer screening, 1997 to 2008.Cancer Epidemiol Biomarkers Prev. 2012; 21: 347-350https://doi.org/10.1158/1055-9965.EPI-11-0818Crossref Scopus (15) Google Scholar A centralized encounter will eliminate the need for patients to overcome multiple system-level hurdles while reducing the time and economic commitment often required of patients to plan each screening activity. Of importance, once a patient has completed all of their necessary screenings, future screenings may not be synchronized because of differing cancer screening recommendations (e.g., colonoscopy every 10 years, mammography every 2 years). Those patients would still greatly benefit from the continuous and comprehensive management of both their immediate as well as longer-term cancer screening needs (e.g., risk assessment, reminders, scheduling, education).In an effort to reduce cancer inequities, it is recommended that these cancer prevention efforts and resources be dedicated to communities that are disproportionately impacted by cancer, including communities of color, low-income communities, and rural communities. In addition, cancer screening efforts should prioritize patients who are overdue for multiple screenings and have overall lower levels of engagement with and access to health care.Notwithstanding the promise of the one-stop-shop approach and the initial evidence supporting its feasibility, it is important that this model of care be rigorously tested to determine its impact, reach, and acceptability. As with all system-level interventions, it is critical to explore the potential unintended consequences that this approach could have on patient burden, provider/clinic burden, cost, and satisfaction. These future studies are needed before disseminating this approach into standard clinical practice. Cancer is currently the second leading cause of death in the U.S. and is expected to claim approximately 600,000 lives in 2021.1American Cancer SocietyCancer facts & figures 2021. American Cancer Society, Atlanta, GA2021https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdfGoogle Scholar In an effort to promote the early detection and prevention of cancer, the U.S. Preventive Services Task Force recommends regular screening for many cancers, including breast, cervical, lung, and colorectal cancers.2U.S. Preventive Services Task Force. A and B recommendations.https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-b-recommendations. Accessed April 2, 2022.Google Scholar There is considerable concern that a national increase in cancer morbidity and mortality rates will be observed after the novel coronavirus disease 2019 (COVID-19) pandemic. In the late spring of 2020, the National Cancer Institute Director, Norman E. Sharpless, warned that “ignoring life-threatening non–COVID-19 conditions such as cancer for too long may turn one public health crisis into many others.”3Sharpless NE. COVID-19 and cancer.Science. 2020; 368: 1290https://doi.org/10.1126/science.abd3377Crossref PubMed Scopus (195) Google Scholar To that end, a recent systematic review reported that during the pandemic and related stay-at-home orders, cancer screening rates and cancer diagnoses have declined significantly.4Alkatout I Biebl M Momenimovahed Z et al.Has COVID-19 affected cancer screening programs? A systematic review.Front Oncol. 2021; 11675038https://doi.org/10.3389/fonc.2021.675038Crossref Scopus (31) Google Scholar In fact, an analysis of >2.5 million patients found that cancer screening rates for colorectal, breast, and cervical cancer fell between 86% and 94% early in the pandemic.5Epic Health Research NetworkDelayed cancer screenings. Epic Health Research Network, Verona, WIMay 4, 2020https://ehrn.org/articles/delays-in-preventive-cancer-screenings-during-covid-19-pandemic/Google Scholar Although signs of recovery in cancer screening rates have been seen,6Labaki C Bakouny Z Schmidt A et al.Recovery of cancer screening tests and possible associated disparities after the first peak of the COVID-19 pandemic.Cancer Cell. 2021; 39: 1042-1044https://doi.org/10.1016/j.ccell.2021.06.019Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar challenges remain. A recent study found that as of March 2021, breast cancer, colon cancer, and cervical cancer screening remained lower than historical averages.7Mast C Muñoz del Río A Heist T Cancer screenings are still lagging. Epic Health Research Network, Verona, WIJune 9, 2021https://epicresearch.org/articles/cancer-screenings-are-still-laggingGoogle Scholar These disruptions in cancer screening efforts may result in increased late-stage cancer diagnoses and ultimately increased cancer-related deaths, for years to come.4Alkatout I Biebl M Momenimovahed Z et al.Has COVID-19 affected cancer screening programs? A systematic review.Front Oncol. 2021; 11675038https://doi.org/10.3389/fonc.2021.675038Crossref Scopus (31) Google Scholar There is also concern that cancer inequities will be exacerbated because of the pandemic. The COVID-19 pandemic has cast a spotlight on flaws in the healthcare system that disproportionally impact those that are systematically marginalized.8Risk of severe illness or death from COVID-19. Centers for Disease Control and Prevention.https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/disparities-illness.html. Updated December 10, 2020. Accessed September 22, 2021.Google Scholar Indeed, some emerging disparities in cancer screening rates during the pandemic have already been identified in the literature.6Labaki C Bakouny Z Schmidt A et al.Recovery of cancer screening tests and possible associated disparities after the first peak of the COVID-19 pandemic.Cancer Cell. 2021; 39: 1042-1044https://doi.org/10.1016/j.ccell.2021.06.019Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar,9Amram O Robison J Amiri S Pflugeisen B Roll J Monsivais P. Socioeconomic and racial inequities in breast cancer screening during the COVID-19 pandemic in Washington State.JAMA Netw Open. 2021; 4e2110946https://doi.org/10.1001/jamanetworkopen.2021.10946Crossref Scopus (21) Google Scholar,10Holcombe RF Tom J Morimoto M et al.Effect of COVID-19-related reductions in cancer screening in Native Hawaiians and across urban and rural communities in Hawaii.J Clin Oncol. 2021; 39: 109https://doi.org/10.1200/JCO.2020.39.28_suppl.109Crossref Google Scholar As the U.S. begins to plan for a postpandemic era, cancer screening must be prioritized with an eye on equity. A return to normal would mean continuing to operate under a flawed system that creates and maintains health inequities. This moment in time presents an opportunity and perhaps an obligation to build a more equitable healthcare system that prioritizes prevention and equity. With regard to cancer, the authors encourage healthcare systems and healthcare professionals to reimagine cancer prevention and control. Toward that end, it is proposed that cancer screening efforts be prioritized and streamlined. Currently, most cancer screening efforts are siloed on the basis of the targeted cancer site. Most patients are required to make multiple appointments and navigate separate healthcare systems to be screened for breast, cervical, colorectal, skin, prostate, and lung cancers. This complex and fragmented model of care is particularly problematic because decades of research suggest that some barriers to cancer screenings include patient time/burden, limited health literacy, and lack of transportation.11Muthukrishnan M Arnold LD James AS. Patients’ self-reported barriers to colon cancer screening in federally qualified health center settings.Prev Med Rep. 2019; 15100896https://doi.org/10.1016/j.pmedr.2019.100896Crossref Scopus (38) Google Scholar, 12Honein-AbouHaidar GN Kastner M Vuong V et al.Systematic review and meta-study synthesis of qualitative studies evaluating facilitators and barriers to participation in colorectal cancer screening.Cancer Epidemiol Biomarkers Prev. 2016; 25: 907-917https://doi.org/10.1158/1055-9965.EPI-15-0990Crossref PubMed Scopus (123) Google Scholar, 13Bruce KH Schwei RJ Park LS Jacobs EA. Barriers and facilitators to preventive cancer screening in Limited English Proficient (LEP) patients: physicians’ perspectives.Commun Med. 2014; 11: 235-247https://doi.org/10.1558/cam.v11i3.24051Crossref Scopus (5) Google Scholar As it stands, many cancer screening research and programmatic efforts focus on patient education, outreach, and navigation. The authors maintain that patient-centered initiatives are necessary yet insufficient. To substantially and sustainably increase cancer screening uptake, it is essential to also implement system-level change. A one-stop-shop approach to cancer screening can help to eliminate organizational and system-level barriers to cancer screening. The one-stop-shop model of care would streamline all aspects of the cancer screening process, including education/outreach, risk assessment, screening tests, results, and follow-up. In this model of care, members of the healthcare team would reach out to patients due or overdue for cancer screening to conduct a comprehensive cancer risk assessment. A member of the healthcare team would then carefully review the results of the assessment with the patients and provide them with the appropriate cancer screening referrals and education. Patients would then be offered the option to complete all of their recommended cancer screening tests either at home (e.g., fecal immunochemical test [FIT], FIT-DNA) or in a same-day clinic. However, in cases where the patient is referred for a colonoscopy, they will likely need to make an additional appointment. After the screening test(s) are completed, a member of the healthcare team would follow-up with the patients to provide them with the results of their tests and make appropriate follow-up recommendations. Patient navigators and care coordinators would be leveraged to help link patients to follow-up care and coordinate future screenings to ensure that they are screened for each cancer in a timely and appropriate way. A similar model of care has been implemented in Israel and has been proven feasible.14Sella T Boursi B Gat-Charlap A et al.One stop screening for multiple cancers: the experience of an integrated cancer prevention center.Eur J Intern Med. 2013; 24: 245-249https://doi.org/10.1016/j.ejim.2012.12.012Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Of importance, offering patients the option to complete all of their recommended cancer screenings within 1 (or a maximum of 2) visits would require careful coordination with local resources. Although many cancer screening tests can be completed at home (e.g., FIT, FIT-DNA) or in a clinic (e.g., Pap test, prostate-specific antigen test), there are other tests that require a radiologic procedure (e.g., low-dose computed tomography, mammography). As such, clinics will need to coordinate with local hospitals or mobile clinics to provide all the necessary cancer screening tests in a centralized and convenient location. Mobile clinics may be particularly useful for those who are geographically isolated and live far from hospitals and radiology centers. The authors acknowledge that system-level changes can require institutional investment, complex coordination between various specialties, and considerable workflow reorganization. However, they believe that it is the responsibility of the institutions and healthcare professionals to assume this burden to help pave the path to cancer prevention, particularly for the most at-risk and vulnerable patients. The authors hypothesize that this one-stop-shop approach to cancer screening could significantly improve cancer screening uptake. The potential benefits of the one-stop-shop model of care are twofold. First, it would likely improve continuity of care by streamlining all aspects of cancer screening efforts. The American Academy of Family Physicians states that continuity of care “reduces fragmentation of care and thus improves patient safety and quality of care.”15American Academy of Family Physicians. Continuity of care, definition of. https://www.aafp.org/about/policies/all/continuity-of-care-definition.html. Accessed April 2, 2022.Google Scholar Extensive research shows that sustained continuity of care is related to improved health outcomes and patient satisfaction.16Cabana MD Jee SH. Does continuity of care improve patient outcomes?.J Fam Pract. 2004; 53 (, PMID: 15581440.): 974-980PubMed Google Scholar The second expected benefit is that patients who are due or overdue for multiple screenings will have the option to complete all of those screenings within 1 (or a maximum of 2) visits. Research shows that compliance with 1 cancer screening is often correlated with compliance with other cancer screenings.17Lemon S Zapka J Puleo E Luckmann R Chasan-Taber L. Colorectal cancer screening participation: comparisons with mammography and prostate-specific antigen screening.Am J Public Health. 2001; 91: 1264-1272https://doi.org/10.2105/AJPH.91.8.1264Crossref PubMed Scopus (137) Google Scholar,18Sinicrope PS Goode EL Limburg PJ et al.A population-based study of prevalence and adherence trends in average risk colorectal cancer screening, 1997 to 2008.Cancer Epidemiol Biomarkers Prev. 2012; 21: 347-350https://doi.org/10.1158/1055-9965.EPI-11-0818Crossref Scopus (15) Google Scholar A centralized encounter will eliminate the need for patients to overcome multiple system-level hurdles while reducing the time and economic commitment often required of patients to plan each screening activity. Of importance, once a patient has completed all of their necessary screenings, future screenings may not be synchronized because of differing cancer screening recommendations (e.g., colonoscopy every 10 years, mammography every 2 years). Those patients would still greatly benefit from the continuous and comprehensive management of both their immediate as well as longer-term cancer screening needs (e.g., risk assessment, reminders, scheduling, education). In an effort to reduce cancer inequities, it is recommended that these cancer prevention efforts and resources be dedicated to communities that are disproportionately impacted by cancer, including communities of color, low-income communities, and rural communities. In addition, cancer screening efforts should prioritize patients who are overdue for multiple screenings and have overall lower levels of engagement with and access to health care. Notwithstanding the promise of the one-stop-shop approach and the initial evidence supporting its feasibility, it is important that this model of care be rigorously tested to determine its impact, reach, and acceptability. As with all system-level interventions, it is critical to explore the potential unintended consequences that this approach could have on patient burden, provider/clinic burden, cost, and satisfaction. These future studies are needed before disseminating this approach into standard clinical practice. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of NIH. This publication was supported by the National Cancer Institute of NIH under award numbers P30CA196521 and K07CA190726. No financial disclosures were reported by the authors of this article. Sarah J. Miller: Conceptualization, Writing - original draft. Jamilia R. Sly: Conceptualization, Writing - review and editing. Lina Jandorf: Conceptualization, Writing - review and editing. Francesca Minardi: Conceptualization, Writing - review and editing. Matthew W. Beyrouty: Conceptualization, Writing - review and editing. Emanuela Taioli: Conceptualization, Writing - review and editing. Neil S. Calman: Conceptualization, Supervision, Writing - review and editing.