Correction: A 2020 study found that colorectal cancer screenings fell by 75 percent early in the pandemic. An earlier version of this article included incorrect information.

When COVID lockdowns began in early 2020, millions of people went without cancer screenings they otherwise would have gotten. The full cost of this lapse in cancer surveillance is only starting to come into focus, but early data suggests it could be immense.

And physicians fear this screening gap could continue getting wider in the years ahead because of other factors exacerbated by the pandemic, such as health care workforce shortages and altered patient habits. 

Screenings for cancer vary vastly in how they’re performed and how often they should be done, but many can only take place in a doctor’s office. The National Cancer Institute (NCI) estimated about 9.4 million people missed cancer screenings they normally would have gotten in 2020. 

This screening gap has been particularly extreme for certain forms of cancer.

A study published in 2020 found that colorectal cancer screenings fell by 75 percent in the U.S. in the first couple of months of lockdown. Screenings for gastrointestinal (GI) cancers tend to be more arduous, with services like colonoscopies involving preparation the day before and anesthesia during the procedure.

Lucio Gordon, one of the authors of the study as well as president and managing physician of  Florida Cancer Specialists, told The Hill his clinic saw a “severe” drop in cancer patients coming in for screenings starting in March 2020.

“The drop was in the magnitude of almost 50 percent, if not more,” said Gordon. “I don’t think we are at the same levels of screening prior to the pandemic.”

Apart from GI cancers, Gordon estimates screenings for lung cancers were also disproportionately affected as they involve CT scans that can be performed only in an office.

For aggressive cancers like lung cancer, one or more years of missed screenings represent the difference between being able to cure the disease or having to start palliative or even hospice care.

After being thrown off schedule by the pandemic, many patients are slow to return for regular tests and procedures to detect cancers. While the COVID lockdowns are now in the rearview mirror and the public health emergency for the pandemic has expired, other immediate pressures still prohibit many from going to the doctor.

The physicians who spoke with The Hill cited issues like loss of employment, rising health care costs and health care worker burnout as contributing to people putting off important cancer screenings.

Debra Patt, executive vice president of Texas Oncology, said the health care system is grappling with nursing and tech shortages compounded by early retirements spurred by the pandemic. 

“What that means is that centers that are doing screening, mammography and colonoscopy and CAT scans, and screening CTs of the lung don’t have the same capacity as they did prior to the pandemic, and we are seeing some pent-up demand complicating that,” she said. 

These shortages contribute to longer wait times for screenings. Patt has heard from colleagues across the country that procedures like CAT scans, which used to take a week to arrange, are taking three to seven weeks.

With all these factors at play, physicians are concerned cancer mortality and severity will only go up in the next few years.

“I think that’s absolutely going to happen,” Patt said.

“What we saw during the pandemic — especially during times of high COVID — was that people had fear to reach their doctors, and so they just avoided what they thought was maybe an elective test. What’s happened since then is that people’s lives are getting in the way of their health care,” she added.

Even health-conscious individuals have been negligent in staying on top of screenings because of the pandemic. Patt recalls one patient she recently saw who was at high risk for breast cancer. The patient was in her 60s, felt a mass in her breast and has known for more than a decade that she has a BRCA gene mutation, which makes her more likely to develop breast cancer.

Despite feeling the mass and knowing of her genetic risk, the patient dragged her feet about going to the doctor because of changes in her life brought on by COVID, which caused her to move. Patt describes this situation as one of many “natural consequences” of the pandemic.

When she disclosed her breast cancer diagnosis last year, journalist and prominent cancer screening advocate Katie Couric, who describes herself as “vigilant, bordering on neurotic, about taking care of my health,” confessed she had not had a mammogram in nearly two years.

“How could that be? Had the pandemic given me a skewed sense of time? Had it messed with my memory?” Couric wrote in her blog.

Friends of Cancer Research CEO Jeff Allen told The Hill the U.S. could see an uptick in “multiple different cancer types” being diagnosed at more advanced stages due to the delay in screenings.

Combating this issue will require a multi-faceted approach that hits at funding issues, revising policies and raising public awareness.

Ezekiel Emanuel, oncologist and former White House adviser, told The Hill, “Waiting for people to show up is not going to work. Positive outreach is critically important.”

When the National Cancer Institute reported on the screening gap last year, it cited a handful of outreach methods that have garnered success. These included going over patient records and flagging those overdue for screenings, holding community luncheons and reaching out through social media.

Solving staffing shortages, which bog down how quickly patients can see providers, will require systemic reforms and targeted programs. Among nurses, enrollment numbers at nursing schools are not growing fast enough, and school faculty are also in short supply. On top of this, a freeze on visas for foreign nurses coming into the U.S. threatens to aggravate the scarcity.

In her state of Texas, Patt noted measures like loan repayment programs have been instituted to help the nursing shortage. She opined that state governments should champion policies that dedicate a portion of the state’s budget to addressing health care worker shortages.

Gordon said insurance companies must also get rid of red tape that deters people from getting screenings, such as prior authorization before getting a procedure.

Yet insurance coverage for preventive services like cancer screenings could soon become harder for people to access. A provision in the Affordable Care Act that ensures preventive service with cost sharing is currently being litigated in a federal lawsuit.

But physicians say more attention on the issue is a good place to start. 

“This is really a national problem,” Patt said. “I do think that heightening awareness will end up in better results for patients. I think it saves lives.”