Experts Discuss the Delay in Imaging Exams for Cancer Patients During COVID-19

Radiologists can play a pivotal role in cancer patients’ return to care

Bonnie Joe

When COVID-19 broke out across the world in 2020, many patients opted to postpone elective, screening and other time-sensitive imaging exams that are important to their health. 

In the U.S., imaging delays related to COVID-19 have resulted in a substantial backlog of screening evaluations, with a projected delay of more than 22 million screening tests for cancer and a 20% reduction in oncology visits between March and June 2020, according to data cited in the Radiology: Imaging Cancer review article, “Cancer Imaging and Patient Care during the COVID-19 Pandemic.”

As the pandemic continues well into 2021, those numbers will undoubtedly continue to climb throughout the world. Particularly for cancer patients, radiologists fear that if and when patients begin to return to receive care, the postponement of imaging appointments may result in advanced or less treatable disease.

“The full impact of delays in cancer screening and treatment will not be evident for years,” said Gary D. Luker, MD, editor of Radiology: Imaging Cancer and co-author of the review article. “Initial studies clearly show more patients diagnosed with advanced stages of cancer. New diagnoses of cancers also decreased as compared with 2019, suggesting missed opportunities to detect cancer at early, more treatable stages.”

In fact, the U.S. National Cancer Institute conservatively estimates 10,000 excess deaths from colon and breast cancer alone within the next 10 years due to delays in screening and treatment as a result of COVID-19.

“Treatment delays in other cancer types will likely fall into this same pattern,” said Adeline Boettcher, PhD, scientific editor of the Radiology subspecialty journals, and co-author on the Radiology: Imaging Cancer review article. “In short, the delays in screening and treatment may lead to an unprecedented rise in diagnosis of advanced cancers, and an increase in the number of deaths due to cancer within the coming years.”

“In short, the delays in screening and treatment may lead to an unprecedented rise in diagnosis of advanced cancers, and an increase in the number of deaths due to cancer within the coming years.”


Breast Cancer Centers Brace for Patients’ Return

Substantial reductions in mammography took place in the months when COVID-19 lockdowns and precautions were instituted.

A presentation at the virtual 2020 San Antonio Breast Cancer Symposium compared breast cancers diagnosed during March-April 2019 with the same period in 2020 and found that during the pandemic, new breast cancer diagnoses decreased by 65%, suggesting the potential for undiagnosed breast cancer.

Knowing this, screening clinics and breast cancer care facilities are poised to manage patients’ return, acknowledging that there will be the potential for added burdens on hospital resources as patients return with complex or late-diagnosed cases due to imaging postponement.

“The biggest concern with delayed or postponed mammograms is finding breast cancers at a later stage, which increases morbidity and mortality,” said Bonnie Joe, MD, PhD, professor and chief of breast imaging at the University of California San Francisco, contributor to the Radiology: Imaging Cancer editorial, “Impact of COVID-19 on Clinical Care and Research in Cancer Imaging: Where We Are Now,” authored by Drs. Luker and Boettcher.

“If women skip or significantly delay screenings due to the pandemic, there will be lives lost due to breast cancer,” Dr. Joe said. “These excess deaths won’t become apparent until years later so the true impact will not be immediately apparent.”

However, Dr. Joe said that COVID-19 has created a subset of patients who may have lost their jobs and/or their insurance. This group of patients may also have a variety of other non-medical related concerns that can be barriers to returning to care.

“Loss of insurance or unemployment are definitely barriers to screening,” Dr. Joe said. “Even if screening exams are provided free of charge, there may be more immediate concerns such as childcare or food insecurity that take priority over a routine screening exam. Health care staff must keep in touch with patients while acknowledging that their circumstances may have changed and being mindful of how that might change the patient’s mindset about screening or treatment. Our ultimate goal is to help these patients to return to regular screening exams as soon as possible.”

Lung Cancer Screenings: Maintaining the Status Quo

Lung cancer screenings are an important tool to detect early lung cancer and had just begun to gain momentum when the pandemic hit in early 2020. Along with the repercussions of missed screenings, there is the risk that patients will begin to skip lung cancer screenings altogether.

“Before the pandemic, some patients didn’t follow through with screenings even after they were scheduled,” said David S. Gierada, MD, professor of radiology, Washington University, St. Louis, MO, who also contributed to the recent Radiology: Imaging Cancer editorial. “This was true for both initial and annual repeat screens. Concerns about safety during the pandemic will exacerbate this issue. For some patients, the safety concerns may tip the risk/benefit balance away from timely screening according to current guidelines.

“While the percentage of patients who will end up progressing to the next stage during the time that detection and/ or treatment were delayed is unknown, the numbers can add up quickly even if the percentage is small, due to the continuation of high lung cancer rates,” Dr. Gierada added.

To prepare for a potential surge of patients, centers are extending hours, providing comprehensive COVID-19 precautions, and minimizing patient contact where they can, such as during registration.

For the backlog of lung cancer screenings, Washington University worked hard to schedule those patients when it was safe to do so.

“The challenge involves accommodating postponed visits on top of patient volumes that have returned to normal within a health care system still under stress due to the ongoing effects of COVID-19,” Dr. Gierada said. “Additional resources and increased use of existing resources are needed.”

At Washington University, a 10-week lung cancer screening backlog was reduced during the summer and early fall when staff contacted and rescheduled patients with missed appointments and offered additional evening and weekend scanning times, he said.

Returning to Care

While telehealth remains an important way to connect patients with their physicians during the pandemic, for cancer care this may not be the best way to maintain continuity of care, especially in cases where patients have delayed important imaging.

As noted by Drs. Joe and Gierada, cancer centers at their institutions have prioritized appointments for cancer patients and created policies to provide safe environments and help patients feel comfortable coming through the door.

Medical organizations have partnered to issue guidelines for managing cancer therapy and imaging during the pandemic. RSNA and other radiology organizations have joined their physician colleagues and patient advocacy groups throughout medicine to encourage patients to #ReturnToCare.

The Return to Care campaign encourages patients to talk to their doctors about scheduling missed or delayed exams, including imaging, where appropriate., the RSNA-ACR public information website, outlines for patients some of the precautions being taken to ensure their safety during imaging exams, noting that in most cases, the benefit of medical care and imaging to their overall health far outweighs any possible risk of infection.

“After having screening appointments postponed and in-person appointments switched to telehealth visits, patients understandably are confused and apprehensive of the safety risks of physically going to a health care facility,” Dr. Luker said. “Physicians need to listen to each patient to learn about personal barriers and concerns about returning to care.”

For More Information

Access the Radiology: Imaging Cancer review, “Cancer Imaging and Patient Care during the COVID-19 Pandemic."

Access the Radiology: Imaging Cancer editorial, “Impact of COVID-19 on Clinical Care and Research in Cancer Imaging: Where We Are Now."

Learn more about the Return to Care campaign at

Direct your patients to