As the pandemic surged, Beth Israel Deaconess Medical Center saw medical visits for serious conditions such as cancer, heart attacks, and strokes drop by as much as 65 percent, according to an analysis that put numbers to a troubling trend so far described mostly anecdotally.
Doctors at the Harvard teaching hospital in Boston, discovered that the number of patients referred to the hospital’s breast cancer and hematologic cancer clinics in April fell 65 percent and 61 percent, respectively, compared with before the pandemic. The numbers take into account normal month-to-month variation in patients.
The group also discovered declines of 33 percent in heart attack patients and 58 percent in stroke patients hospitalized in March and April. The researchers discussed their findings at an online Harvard Medical School conference Thursday and have submitted them to a medical journal.
Dr. Dhruv Kazi, associate director of the hospital’s Center for Outcomes Research in Cardiology and one of the researchers, blamed the declines partly on “genuine fear” among people worried they could get infected with coronavirus at hospitals inundated with COVID-19 patients.
“I will just sit out my stroke. How bad can it be?” he said.
He also said the messages that officials put out as the pandemic hit might have confused people. Amid preparations for an influx of coronavirus patients in February and March, state officials and hospitals leaders were afraid that hospitals could become overwhelmed with COVID-19 patients, as happened in Italy and New York, and cancelled non-urgent elective procedures. Some residents may have decided that milder symptoms of a stroke or heart attack should be tolerated unless overtly life threatening.
And the public may not have understood the painstaking precautions hospitals were taking, such as universal mask policies and separate units for COVID-19 patients, to keep the virus from spreading to other patients.
But the problem goes beyond messaging, Kazi said. He said the health care system also has suffered true disruption. Cancer screening tests such as mammography and colonoscopy have been virtually stopped, which may result in fewer diagnoses — and fewer patients arriving at hospital clinics for second opinions or to plan their treatments. Postponement of seemingly elective appointments like a routine visit to a primary care physician or for a mammogram have the potential to result in harm from delayed diagnosis and treatment, he said.
Hospital leaders across the country have talked about the decline in emergency room patients arriving with minor problems such as sprained ankles and stomachaches as well as with serious illnesses like heart attacks and strokes. At Massachusetts General Hospital, Dr. David Brown said the number of stroke, heart attack, and brain hemorrhage cases fell 30 percent during the height of the pandemic in March and April — though these cases have started to rise again. These declines worry Brown, chief of emergency medicine at the hospital. If untreated, “these have much higher mortality rates than COVID,” he said.
A study released last month by the Journal of the American College of Cardiology analyzed data from nine medical centers, including Mass. General and UMass Memorial Medical Center in Worcester, and found a 38 percent drop in March in cardiac catheterization procedures to treat a certain type of serious heart attack. Similarly, researchers this week reported a 39 percent drop in imaging tests to diagnose stroke in March in 856 US hospitals.
Dr. Kevin Tabb, president of Beth Israel Lahey Health, said he asked researchers at his hospital to analyze declines in care in a number of areas because he was hearing anecdotal reports from doctors across the region about patients arriving much later for treatment than usual, including a woman in her 20s with severe abdominal pain for five days. By the time she arrived in the emergency department, her appendix had ruptured and she had sepsis, a serious body-wide infection.
Tabb said, even as coronavirus cases surged, he and other hospital leaders talked about this phenomenon during their regular morning telephone call with Governor Charlie Baker and other officials overseeing the state’s response to the pandemic. During a press conference on April 25, Baker urged residents not to avoid seeking care for serious conditions like strokes and heart attacks.
Less has been written about the impact of the pandemic on cancer diagnoses. Cancer patients who were already in treatment seemed overall to continue chemotherapy and radiation — though hospitals changed treatment protocols to require fewer chemotherapy infusions and postponed surgeries considered non-urgent. The number of cancer patients hospitalized at Mass. General, for example, dropped 47 percent in March and April, compared to the same time last year.
Many hospitals created separate treatment units for oncology patients infected with coronavirus, lessening the risk of transmission for other patients.
But doctors at several large medical centers said they are clearly seeing fewer newly-diagnosed cancer patients.
Dr. David Steensma, an oncologist at Dana-Farber Cancer Institute who specializes in blood cancers, said two patients recently arrived at the emergency department with hemoglobin levels in their blood as low as 3 — normal levels are 12 to 15 — and were diagnosed with leukemia. “They could hardly get out of bed, but they were so worried about presenting to a doctor, they put it off as long as they could,” he said.
Steensma said some patients may be going to local hospitals because they are afraid to come to medical centers in Boston, which are treating hundreds of coronavirus patients. "I’m getting five to six e-mails a day from doctors in Maine, New Hampshire, and the Berkshires saying I have this patient and they don’t want to come to Boston. They are looking for advice. Those are patients who in the past may have come to us for a second opinion and entered into clinical trial.”
UMass Memorial Medical Center doctors said cancer patients have declined in number there too. “Normally with cancer, people want to be seen immediately,” said Dr. Jonathan Gerber, chief of hematology oncology. “We have seen people go in the opposite direction.”
He has seen people with “extraordinarily high white blood cell counts" come into the emergency department and end up with a leukemia diagnoses. “They may have literally waited until they couldn’t have waited any more,” he said.
At the same time, he said he believes “a lot of things are going undiagnosed. It’s almost inevitable there will be more advanced cases that come in” as a result.
Kazi and other Beth Israel Deaconess researchers said it may take months for doctors to understand the impact of delayed care on patients — and if it actually leads to complications or earlier death.
The same is true for the impact of delays in seeking treatment for heart attack and stroke. It’s unclear whether those patients who did not come to emergency departments had mild, moderate, or severe cardiovascular problems. And whether changes in lifestyle — less physical exertion during quarantine, for example — could have led to fewer heart attacks.
The effect of any delays may not be clear until researchers delve into whether the increased number of patients who died at home during the pandemic died of COVID-19 — or whether some of those people died of untreated heart attacks and strokes.
"We see many patients who have an episode of chest pain and don’t come in. Six months later we do a test and see they have a blocked artery in that area,'' said Dr. Robert Yeh, director of Beth Israel Deaconess’s Center for Outcomes Research in Cardiology and a coauthor on the study. “For some people it might be OK, for other people it’s quite dangerous.”
Liz Kowalczyk can be reached at firstname.lastname@example.org.