LANCASTER, S.C. — Oncologist Kashyap Patel brandishes test results he’s eager to share with his patient, Tamaki Caldwell, showing that her advanced ovarian cancer, once the size of tennis balls, is in remission. Smiling, she says, “I’m going to frame this.”
It’s a rare bright moment for Caldwell, 53, who knows she is in the fight of her life, one made significantly more arduous by the coronavirus pandemic. She started having abdominal pain last year — “it was like grab and release, grab and release” – but she didn’t see a doctor for months because of concerns about the pandemic and because she was taking care of her grandmother, who had COVID-19, the disease caused by the virus.
Now, after six months of chemotherapy, Caldwell feels “like somebody whopped me,” she said during a visit to Patel’s clinic in late summer. “But I did what I had to do.”
COVID and cancer are a menacing mix — for everyone, but especially for people of color from low-income communities. African Americans and Hispanics are about twice as likely as white people to die of COVID, according to the Centers for Disease Control and Prevention.
Black cancer patients are at particularly high risk for complications and hospitalizations. Even before the pandemic, Black people had lower survival rates for many cancers compared with white people. Now, with the pandemic grinding on, many doctors fear those inequalities will worsen.
“COVID put cancer and health-care disparities on steroids,” Patel said as he walked through his clinic, offering patients words of encouragement. “I have never seen this many people presenting at Stage 3 and 4.” Even for people like Caldwell, who responded to the treatment, he said, “Stage 4 cancer is like sitting on a volcano” because it frequently recurs.
Last year, as the pandemic unfolded, millions of cancer screening and diagnostic tests were canceled and thousands of surgical procedures postponed, in part to protect patients. Researchers say the pause, and subsequent delayed diagnoses and treatments, will probably result in an increase in cancer deaths over the next several years — but they don’t know the extent.
Jennifer S. Haas, a cancer prevention expert and primary care doctor at Massachusetts General Hospital in Boston, said she and her colleagues have seen an unusually high number of advanced stomach cancers and esophageal malignancies over the past several months.
“People have been trying to ignore symptoms for a year because they didn’t want to come in,” Haas said.
COVID and cancer share risk factors that disproportionately affect people of color: higher rates of underlying conditions such as diabetes or hypertension; a lack of health insurance or access to a primary-care physician; and jobs that can cause health problems.
“If you work in an environment without air purification or filtration, that’s a problem,” Haas said.
Many of those most acutely affected are women, whose family responsibilities and financial stress can make it difficult to focus on their own health, doctors say.
“They have sacrificed themselves to deal with the needs of the family: Are my children getting schooling, how do I take care of the older adults in my life, how do I manage everything?” said Debra Patt, a breast cancer specialist in Austin and an executive vice president of Texas Oncology.
Long after the pandemic subsides, she worries, some patients will be struggling with advanced cancer.
“The effects of this will go on for years,” Patt said.
One of her patients, Christina Cook, a 44-year-old African American woman who lives in San Marcos, Texas, discovered a small lump in her right breast just as the pandemic unfolded last year.
“It felt like a baby rock,” Cook said. “But I had bigger things to worry about.”
As stores closed, Cook was busy looking for food, toilet paper and feminine hygiene products for her two daughters. She soon lost her job shuttling people from an apartment complex to Texas State University. Her younger daughter, a high school senior, was so miserable about the disruption to school and graduation festivities that Cook bought a cat to cheer her up.
By last December, the peach-size mass in Cook’s breast was extremely painful. When Cook, who was uninsured, sought care at a hospital, staffers said their ultrasound machine was broken, she said. At the urging of her older daughter, she went to a Planned Parenthood clinic, where staffers quickly arranged for a mammogram, got her enrolled in Medicaid and helped her find Patt, who has been treating her for triple-negative breast cancer, an aggressive form of the disease more prevalent among Black women.
Cook is responding to treatment and plans to have a mastectomy in December.
“But I’m terrified that I cut it too close, that I neglected myself too long and could have easily taken myself out,” Cook said.
Crystal Whetstone, 37, one of Patel’s patients, said she found a dime-size lump in her right breast in spring 2020 but was too nervous about the coronavirus and too busy with two jobs — one in sales, the other running a dance studio called Diamond Divas — to get it checked. In addition, she was taking care of her 13-year-old son, who was struggling with remote school, and she was having trouble enrolling in Medicaid.
By the time she was diagnosed with breast cancer earlier this year, “I had a big cluster of cancer,” said Whetstone, who wore a red T-shirt emblazoned with Mickey Mouse. Now, she requires more intensive treatment than if she had been diagnosed at an earlier stage.
Recently, she and her son were diagnosed with COVID-19.
“I was stuck in bed for two weeks,” said Whetstone, who is still debating whether to get vaccinated.
Patel, a 60-year-old native of western India, said patients with delayed diagnoses represent collateral damage from the pandemic. In addition to their lowered chances of survival, the cost of their treatment is much higher, often reaching hundreds of thousands of dollars, he said.
The pandemic has dealt setbacks to cancer prevention efforts among people of color but also has compelled doctors to think of new ways to reach these communities.
Sophie M. Balzora, a gastroenterologist at NYU Langone Health in New York, worries that the pause in colorectal cancer screening in early 2020 has hurt progress against the disease in Black Americans, the racial group most likely to be diagnosed with the illness and to die of it.
Federally qualified health centers, which provide care to many low-income Americans, routinely hand out fecal immunochemical tests, called FIT and administered at home, to detect blood in the stool, which can be an early sign of colorectal cancer. If the test is positive, a patient is advised to get a colonoscopy. During the pandemic, distribution of the tests was temporarily suspended, as were follow-up colonoscopies at many facilities.
“It is going to be a huge mountain to climb to get back to where we were” in narrowing disparities, Balzora said. “People will be diagnosed at a later stage and the later your stage, the worse your likelihood of survival.”
Kavita Patel, a health policy expert and primary-care physician who works at Mary’s Center clinic in Prince George’s County, Maryland, an area hit hard by the pandemic, said uninsured patients are facing major delays in getting colonoscopies and other tests. “I have written orders for mammograms eight months ago that have expired, and I have had to reorder,” she said.
Haas at Massachusetts General said the lesson from the pandemic is that “maybe we shouldn’t expect everyone to come to doctors’ offices,” knowing that it is easier for people who are affluent and insured. She said more at-home tests, including for the human papillomavirus, a major cause of cervical cancer, would increase screening. Hospitals, including hers, are hiring more community health nurses to reach people outside of the hospital and doctors’ offices, she said.
Other groups are urging people of color and other patients to resume cancer screening, including the Community Oncology Alliance, which represents cancer doctors, and the nonprofit group CancerCare. Kashyap Patel is the president of the community oncologists’ group.
When the pandemic hit last year, Patel, who is chief executive of Carolina Blood and Cancer Care Associates, scrambled to keep treating patients while keeping them and his staff safe. He closed the Lancaster clinic for several months and referred his patients to his second clinic, in Rock Hill, S.C.
Patel switched some patients from chemotherapy infusions to oral anti-cancer drugs to minimize the risks of in-person visits. Once coronavirus vaccines became available, he and his staff persuaded more than 150 patients and their relatives to receive the shots, including some skeptics who described the vaccine as “chemical warfare.” He added several hours to his clinics’ schedules to try to catch up with patients, while worrying about the stress on his staff.
And he is trying to expand services, hoping to receive funding for mobile lung-cancer screening next year.
The coronavirus remains a serious threat in Lancaster County, which is an hour south of Charlotte and dotted with tobacco and corn farms and mobile homes. The positive rate for coronavirus tests is about 12%, about double the national average, according to the CDC. Less than half of the population in that county has been fully vaccinated, the CDC says.
Still, Caldwell remains upbeat, praising Patel and her siblings for taking care of her. Looking back, she said, she “really had too much going on” to immediately react to the pain she now realizes was caused by cancer.
“Hopefully, I am getting over this,” she said. “I am going to beat this and get back to my regular life.”