Disasters delay early cancer diagnoses

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In the months after Hurricanes Irma and Maria tore through Puerto Rico, colorectal cancer (CRC) diagnoses dropped by nearly half. Then came the COVID-19 pandemic — and another plunge.

The cancer didn’t go away, though; it just became more difficult to catch early.

A new study published in Cancer, the journal of the American Cancer Society, shows how large-scale disasters delayed routine screenings across the island, leading to a rebound in late-stage CRC cases in the months that followed.

“These findings suggest that limited health care access during these events may have delayed cancer detection and may have worsened health outcomes,” said Tonatiuh Suárez-Ramos, MS, co-lead author of the study. “This issue is especially critical in Puerto Rico, since the health care system already faces important challenges.”

Researchers analyzed nearly a decade of data from the Puerto Rico Central Cancer Registry, tracking trends from 2012 to 2021. They found two major drop-offs: first in September 2017, when back-to-back hurricanes devastated infrastructure across the island; and again, in April 2020, during the early lockdowns of the COVID-19 pandemic.

In a typical September, approximately 161 new CRC cases would’ve been expected. But, in the month Maria made landfall, only 82 cases were diagnosed — a 17.5% drop. After a slow recovery, screening volumes nosedived again in April 2020, when just 50 new cases were reported — nearly 70% below projections.

While overall numbers eventually crept back up, the mix of cases looked different. Early-stage diagnoses remained lower than expected, while late-stage cases rose above historical trends.

A shift that could cost lives

“The number of monthly cases increased during the remainder of each study period,” researchers wrote. “[but] early-stage CRC cases experienced the largest decrease after each interruption.”

By the end of 2021, diagnoses of early-stage CRC had not returned to normal levels. Late-stage diagnoses, on the other hand, had surpassed projections. For December 2021 alone, there were 71.5 late-stage cases diagnosed — compared with 59.8 expected.

That shift could have major implications for outcomes. Delays in colorectal cancer detection are closely tied to poorer prognoses, reduced treatment options, and lower survival rates. Other studies have found that even a three-month disruption in screening can increase the likelihood that a patient will be diagnosed at an advanced stage.

Once symptoms appear, it’s often too late for early intervention.

“Our study demonstrates how disruptive disasters can be to early diagnosis,” the researchers wrote. “In part, this may be because patients with early-stage CRC are more likely to be asymptomatic.”

Screening rates were already a struggle

Even before the hurricanes and the pandemic, Puerto Rico faced challenges with preventive care. CRC is the second most common cancer on the island, and screening rates have long lagged behind the mainland U.S.

Among adults aged 45 to 75, only 55.5% were up to date with screening as of 2022 — compared to 66.9% nationally. For Medicaid patients, the gap was even wider: a separate study found that screening rates dropped 25% in 2017, after the hurricanes, and 39% in 2020, during the pandemic.

Suárez-Ramos and his colleagues believe these gaps were only worsened by damaged infrastructure, overwhelmed hospitals, and a loss of medical personnel.

“Understanding these disruptions can help develop more adaptable and resilient strategies to ensure the continuity of essential care,” said Yisel Pagán-Santana, DrPH, co-lead author of the study.

Disasters disrupt care — but not equally

Interestingly, the study found that geographic access played a role in how care was disrupted. During the hurricanes, declines in cancer diagnoses were less severe in Puerto Rico’s metropolitan region, where hospital density is higher. During the pandemic, the declines were more uniform across the island, likely due to broad executive orders limiting in-person care.

While the drop in early-stage diagnoses was pronounced, the rebound afterward was not enough to catch up. Patients between ages 50 to 75 — the recommended screening group — still hadn’t reached expected levels of diagnosis by the end of 2021.

For patients under 50 and over 76, late diagnoses climbed above predicted levels. These patients are outside standard screening guidelines but may have sought care after developing more advanced symptoms.

“Ultimately, our goal is to help people live longer, healthier lives by making health care systems more resilient and accessible, even in times of crisis,” said Karen J. Ortiz-Ortiz, DrPH, senior author of the study.

What comes next

The findings add urgency to efforts to modernize emergency preparedness plans for health systems, particularly when it comes to oncology care. The authors call for targeted strategies to keep cancer services running during future hurricanes, pandemics, and other large-scale events.

In Puerto Rico, that means preparing not just for power outages and supply chain disruptions — but also for the quiet risks that come when screenings stop.

Ortiz-Ortiz says the study is just the beginning of that conversation. “By evaluating the impact of events like hurricanes and the COVID-19 pandemic, we hope to start the conversation about long-term solutions to improve cancer care coordination, reduce health disparities, and ensure continued access to care,” she said. “Ultimately, our goal is to help people live longer, healthier lives by making health care systems more resilient and accessible, even in times of crisis.”