research paper on cancer

Treatment Research

In a new study in mice, researchers showed they could enhance radiation therapy by boosting levels of the BAMBI protein in MDSC immune cells in the tumor microenvironment. After radiation, T cells flooded into the tumor and killed tumors elsewhere in the body.

In a clinical trial, people being treated for cancer who participated in virtual mind–body fitness classes were less likely to be hospitalized, and had shorter stays when they were hospitalized, than people who did not take the classes.

NCI’s James H. Doroshow, M.D., reflects on the accomplishments of NCI-MATCH, a first-of-its-kind precision medicine cancer trial, and gives an overview of three new successor trials: ComboMATCH, MyeloMATCH, and iMATCH.

A new study, conducted largely in mice, may help explain why a currently used molecular marker—called mismatch repair deficiency—doesn’t always work to predict which patients will respond to immunotherapies called immune checkpoint inhibitors.

New approach may increase the effectiveness of T-cell-based immunotherapy treatments against solid tumors.

A cancer-infecting virus engineered to tamp down a tumor’s ability to suppress the immune system shrank tumors in mice, a new study shows. The modified oncolytic virus worked even better when used along with an immune checkpoint inhibitor.

Despite recommendations, a new analysis shows few people with cancer undergo germline testing to learn if their cancer may have been caused by gene changes inherited from a parent. Germline testing can help doctors determine the best treatments for a patient and help identify people whose family members may be at higher risk of cancer.

ComboMATCH will consist of numerous phase 2 cancer treatment trials that aim to identify promising drug combinations that can advance to larger, more definitive clinical trials.

A new study has compared three formulations of an mRNA vaccine designed to treat cancers caused by human papillomavirus (HPV) infections. All three vaccines showed promise in mice.

Researchers have identified a mechanism by which cancer cells develop specific genetic changes needed to become resistant to targeted therapies. They also showed that this process, called non-homologous end-joining (NHEJ), can potentially be disrupted.

For some people with cancer, is 6 months of immunotherapy the only treatment they might ever need? Or 4 weeks of immunotherapy followed by minor surgery? Results from several small clinical trials suggest these scenarios may be bona fide possibilities.

Two research teams have developed ways of overcoming barriers that have limited the effectiveness of CAR T-cell therapies, including engineering ways to potentially make them effective against solid tumors like pancreatic cancer and melanoma.

In people with cancer treated with immune checkpoint inhibitors, a rare, but often fatal, side effect is inflammation in the heart, called myocarditis. Researchers have now identified a potential chief cause of this problem: T cells attacking a protein in heart cells called α-myosin.

Researchers have modified a chemo drug, once abandoned because it caused serious gut side effects, so that it is only triggered in tumors but not normal tissues. After promising results in mice, the drug, DRP-104, is now being tested in a clinical trial.

Two research teams have developed a treatment approach that could potentially enable KRAS-targeted drugs—and perhaps other targeted cancer drugs—flag cancer cells for the immune system. In lab studies, the teams paired these targeted drugs with experimental antibody drugs that helped the immune system mount an attack.

Inflammation is considered a hallmark of cancer. Researchers hope to learn more about whether people with cancer might benefit from treatments that target inflammation around tumors. Some early studies have yielded promising results and more are on the horizon.

NCI researchers are developing an immunotherapy that involves injecting protein bits from cytomegalovirus (CMV) into tumors. The proteins coat the tumor, causing immune cells to attack. In mice, the treatment shrank tumors and kept them from returning.

FDA has approved the combination of the targeted drugs dabrafenib (Tafinlar) and trametinib (Mekinist) for nearly any type of advanced solid tumor with a specific mutation in the BRAF gene. Data from the NCI-MATCH trial informed the approval.

People with cancer who take immunotherapy drugs often develop skin side effects, including itching and painful rashes. New research in mice suggests these side effects may be caused by the immune system attacking new bacterial colonies on the skin.

Researchers have developed tiny “drug factories” that produce an immune-boosting molecule and can be implanted near tumors. The pinhead-sized beads eliminated tumors in mice with ovarian and colorectal cancer and will soon be tested in human studies.

Women are more likely than men to experience severe side effects from cancer treatments such as chemotherapy, targeted therapy, and immunotherapy, a new study finds. Researchers hope the findings will increase awareness of the problem and help guide patient care.

Research to improve CAR T-cell therapy is progressing rapidly. Researchers are working to expand its use to treat more types of cancer and better understand and manage its side effects. Learn how CAR T-cell therapy works, which cancers it’s used to treat, and current research efforts.

Experts say studies are needed on how to best transition telehealth from a temporary solution during the pandemic to a permanent part of cancer care that’s accessible to all who need it.

Removing immune cells called naive T cells from donated stem cells before they are transplanted may prevent chronic graft-versus-host disease (GVHD) in people with leukemia, a new study reports. The procedure did not appear to increase the likelihood of patients’ cancer returning.

A specific form of the HLA gene, HLA-A*03, may make immune checkpoint inhibitors less effective for some people with cancer, according to an NCI-led study. If additional studies confirm the finding, it could help guide the use of these commonly used drugs.

The success of mRNA vaccines for COVID-19 could help accelerate research on using mRNA vaccine technology to treat cancer, including the development of personalized cancer vaccines.

Aneuploidy—when cells have too many or too few chromosomes—is common in cancer cells, but scientists didn’t know why. Two new studies suggest that aneuploidy helps the cells survive treatments like chemotherapy and targeted therapies.

New research suggests that fungi in the gut may affect how tumors respond to cancer treatments. In mice, when bacteria were eliminated with antibiotics, fungi filled the void and impaired the immune response after radiation therapy, the study found.

FDA has approved belumosudil (Rezurock) for the treatment of chronic graft-versus-host disease (GVHD). The approval covers the use of belumosudil for people 12 years and older who have already tried at least two other therapies.

In lab studies, the antibiotic novobiocin showed promise as a treatment for cancers that have become resistant to PARP inhibitors. The drug, which inhibits a protein called DNA polymerase theta, will be tested in NCI-supported clinical trials.

A drug called avasopasem manganese, which has been found to protect normal tissues from radiation therapy, can also make cancer cells more vulnerable to radiation treatment, a new study in mice suggests.

While doctors are familiar with the short-term side effects of immune checkpoint inhibitors, less is known about potential long-term side effects. A new study details the chronic side effects of these drugs in people who received them as part of treatment for melanoma.

Cholesterol-lowering drugs known as PCSK9 inhibitors may improve the effectiveness of cancer immune checkpoint inhibitors, according to studies in mice. The drugs appear to improve the immunotherapy drugs’ ability to find tumors and slow their growth.

Researchers have developed a nanoparticle that trains immune cells to attack cancer. According to the NCI-funded study, the nanoparticle slowed the growth of melanoma in mice and was more effective when combined with an immune checkpoint inhibitor.

A comprehensive analysis of patients with cancer who had exceptional responses to therapy has revealed molecular changes in the patients’ tumors that may explain some of the exceptional responses.

Researchers are developing a new class of cancer drugs called radiopharmaceuticals, which deliver radiation therapy directly and specifically to cancer cells. This Cancer Currents story explores the research on these emerging therapies.

FDA has recently approved two blood tests, known as liquid biopsies, that gather genetic information to help inform treatment decisions for people with cancer. This Cancer Currents story explores how the tests are used and who can get the tests.

Cancer cells with a genetic feature called microsatellite instability-high (MSI-high) depend on the enzyme WRN to survive. A new NCI study explains why and reinforces the idea of targeting WRN as a treatment approach for MSI-high cancer.

Efforts to contain the opioid epidemic may be preventing people with cancer from receiving appropriate prescriptions for opioids to manage their cancer pain, according to a new study of oncologists’ opioid prescribing patterns.

The gene-editing tool CRISPR is changing the way scientists study cancer, and may change how cancer is treated. This in-depth blog post describes how this revolutionary technology is being used to better understand cancer and create new treatments.

FDA’s approval of pembrolizumab (Keytruda) to treat people whose cancer is tumor mutational burden-high highlights the importance of genomic testing to guide treatment, including for children with cancer, according to NCI Director Dr. Ned Sharpless.

Patients with acute graft-versus-host disease (GVHD) that does not respond to steroid therapy are more likely to respond to the drug ruxolitinib (Jakafi) than other available treatments, results from a large clinical trial show.

NCI is developing the capability to produce cellular therapies, like CAR T cells, to be tested in cancer clinical trials at multiple hospital sites. Few laboratories and centers have the capability to make CAR T cells, which has limited the ability to test them more broadly.

An experimental drug may help prevent the chemotherapy drug doxorubicin from harming the heart and does so without interfering with doxorubicin’s ability to kill cancer cells, according to a study in mice.

In people with blood cancers, the health of their gut microbiome appears to affect the risk of dying after receiving an allogeneic hematopoietic stem cell transplant, according to an NCI-funded study conducted at four hospitals across the globe.

A novel approach to analyzing tumors may bring precision cancer medicine to more patients. A study showed the approach, which analyzes gene expression using tumor RNA, could accurately predict whether patients had responded to treatment with targeted therapy or immunotherapy.

Bone loss associated with chemotherapy appears to be induced by cells that stop dividing but do not die, a recent study in mice suggests. The researchers tested drugs that could block signals from these senescent cells and reverse bone loss in mice.

Some experts believe that proton therapy is safer than traditional radiation, but research has been limited. A new observational study compared the safety and effectiveness of proton therapy and traditional radiation in adults with advanced cancer.

In people with cancer, the abscopal effect occurs when radiation—or another type of localized therapy—shrinks a targeted tumor but also causes untreated tumors in the body to shrink. Researchers are trying to better understand this phenomenon and take advantage of it to improve cancer therapy.

An experimental drug, AMG 510, that targets mutated forms of the KRAS protein completely shrank tumors in cancer mouse models and data from a small clinical trial show that it appears to be active against different cancer types with a KRAS mutation.

Researchers have engineered an oncolytic virus to kill cancer cells and boost the immune response against tumors. In a new study, the virus provided T cells around tumors with a hormone they need for their own cell-killing functions.

FDA has approved entrectinib (Rozlytrek) for the treatment of children and adults with tumors bearing an NTRK gene fusion. The approval also covers adults with non-small cell lung cancer harboring a ROS1 gene fusion.

A new NCI-supported study showed that altering cancer cell metabolism by feeding mice a diet very low in the nutrient methionine improved the ability of chemotherapy and radiation therapy to shrink tumors.

An NCI-funded clinical trial is testing the immunotherapy drug nivolumab (Opdivo) in people who have advanced cancer and an autoimmune disease, such as rheumatoid arthritis, lupus, or multiple sclerosis, who are often excluded from such trials.

Researchers have identified a protein called CD24 that may be a new target for cancer immunotherapy. The protein is a ‘don’t eat me’ signal that prevents immune cells called macrophages from engulfing and eating cells.

Injecting cells undergoing necroptosis, a form of cell death, into tumors in mice kickstarted an immune response against the tumors, researchers have found. When combined with immunotherapy, the treatment was effective at eliminating tumors in mice.

Researchers have identified proteins that may play a central role in transforming T cells from powerful destroyers to depleted bystanders that can no longer harm cancer cells. The findings could lead to strategies for boosting cancer immunotherapies.

Did you know that NCI supports clinical trials of new treatments for pet dogs with cancer? Learn more about NCI’s comparative oncology studies and how they may also help people with cancer.

Researchers have discovered a potential way to turn on one of the most commonly silenced tumor-suppressor proteins in cancer, called PTEN. They also found a natural compound, I3C, that in lab studies could flip the on switch.

New findings from a clinical trial suggest that a single dose of radiation therapy may control painful bone metastases as effectively as multiple lower doses of radiation therapy.

The expanding use of cancer immunotherapy has revealed a variety of side effects associated with this treatment approach. Researchers are now trying to better understand how and why these side effects occur and develop strategies for better managing them.

The investigational immunotherapy drug bintrafusp alfa (also called M7824), a bifunctional fusion protein, shrank the tumors of some patients with advanced HPV-related cancers, according to results from a phase 1 clinical trial.

A new study provides insight into how cancer immunotherapy works and suggests ways to enhance the treatment’s effectiveness. The NCI-led study, published in Science, examined the effect of high potassium levels on T cells.

Pain is a common and much-feared symptom among people with cancer and long-term survivors. As more people survive cancer for longer periods, there is a renewed interest in developing new, nonaddictive approaches for managing their chronic pain.

• Introduction
• Conclusions
• Article Information

eTable 1. Description of cancer cases diagnosed in Manitoba, Canada from January 2015 to December 2021

eTable 2. Ratios and 95% confidence intervals between fitted and counterfactual incidence values for cancer sites with no significant COVID-19-by-time interaction from April 2020 to December 2021

eTable 3. Ratios and 95% confidence intervals between fitted and counterfactual incidence values for cancer sites with a significant COVID-19-by-time interaction by month from April 2020 to December 2021

eTable 4. Ratios and 95% confidence intervals between fitted and counterfactual incidence values for breast, colon, rectal, and lung cancer by age group and month from April 2020 to December 2021

eTable 5. Estimated cumulative fitted and counterfactual number of cancer cases, difference, and percent difference by site as of December 31, 2021

eFigure 1. Incidence rate for breast cancer for women <50, 50 to 74, and ≥75 years of age by month, Manitoba

eFigure 2. Incidence rate for lung cancer for individuals <50 years, 50 to 74, and ≥75 years of age by month, Manitoba

eFigure 3. Incidence rate for colon cancer for individuals <50, 50 to 74, and ≥75 years of age by month, Manitoba

eFigure 4. Incidence rate for rectal cancer for individuals <50 years of age, 50 to 74, and ≥75 years of age by month, Manitoba

eAppendix 1. Cancer types included in each category and International Classification of Diseases for Oncology version 3 (ICD-O-3) codes

eAppendix 2. R code and simulated data for an interrupted time series analysis

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Decker KM , Feely A , Bucher O, et al. New Cancer Diagnoses Before and During the COVID-19 Pandemic. JAMA Netw Open. 2023;6(9):e2332363. doi:10.1001/jamanetworkopen.2023.32363

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New Cancer Diagnoses Before and During the COVID-19 Pandemic

• 1 Paul Albrechtsen Research Institute CancerCare Manitoba, Winnipeg, Manitoba, Canada
• 2 Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
• 3 Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Manitoba, Canada
• 4 Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
• 5 Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
• 6 Section of General Surgery, Department of Surgery, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
• 7 Section of Radiation Oncology, Department of Radiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
• 8 Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, Manitoba, Canada

Question   Is there an association between the COVID-19 pandemic and cancer incidence in Manitoba, Canada?

Findings   In this cross-sectional study including 48 378 individuals with cancer diagnoses, a significant decrease in cancer diagnosis incidence was observed in the first few months of the pandemic, particularly in breast, colon, and rectal cancer incidence. Other cancer sites showed minimal long-term changes in incidence.

Meaning   The COVID-19 pandemic was associated with an initial decrease in cancer incidence followed by a return to previous incidence rates for most cancer sites.

Importance   Disruptions to health care during the COVID-19 pandemic may have led to missed cancer diagnoses. It is critical to evaluate the association between the COVID-19 pandemic and cancer incidence to address public and patient anxiety, inform recovery efforts, and identify strategies to reduce the system’s vulnerability to future disruptions.

Objective   To examine the association between the COVID-19 pandemic and cancer incidence in Manitoba, Canada.

Design, Setting, and Participants   A population-based cross-sectional study design was conducted using data from the Manitoba Cancer Registry and an interrupted time-series analysis. All individuals diagnosed with cancer in Manitoba, Canada, from January 1, 2015, until December 31, 2021, were included. Individuals diagnosed with breast, colon, rectal, or lung cancer were grouped by age as follows: younger than 50 years, 50 to 74 years, and 75 years and older.

Exposures   COVID-19 pandemic.

Main Outcomes and Measures   Age-standardized cancer incidence rates and the estimated cumulative difference between the number of cases in the absence of COVID-19 and observed (fitted) number of cancer cases.

Results   A total of 48 378 individuals were included. The median (IQR) age at diagnosis was 68 (59-77) years and 23 972 participants (49.6%) were female. In April 2020, there was a 23% decrease in overall cancer incidence. Cancer incidence decreased by 46% for breast, 35% for colon, 47% for rectal, 50% for head and neck, 65% for melanoma, and 33% for endocrine cancer diagnoses and increased by 12% for hematological cancer diagnoses and 8% for diagnoses of cancers with an unknown primary site. Lung cancer incidence remained stable until December 2020 when it decreased by 11%. Brain and central nervous system and urinary cancer diagnoses decreased consistently over time from April 2020 to December 2021 by 26% and 12%, respectively. No association was observed with gynecologic (1% increase), other digestive (1% decrease), or pancreatic (7% increase) cancer incidence. As of December 2021, Manitoba had an estimated deficit of 692 (5.3%) cancers. The largest estimated deficits were for breast (273 cases, 14.1% deficit), colon (133 cases, 12.2% deficit), and lung cancers (132 cases, 7.6% deficit).

Conclusions and Relevance   In this study, the COVID-19 pandemic was associated with an initial decrease in cancer diagnosis incidence followed by a recovery for most cancer sites. However, the cumulative deficit for some cancers with high fatality needs immediate attention.

The COVID-19 pandemic led to the reorganization of health services to provide care for patients with COVID-19. This reorganization included greater use of virtual visits, temporary suspension of or reduction in cancer screening and diagnostic services, triaging patients with cancer for treatment based on acuity, and the redeployment of cancer care staff. Measures to address COVID-19 also varied throughout Canada and over time as COVID-19 caseloads changed. 1

Disruptions to routine health care services may lead to missed or delayed diagnoses for individuals with suspected cancer, leading to a potential cohort of individuals with missing cancer diagnoses. 2 Modeling studies have estimated that these individuals could experience more advanced disease at diagnosis and inferior outcomes, including decreased survival. 3 - 5 It is therefore critical that we examine the association between the disruptions of the COVID-19 pandemic and the cancer care system in order to address public and patient anxiety, direct COVID-19 recovery efforts, and identify strategies for reducing the system’s vulnerability to future disruptions. We previously found a 23% decrease in the number of new cancer diagnoses, an 83% decrease in Papanicolaou tests, an 81% decrease in fecal occult blood tests, and a 54% decrease in the number of screening mammograms at the start of the pandemic in Manitoba. 6 , 7 In this study, using a population-based cross-sectional study design and an interrupted time-series analysis, we examined the association between the COVID-19 pandemic and age-standardized cancer diagnosis incidence rates by disease site and estimated the difference between the observed and estimated number of cancer cases that may have been diagnosed in the absence of COVID-19.

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the University of Manitoba’s Health Research Ethics Board, Manitoba Health’s Health Information Privacy Committee, and CancerCare Manitoba’s Research and Resource Impact Committee. Because data were deidentified, informed consent was not required. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

Manitoba, located in central Canada, has a population of approximately 1.39 million. Two-thirds of the population live in the capital city of Winnipeg. CancerCare Manitoba is the provincial cancer agency responsible for providing clinical services to all residents of Manitoba who are diagnosed with cancer. Prior to COVID-19, approximately 6000 individuals were diagnosed with cancer and 5000 received treatment or follow-up care at CancerCare Manitoba each year. The first COVID-19 case in Manitoba was identified on March 12, 2020. By the end of March, the government had implemented restrictions to mitigate the impact of virus. The peak of the first wave occurred in March 2020, the second in November 2020, and the third in May 2021. 8 By October 1, 2021, approximately 70% of Manitoba residents were fully vaccinated. 8

We used a population-based cross-sectional study design to examine the rate of new cancer diagnoses over time before (January 2015 until February 2020) and after the start of the COVID-19 pandemic and the interventions that were implemented to mitigate its impact (April 1, 2020, to December 31, 2021). All individuals diagnoses with cancer in Manitoba from 2015 to 2021 were included.

Cancer cases were determined using the Manitoba Cancer Registry, a high-quality, population-based registry that is legally mandated to collect and maintain accurate, comprehensive information about cancer diagnoses in Manitoba. 9 The Manitoba Cancer Registry uses disease site groupings according to the International Classification of Diseases for Oncology, Third Edition ( ICD-0-3 ). Population data were based on estimated Manitoba Health coverage provided by Manitoba Health.

Outcomes included the age-standardized cancer incidence rate per 100 000, the estimated cumulative difference in the number of new cancer diagnoses, and the estimated percentage cumulative difference in the number of new cancer diagnoses. The estimated cumulative difference in new cancer diagnoses was defined as the difference between the monthly cumulative counterfactual count (the estimated number of diagnoses in the absence of COVID-19) and the monthly cumulative fitted count (ie, the observed number of diagnoses smoothed). The estimated percentage cumulative difference in the number of new cancer diagnoses was defined as the cumulative difference in the fitted count divided by the cumulative difference in the counterfactual count.

Consistent with routine reporting, cancers were categorized into the following sites: all cancers, breast, lung, prostate, colon, rectal, hematologic, urinary, unknown primary site, head and neck, brain and central nervous system, gynecologic, other digestive, melanoma, pancreatic, endocrine, and other. eAppendix 1 in Supplement 1 lists the cancers in each category and ICD-O-3 codes. Because of the impact of the pandemic on breast and colorectal cancer screening found in prior analyses, 7 we examined breast, colon, and rectal cancers separately for individuals younger than 50 years, 50 to 74 years (ie, eligible for screening), and 75 years and older. Rates were age standardized to the 2011 Canadian population using the direct method.

We used an interrupted time-series analysis that, unlike pre-post study designs, takes into consideration baseline or seasonal trends. 10 If baseline trends are not considered, the difference between the number of diagnoses observed and the number expected in the absence of COVID-19 will be either overestimated (if there was a downward trend in diagnoses prior to the pandemic) or underestimated (if there was an upward trend in diagnoses prior to the pandemic). We compared post–COVID-19 (April 2020 onward) cancer incidence rates to counterfactual rates as if the pandemic had not occurred based on pre–COVID-19 trends (baseline rates) and quantified monthly new cancer diagnoses by cancer type.

Generalized linear models were run and selected for each cancer site based on the distribution of the data (ie, Poisson, generalized Poisson, negative binomial, gamma, or inverse gaussian). To do this, we plotted the projected mean and variance of each model and the observed mean and variance in the data. 11 Scaled quantile residual plots were also used to evaluate the uniformity of residuals and dispersion. 12 Each model included a binary intervention term equal to 0 during the pre–COVID-19 period and 1 during the COVID-19 period and a time term defined as the number of months since the start of the study period. Fitted values (ie, smoothed observed values) were generated using the observed values in the data frame. Counterfactual values were generated by projecting values with the binary indicator of the pandemic as 0 rather than 1. Nonlinear time and seasonality effects were accounted for in the regression model using a flexible spline function. 13

After the generalized linear model was selected, models were fine-tuned by comparing the adjusted McFadden R 2 between subsequent models. 14 Plots were produced using observed, counterfactual, and fitted values. If the counterfactual did not follow the baseline trend, the model was modified (ie, the number of degrees of freedom for splines was reduced) until the counterfactual was consistent with the baseline trend. COVID-19–by–time interactions were considered if the plotted-fitted values in the COVID-19 period did not fit the observed data well (eg, observed values were below fitted values during the early COVID-19 period but higher during the later COVID-19 period). Time interactions were found for some cancer sites but still demonstrated poor fit (ie, fitted values did not fit observed values well). Therefore, we created multiple COVID-19 dummy variables representing different periods during the pandemic to provide a slope for each period, which enabled more accurate projections. The following R packages were used: haven, splines, Hmisc, lattice, MASS, ggplot2, car, DHARMa, multcomp, lmtest, glmmTMB, and forest plot. March 2020 was excluded from the analyses because COVID-19 restrictions and changes to visit and treatment protocols were implemented incrementally throughout March. 6 , 15 , 16

Ratios between counterfactual and fitted estimates and 95% CIs derived from contrast statements were calculated. The estimated cumulative difference in the number of diagnoses during the pandemic was calculated as of December 31, 2021, and plotted using a forest plot. The 95% CIs for the cumulative difference estimates were calculated with parametric bootstrapping and 1000 replications. Data analyses were performed in SAS version 9.4 (SAS Institute) and R version 4.1.30.5 (R Foundation). eAppendix 2 in Supplement 1 provides R code and simulated data for conducting the interrupted time-series analysis.

From 2015 to 2021, there were 48 378 cases of cancer diagnosed in Manitoba (eTable 1 in Supplement 1 ). The median (IQR) age at diagnosis was 68 (59-77) years and 23 972 participants (49.6%) were female. Ratios between fitted and counterfactual incidence rates by month and 95% CIs are provided in eTables 2-4 in Supplement 1 . Figure 1 shows observed, counterfactual, and fitted age-standardized cancer incidence rates for all cancer sites combined from January 1, 2015, to December 31, 2021 (excluding March 2020). The 95% CI of the ratio of the fitted to counterfactual value is also included. In April 2020, there was a 23% decrease in cancer incidence. By June 2020, there was no significant difference between the fitted and counterfactual cancer incidence rates.

Figure 2 shows the observed, counterfactual, and fitted age-standardized incidence rates for breast (n = 6548), lung (n = 6477), prostate (n = 5849), colon (n = 3876), and rectal (n = 2021) cancers. in April 2020, there was a 46% decrease in breast cancer incidence. Breast cancer incidence remained 11% lower than the counterfactual until December 2021. There was no association observed with breast cancer incidence among women younger than 50 years, a decrease of 46% in April 2020 and 73% in May 2020 in women aged 50 to 74 years (screening eligible) followed by a sustained decrease below the counterfactual, and a 20% sustained decrease among women 75 years and older (eFigure 1 in Supplement 1 ). Lung cancer incidence remained stable until December 2020 when it decreased by 11%. Because of this decrease, we ran a post hoc subgroup analysis by age to see if the association was consistent across age groups. An association was seen only in the 75 years and older age group (eFigure 2 in Supplement 1 ), where lung cancer incidence decreased by 46% in April 2020. There was no association observed with prostate cancer incidence. Colon cancer incidence decreased by 35% in April 2020. By August 2020, there was no difference between the counterfactual and fitted colon cancer incidence rate. There was no association observed for colon cancer incidence among individuals younger than 50 years and a 34% decrease in those aged 50 to 74 years and those 75 years and older in April 2020 (eFigure 3 in Supplement 1 ). Rectal cancer incidence decreased in April 2020 by 47%. By May 2020, incidence was 5% higher than the counterfactual. Except for April 2020 for the 50 to 74 years age group for whom incidence decreased by 45%, rectal cancer incidence rate was nonsignificantly higher than the counterfactual in all 3 age groups (eFigure 4 in Supplement 1 ).

Figure 3 shows the age-standardized observed, counterfactual, and fitted incidence rates for hematologic (n = 4655), unknown primary (n = 1764), head and neck (n = 1674), endocrine (n = 1130), melanoma (n = 1952), and brain and central nervous system (n = 662) cancers. There was a 12% increase in hematologic cancer incidence in April 2020 followed by a 4% decrease in January 2021. There was an 8% increase in the incidence of unknown primary site cancers in April 2020 followed by an 18% decrease in January 2021. Head and neck cancer incidence decreased by 50% in April 2020, but this increase was no longer significant by June 2020. Endocrine cancer incidence decreased by 33% in April 2020 and then slowly increased over time to 27% higher than the counterfactual in December 2021. Melanoma decreased by 65% in April 2020, then increased to 9% below the counterfactual in May 2020. From April 2020 to December 2021, brain and central nervous system incidence decreased by 26%. Urinary cancer incidence (n = 2982) decreased by 12% ( Figure 4 ). There was no association observed with gynecologic (n = 3228), other digestive (n = 3164), pancreatic (n = 1352), or cancers combined into the other category (n = 1053) ( Figure 4 ).

Figure 5 and eTable 5 in Supplement 1 show the estimated cumulative difference and percentage cumulative difference between the fitted and counterfactual number of cancer diagnoses. As of December 2021, Manitoba had 692 (5.3%) fewer cancers diagnosed than expected in the absence of COVID-19. The largest estimated differences were for breast (273 cases, 14.1% deficit), colon (133 cases, 12.2% deficit), lung (132 cases, 7.6% deficit), prostate (99 cases, 5.6% deficit), urinary (99 cases, 11.7% deficit), melanoma (68 cases, 11.5% deficit), and brain and central nervous system (56 cases, 25.6% deficit) cancers. There was an estimated surplus in the number of cancer cases for rectal (12 cases, 2.4% surplus), hematologic (34 cases, 3.0% surplus), gynecologic (8 cases, 1.0% surplus), pancreatic (25 cases, 7.3% surplus), and cancers combined into the other category (25 cases, 10.3% surplus). There was no deficit or surplus for endocrine cancers.

In this cross-sectional study, we observed a decrease in overall age-standardized cancer diagnosis incidence and incidence for most cancer sites in Manitoba at the beginning of the COVID-19 pandemic. Longer-term decreases in incidence and cumulative deficits in the number of diagnoses were seen for breast, lung, prostate, colon, urinary, melanoma, and brain and central nervous system cancers. The association between the COVID-19 pandemic early on and breast and colon cancer incidence in individuals aged 50 to 74 years and the cumulative deficits may be explained by reductions to Manitoba’s breast and colorectal cancer screening programs during April and May 2020 7 and reductions in the rate of colonoscopies in the province. The increase in rectal cancer incidence above the counterfactual in May 2020 is likely related to the use of a central endoscopy waitlist for most endoscopies performed in Winnipeg and the prompt and appropriate triaging of individuals with suspected rectal cancer. The decrease in breast cancer incidence among women 75 years and older may be related to reductions in diagnostic mammography availability, reluctance to seek medical care during the pandemic, or the impact of COVID-19 on mortality among older adults. 17 , 18

The association between the COVID-19 pandemic and lung cancer incidence differed from breast and colorectal cancers. Lung cancer incidence dropped in December 2020 (wave 2) but only among individuals 75 years and older. This may be partly due to the increased rate of COVID-19 infections in Manitoba in the second and third waves leading to a higher number of deaths among individuals with undiagnosed lung cancer. These individuals were more vulnerable in general as well as to severe COVID-19 outcomes because of advanced age and comorbidities. 19 , 20 These individuals may also have been reluctant to seek health care. 21

Head and neck and melanoma cancer incidence also decreased at the start of the pandemic, likely due to reductions in primary care visits, but returned to prepandemic levels quickly. The decrease in urinary cancer incidence persisted over time without any observed recovery. This may reflect reduced access to cystoscopy, challenges diagnosing and managing urothelial tumors throughout the COVID-19 pandemic, or a decrease in the incidental diagnosis of kidney cancers because of reduced abdominal imaging availability. Brain and central nervous system and endocrine cancer incidence also showed large decreases in incidence but because of the small number of cases, the results must be interpreted with caution. Because the pre–COVID-19 baseline for hematologic cancers is inconsistent and there was no cumulative difference by December 2021, the post–COVID-19 change in hematologic cancer incidence may be due to a random variation.

We found no association between the COVID-19 pandemic and prostate, gynecologic, other digestive, pancreatic, or other cancer incidence. Organized prostate cancer screening for asymptomatic individuals using the prostate-specific antigen test is not recommended in Canada. 22 Because prostate-specific antigen testing is not standardized, the actual practice is variable, which leads to unstable incidence of prostate cancer diagnosis and varying rates of overdiagnosis. Hence, prostate cancer has unreliable counterfactual values. The other cancers for which no association in incidence was observed are frequently diagnosed symptomatically and often have a high fatality rate. Therefore, despite pandemic restrictions, the health care system was still able to diagnose and prioritize these cancers resulting in minimal or no cumulative differences in the number of diagnoses.

Prior studies have evaluated the association between the COVID-19 pandemic and cancer incidence in Canada 23 - 28 and internationally 29 - 31 and also found significant declines in cancer incidence early in the pandemic, although the association for each cancer site differed by jurisdiction. However, most of these studies have important limitations, including using a pre-post study design that inadequately controls for time trends and can bias the estimated differences in the number of cancer cases 23 - 30 ; only including cancers diagnosed at a single center, resulting in a small number of cases and limited generalizability 24 , 25 , 27 , 30 ; and having a short follow-up time that provides no information about the association between the pandemic and cancer incidence over the long term. 23 - 25 , 29 , 31

This study includes several important strengths. First, we used population-based, high-quality cancer registry data. Second, our interrupted time-series analysis had a long preintervention period that permitted the evaluation of outcomes before the start of the COVID-19 pandemic and the inclusion of seasonality and interactions between COVID-19 pandemic onset and time in the analysis. 10

This study has limitations. Although we included the first 3 waves (21 months) of the COVID-19 pandemic, the association between COVID-19 and subsequent waves as well as by area of residence and sex must still be measured. This work is ongoing. We did not adjust for multiple comparisons; hence our results are exploratory. Because the association between the COVID-19 pandemic and cancer incidence may differ between jurisdictions, our results must be interpreted within the Manitoba context. Population-based studies should be performed elsewhere that consider pre–COVID-19 trends in cancer incidence and include sufficient follow-up time. The R code and simulated data we have provided in Supplement 1 will help facilitate this work.

In this study, the COVID-19 pandemic was associated with a significant decrease in cancer incidence in Manitoba, Canada, in May and April 2020, primarily in breast, colon, and rectal cancer incidence. Breast and lung cancer incidence among individuals 75 years and older, urinary, and brain and central nervous system cancers showed sustained decreases. All other cancer sites demonstrated minimal long-term changes in incidence. However, the cumulative deficit for some high-fatality cancers is concerning and needs attention from health care delivery organizations. Because of the heterogeneity in the association between the COVID-19 pandemic and cancer incidence, observational studies should be done to examine this association in other regions.

Accepted for Publication: July 30, 2023.

Published: September 5, 2023. doi:10.1001/jamanetworkopen.2023.32363

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Decker KM et al. JAMA Network Open .

Corresponding Author: Kathleen M. Decker, PhD, Paul Albrechtsen Research Institute CancerCare Manitoba, 825 Sherbrook St, Winnipeg, MB R3A 1M5, Manitoba, Canada ( [email protected] ).

Author Contributions: Dr Decker and Mr Lambert had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design : Decker, Bucher, Singh, Lambert.

Acquisition, analysis, or interpretation of data : All authors.

Drafting of the manuscript : Decker, Bucher, Thiessen, Lambert.

Critical review of the manuscript for important intellectual content : All authors.

Statistical analysis : Decker, Feely, Bucher, Lambert.

Obtained funding : Decker, Bucher, Czaykowski, Singh, Lambert.

Administrative, technical, or material support : Kim, Pitz.

Supervision : Decker, Lambert.

Conflict of Interest Disclosures: Dr Singh reported serving on advisory boards or consulting for Pendopharm, Ferring Canada, Amgen Canada, Roche Canada, Sandoz Canada, Takeda Canada, Bristol Myers Squibb Canada, and Guardant Health. None of these advisory board and consulting activities are related to the submitted manuscript. No other disclosures were reported.

Funding/Support: This work was supported by a research grant from Research Manitoba and the CancerCare Manitoba Foundation (2020-2021; funding reference No. 4459) and the Canadian Institutes of Health Research (2022-2024; funding reference No. 179890).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: We thank Katie Galloway, MSc, and Grace Musto, BSc (Department of Epidemiology and Cancer Registry, CancerCare Manitoba), for providing feedback on this article; Erin Dean, MD (Department of Medical Oncology, CancerCare Manitoba), for assistance interpreting outcomes; and Kelly Brown, MSc (Department of Epidemiology and Cancer Registry, CancerCare Manitoba), for study coordination. These individuals received no compensation for their contributions.

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How Cancer Is Affecting the AANHPI Population

Death rates for certain cancers are two to three times higher for native hawaiian and pacific islanders.

Rachel Nania,

A new report highlights cancer’s burden on one of the country’s fastest-growing populations. While the disease — most commonly diagnosed in older adults — remains the second-leading cause of death in the United States, it’s the top killer among Chinese, Filipino, Korean and Vietnamese Americans, beating out heart disease, according to research published May 1 by the American Cancer Society. Meanwhile, death rates for what health experts consider largely preventable cancers — like stomach, liver and cervical — are two to three times higher among Native Hawaiian and other Pacific Islanders compared with their white counterparts. 

The report is the first of its kind to take a “disaggregated” look at cancer in the AANHPI population, which stands for Asian American, Native Hawaiian and Pacific Islander. Historically, cancer statistics for Asian Americans and Pacific Islanders have been lumped together, says report lead author Nikita Wagle, principal scientist in cancer surveillance research at the American Cancer Society.

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“However, this population is so heterogeneous; there’s so much diversity,” she says. And drilling down and taking a closer look at how cancer affects each group “can better facilitate cancer prevention and early detection,” she explains.

Different groups bear different burdens

The report looked at trends in cancer incidence and deaths, and made these findings.

Prostate, lung and colorectal cancer are leading threats. The most commonly diagnosed cancer in AANHPI men overall is prostate cancer , but there are a few exceptions:

• Lung cancer is the most common cancer among Chinese, Vietnamese, Laotian and Chamorro/Guamanian men.
• Colorectal cancer is the most common cancer among Korean, Hmong and Cambodian men.

Breast cancer is the most common cancer among women in every AANHPI group. However, there’s variation among the groups, ranging from 17 percent of all cancers in Hmong women to 44 percent in Fijian women.

Cancer is diagnosed later in AANHPI individuals. People in AANHPI groups are generally diagnosed with cancer at a later stage compared with white individuals.

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• Notably, about 50 percent of breast cancers in Guamanian, Samoan, Pakistani, Tongan, Laotian and Hmong women are diagnosed at an early stage , when the cancer is most treatable, compared with 68 percent in white women and 73 percent in Japanese women.

Death disparities are striking for certain cancer types. Overall, Asian Americans are 40 percent less likely to die from cancer than white individuals in the U.S., but they are nearly 40 percent more likely to die from liver cancer and twice as likely to die from stomach cancer. Meanwhile, those in the Native Hawaiian and Pacific Islander groups have a 7 percent lower overall cancer mortality compared with white Americans, but death rates are 30 percent higher for breast cancer, 75 percent higher for liver cancer and roughly two to three times higher for cervical, stomach and uterine (endometrial) cancers.

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Lung and breast cancer are the leading killers. Lung cancer is the leading cause of cancer death for all AANHPI groups. It’s also the leading cause of cancer death for women, except Filipino, Asian Indian, Samoan and Guamanian women, among whom breast cancer leads.

Survival rates are lower for many. With the exception of Asian Indian individuals, AANHPI groups have a lower overall five-year cancer survival rate compared with white individuals.

A ‘culturally tailored’ approach   

A number of factors fuel the disparities highlighted in this report, researchers say. Some ethnic groups within the AANHPI population are more likely to have obesity , which is a risk factor for several types of cancer, including liver, breast and stomach. Others are more likely to smoke or face barriers to screening and treatment. That is why promoting preventive behaviors and cancer resources throughout the AANHPI population is needed, Wagle says. “However, it has to be from a culturally tailored lens, [so] that we can connect with some of these groups in a better way,” she adds. 

The term “Asian” refers to a person with origins in the Far East, Southeast Asia or the Indian subcontinent, the report states, encompassing about 24 million people in the U.S. The term “Native Hawaiian and other Pacific Islander” refers to people from Hawaii, Guam, Samoa, Tonga or other Pacific islands throughout Polynesia, Micronesia and Melanesia, roughly 1.7 million people in the U.S.

“It’s essential that we acknowledge the diversity of the Asian American, Native Hawaiian and other Pacific Islander population. Consideration of cultural appropriateness, translation into native languages, improved access to health care and patient navigation could help increase knowledge and uptake of cancer screening and preventive services,” Ahmedin Jemal, senior vice president of surveillance and health equity science at the American Cancer Society, said in a statement.

Rachel Nania is an award-winning health editor and writer at AARP.org, who covers a range of topics including diseases and treatments. 

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