As the country plunged into recession between 2008 and 2012, something unexpected happened: An earlier small decline in the number of new cancer cases became a much bigger one.
The authors of a published last month by the Cancer Prevention Institute of California believe they have a plausible explanation for the trend: People who lost their incomes or health insurance during that time were less likely to get routine screenings or visit the doctor.
The researchers鈥� analysis of data from the , published in the journal Cancer Causes &聽Control, shows that in the state鈥檚 30 largest counties, cancer diagnosis rates during the recession and subsequent recovery dropped by 3.3 percent annually for males and 1.4 percent for females 鈥斅爉uch faster than the average decline of 0.7 percent for males and 0.5 percent for females documented over the previous decade.
A 聽in the Journal of Cancer covering the years from 1973 to 2008 found that the incidence and treatment of cancer in the United States dropped during recessions and with increased unemployment rates. During such periods, patients were perhaps more likely to forgo tests for early detection or ignore symptoms due to financial consideration, the researchers suggested.
The recent study from California buttresses that earlier finding.聽The largest drops were seen in the rates for prostate, lung and colorectal cancers. The declining rates of most cancers were especially noteworthy given the growing population of aging Baby Boomers, since cancer is more common later in life.
If people did delay getting screened for early-stage cancers during the recession, 鈥渕ight we then start seeing an uptick of late-stage cancers?鈥� wondered Scarlett Lin Gomez, the study鈥檚 lead author and a researcher with the Cancer Prevention Institute of California.
Dr. Jennifer Hastings, who was not involved with the study, expects that to be the case. She is director of the transgender health care program for Planned Parenthood Mar Monte, which serves 29 counties in California and 13 in Nevada. The clinics screen for breast, cervical and colon cancer.
Hastings said doctors at her clinics started seeing more patients with advanced cancers and other serious illnesses starting in 2014, as previously uninsured people obtained coverage under the Affordable Care Act and began seeking care.
鈥淭here was great surprise about how sick people were,鈥� she said. With the fate of the ACA now in limbo, Hastings said she鈥檚 very concerned about those people losing coverage.
Michelle Quiogue, a family doctor with Kaiser Permanente in Bakersfield and president-elect of the California Academy of Family Physicians, said she frequently sees patients make medical decisions based on the cost of care.
鈥淓ven when people have insurance, they will delay care if the cost share is too high,鈥� Quiogue said.
During the recession, a number of her patients lost their job-based health insurance and stopped coming in for regular check-ups, she said. They didn鈥檛 return until they gained insurance under the ACA.
Lisa Schlager, vice president of community affairs and public policy for , a Tampa, Fla.-based nonprofit advocacy group focusing on hereditary ovarian and breast cancers, said it鈥檚 common for people to wait to seek treatment because they don鈥檛 have insurance or don鈥檛 have the money to pay medical bills or high deductibles.
Schlager recalled a woman who was between jobs when she felt a lump in her breast. The woman decided to wait until she found a new job 鈥斅爐hen waited a few more months before her employer-sponsored insurance kicked in. By the time she went in for an exam, her cancer had advanced. She died of it.
鈥淚t鈥檚 sad, but it鈥檚 a reality in our country that money a lot of times drives the medical services that people receive or seek out,鈥� Schlager said.
However, the state of the economy is not the only factor that can explain the drop in cancer diagnoses during the recession.
Dennis Deapen, director of the Los Angeles County Cancer Surveillance Program and a professor at the University of Southern California鈥檚 Keck School of Medicine, offered some alternative explanations for the declines in diagnoses of certain cancers, including prostate, lung and colorectal.
鈥淚t struck me that there鈥檚 good reason that those particular cancers would have been declining over that period, regardless of economic factors,鈥� he said, noting that prostate cancer diagnosis rates, which dropped 6.3 percent annually during the study period, 鈥渉ave been plunging for years.鈥�
That鈥檚 largely attributable to evolving guidelines for prostate cancer screening.
In 2008, the U.S. Preventive Services Task Force recommended against routine screening for prostate cancer among men over 75; in 2011, it recommended against the routine use of prostate-specific antigen screening in healthy men. Prior to that, Deapen said, prostate cancer was actually over-diagnosed.
Lung cancer diagnosis rates also have been dropping in recent years, at least partly due to a decrease in smoking, especially in California, he added. And colorectal cancer has declined because improved screening techniques have allowed for the removal of precancerous polyps.
Deapen said the diagnosis of some other cancers, including melanoma, is more likely to be influenced by economic factors. Melanoma often is discovered because a patient asks a doctor to check a mole, or the doctor independently notices it during a medical visit.
鈥淚f you鈥檝e lost access, that doesn鈥檛 happen,鈥� Deapen said. The incidence of melanoma flattened or showed slight declines during the recession years, compared with annual increases in the previous decade.
Deapen said he is interested to find out whether increased access to health care under the Affordable Care Act will have the opposite effect of the findings described in the study, allowing more people to get diagnosed 鈥斅燼nd treated 鈥斅爀arlier.
He cited evidence that the ACA led to earlier diagnosis and saved lives. Without solid details about a replacement plan, he said he wasn鈥檛 ready to comment on whether that trend might be reversed if the law is repealed.
This story was produced by , which publishes , an editorially independent service of the .