With the advent of SARS-CoV-2 and the resulting pandemic COVID-19, physicians are facing unprecedented disruption of normal operations. Worldwide, hospitals and clinics have been compelled to postpone routine screenings and elective procedures. Fears of exposure also led patients to cancel appointments, delay rescheduling or even skip annual screenings altogether.

For patients with heart disease and cancer, the two leading causes of death globally, the potential effects may be dire not just in the near term, but for years to come.

As a leading global medical technology and life sciences company, GE Healthcare acknowledges that imaging has played a large role in tackling the pandemic. With our intensive focus on the most advanced cardiology and oncology equipment, we're assuming a leadership role to support physicians in making faster, more informed decisions with our intelligently efficient devices, data analytics, applications and services. The need may have never been more urgent than it is now, and here's why.

The Centers for Disease Control and Prevention recently reported that from a survey of more than 4,900 adult respondents, as of June 30, approximately 41% reported avoiding medical care because of concerns related to COVID-19, including 12% that avoided urgent or emergency care and 31.5% that avoided routine care.

Effects have been most noticeable in both cardiology and oncology. A Gallup poll conducted March 28 – April 2, 2020 of 7,276 American adults asked, "If you needed medical treatment right now, how concerned would you be about being exposed to coronavirus at a doctor's office or hospital?" Among respondents, 48% with heart disease said they were "very concerned" and 38% were "moderately concerned." Among those with cancer, 39% were “very concerned” and 50% were “moderately concerned.”

As a result of the pandemic's affect on cardiology and oncology, imaging, mobile diagnostics, and monitoring devices have become even more critical to efficient and seamless delivery of healthcare services. GE Healthcare has the world’s largest installed base of all three, with over 4 million systems worldwide.

Over 80% of GE Healthcare’s imaging systems are connected through iCenter, a secure, cloud-based asset maintenance and management software tool, for remote monitoring, enabling diagnostic consultations with skilled, off-site engineers, predictive maintenance and asset management analytics.

According to iCenter data, actual scanning volume of GE imaging systems globally was down by as much as 43% in mid-March 2020, and with an average dip by at least 20% over a two-month period, before fully recovering to pre-COVID levels. Scanning volumes with GE mammography and with interventional & vascular imaging equipment, two modalities dedicated to the detection and treatment of cancer and heart disease respectively, saw even further concentrated drops before recovering.

Heart Patients Noticeably Absent

Cardiovascular diseases are the leading cause of death globally. And while COVID continues to surge, having killed 1.4 million globally thus far, heart disease continues to impact millions everywhere.

Heart patients who contract COVID-19 can experience cardiac injury, arrhythmia and myocarditis leading to heart failure. Other studies have identified cardiac infections, along with cardiac involvement and myocardial inflammation.

"Myocardial inflammation can be characterized by advanced cardiac imaging," said Ashutosh Banerjee, General Manager of Cardiology Solutions at GE Healthcare. "Cardiac echo, MRI and CT have become important tools to understand cardiac impact on COVID patients."

"We have been estimating an influx of cardiology patients post-COVID," said GE Healthcare’s Global Cardiology Strategist LeaAnne Dantin. "That's due to patients who have had COVID and suffer the effects of the virus strains, and from medications necessary to treat the virus. Another population is patients who have neglected to be seen by a cardiologist, and because of those factors, elective procedures decreased by more than 50%, and in some cities up to 70%."

Additionally, Dantin said, this myocarditis and its inflammation differs from what cardiologists have seen previously. It is a unique pattern of cell damage likely due to a combination of direct viral injury and cardiac damage due to the host’s immune response. "During autopsy, it's revealed that about 40% of deaths are related to cardiology conditions from the virus," she said.

The way many things "used to be done" is no longer relevant in a COVID world, Banerjee and Dantin say.

"Right now, we collaborate with clinicians and opinion leaders on research projects, help make sense of the immense data that is being recorded, and devise new solutions and standards of care to be sure they're ready when volume returns to hospitals," Banerjee said.

The goal is to provide decision support tools to help treat more quickly and efficiently, with an emphasis on prevention, reduced exposure time, and precision monitoring, and to obtain information quickly in a remote setting—without having to be in front of a patient, said Dantin.

"However, the focus remains on the patient and not the process," she said.

Meanwhile, that decision to avoid seeking care has coined the inevitable question: "Where have all the heart attacks gone?"

Late Patients Reduce Their Opportunities

On June 3, the European Society of Cardiology likened the "collateral damage" of COVID-19 to being "the next pandemic wave." It cited a survey of more than 3,000 health professionals from 141 countries on six continents showing a major decline in patients admitted to the hospital for heart attack during the pandemic—similar findings were reported for stroke patients. When patients did present, they were often too late for effective emergency intervention, reducing opportunities for survival and morbidity.

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Interventions Are Not Elective

One intervention showed dramatic decreases. Early September, data reported in Catheterization and Cardiovascular Interventions from 48 states and 360 unique cardiac catheterization laboratories showed percutaneous coronary intervention volumes dropped by 55%, transcatheter aortic valve replacement volumes dropped by 64% with cardiologists reporting an increase in late presenting ST‐elevation myocardial infarctions and deaths among patients waiting for transcatheter aortic valve replacement.

This resulted in "unprecedented large‐scale procedural deferrals, plummeting procedural volumes, and negative impacts on patient outcomes," the study authors said.

The phenomenon wasn't confined to the U.S, or to major health systems in major cities. In American Heart Journal Plus: Cardiology Research and Practice a tertiary hospital in England reported a 48.5% drop in its cardiac catheterizations.

"We need to remind people that heart interventions are not elective," said Banerjee. "If they have heart pain or are in some type of discomfort, they need to go to the ER. Interventions are still required, diagnoses are still available, and one of the safest places to go is the hospital."

GE Healthcare’s vision for precision health is to provide the right outcome for the right patient, delivered at precisely the right point of care. To that end, GE Healthcare's MAC ECG™, Vscan™, Vivid™ cardiac ultrasound, CT and MRI are part of the comprehensive suite of cardiac evaluation tools, Banerjee said. Those initiatives are supported by Edison, GE Healthcare's intelligence platform that is designed to help achieve greater efficiency, improve patient outcomes, and increase access to care.

And as cath labs look for increased efficiencies in the COVID environment, inventory management is critical, and can benefit from GE Healthcare's Interventional Cardiology Insights (ICI) solution, also built on Edison. It also connects to Centricity™ Cardio Workflow, a framework for all data and information management.

Respecting Time to Diagnosis and Treatment

Cancer doesn't typically create the same kinds of sudden, acute symptoms as heart disease. Mask-wearing and social distancing are highly effective to discourage COVID-19 transmission, but as with heart disease, they can't stop cancer.

"Delay in diagnosis can ultimately lead to cancer presentation at more advanced stages, resulting in poorer clinical outcomes," said GE Healthcare’s General Manager of Oncology Solutions, Dr. Ben Newton. "Even a delay of two or four weeks, with some cancers, makes a huge difference in terms of those outcomes. Time to diagnosis and time to treatment are so important."

Those facts, he said, are supported by a November 2020 systematic review and meta-analysis in The BMJ⁵ journal that found the impact of cancer treatment delay on mortality can now be quantified for prioritization and modeling. "Even a four-week delay of cancer treatment is associated with increased mortality across surgical, systemic treatment, and radiotherapy indications for seven cancers," the authors wrote.

As an example, a study that reflected on 10 months of clinical activity in the United Kingdom during the pandemic in Nature Reviews Clinical Oncology admitted that "cancer services have been badly hit." Out of approximately 1,800 patients, two in three reported that their cancer care had been affected, and one in three reported changes in treatment.

In England, some 3.4 million fewer key diagnostic tests or –35% were performed between March and August 2020 compared with the same period in 2019.

“There’s really almost no way that doesn’t turn into increased mortality,” with the full effects likely to play out over a decade, Ned Sharpless, director of the National Cancer Institute, told the Wall Street Journal, as he reflected on decreased cancer screenings overall.

Rebound Signals Patient 'Catch-Up'

Treatment centers documented the decline. GenesisCare, formerly 21^st Century Oncology, one of the world's largest cancer treatment providers, reported in mid-October that its facilities worldwide saw an increase in patients presenting with advanced (metastatic) disease, increasing the risk of mortality, and that a noticeable decline was reported in new patient cases since the COVID-19 pandemic started.

"In the U.S., physicians have recorded a double-digit percentage of declines in new patient cases for curative breast, lung, and prostate cancers," the company said in a statement. In November, GE Healthcare and GenesisCare announced a strategic partnership aimed at improving patient outcomes for both cancer and heart disease.

In August, a report in JAMA Network Open, done in conjunction with Quest Diagnostics, found a significant decline in newly identified patients with six common types of cancer—breast, colorectal, lung, pancreatic, gastric, and esophageal—mirroring findings from other countries. The authors noted that the Netherlands Cancer Registry saw as much as a 40% decline in weekly cancer incidence.

Among the senior population, a study of more than 6 million Medicare beneficiaries found that at the peak of the pandemic in April, screening for breast, colon, prostate, and lung cancer were lower by 85%, 75%, 74%, and 56%, respectively. The report in JCO Clinical Cancer Informatics determined that decline in cancer screening rates, physician E&M visits, and administration of cancer therapies will likely translate into both a stage migration to more advanced cancer at diagnosis and higher cancer mortality among senior citizens in the United States.

GE Healthcare saw usage of its diagnostic imaging equipment decline to around 30% of normal levels from March until June, said Newton. "But for July to September, a rebound occurred for use of contrast agents and molecular imaging agents—gradually returning to pre-COVID levels, an indication that screening and diagnostic volumes are recovering. But we still have this group of people that should have been seen from March until now, patients that have been missed and will still need to be screened and diagnosed."

The Technological Future Is Here

Newton said nimble adaptation to the virtual world of telehealth and its technologies has been necessary during COVID—and has sped up their adoption in many institutions.

"We must provide the technology and solutions to care for patients from a virtual and connectivity standpoint," he said.

He cited GE Healthcare oncology solutions designed to help cancer care providers gain the upper hand with an innovative suite of diagnostic and treatment technologies that improve detection, clinical and operational efficiency and outcomes, and lead to precision cancer care along the pathway.

Newton also said separating vulnerable patients from those infected with COVID, and diagnostic care from routine care, will be a new way of doing things. This means rapid, mobile diagnostic centers will be needed, along with modular solutions for imaging, chemo treatment, and even waiting rooms that can be placed quickly for cancer screening and diagnosis—away from usual hospital settings.

"Think of this as an enactment of social distancing in the context of clinical care," he said. "These changes are here to stay, and we must hone and scale what we can do for customers and patients perhaps in even more dramatic and sustainable ways than we thought."

Innovation Comes in a Box

An example of such innovation is GE's prefabricated cabin outside Henri-Mondor University Hospital in Créteil, France, near Paris, a model that's been sent in multiples to the United Kingdom. The "CT in a box" is a modular machine that captures the same robust imagery of traditionally installed CT scanners, and also smoothes patient flow across the hospital.

"It's one example of how we've been able to support our customers and patients and we’ve been able to do this over and over, all over the world, as we entered this different space," Newton said.

Since providers must also separate, or minimize direct contact under COVID protocols, the NAVIFY Tumor Board, in conjunction with Roche, addresses that need with fully digital workflow solutions. These enable a more comprehensive view of each patient so specialists may review all relevant files quickly where they are and align on the best possible personalized treatment.

Another example of how GE Healthcare has focused efforts around the pandemic has been to shift focus and capabilities from developing imaging tools from cancer and cardiology to a focus on COVID pneumonia, Newton said.

"The collaboration with academic centers globally, in particular the University of Oxford, includes using that data to develop algorithms that predict which patients are going to be susceptible to more detrimental aspects of COVID infections," he said.

"We've repurposed the kind of machinery we've always had that was focused on quality, and utilizing data science, we can try to identify ways of predicting who will be affected worse, so they can be triaged, protected and monitored more closely since they might be more susceptible," he said. "That could help in coming months and years to prevent damage and treat earlier—both really positive things to do."

1 “Characteristics Associated With Out-of-Hospital Cardiac Arrests and Resuscitations During the Novel Coronavirus Disease 2019 Pandemic in New York City,” JAMA Cardiol. 2020;5(10):1154-1163. doi:10.1001/jamacardio.2020.2488

2 “Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy.” July 30, 2020; N Engl J Med 2020; 383:496-498
DOI: 10.1056/NEJMc2010418.

3 “The Covid-19 Pandemic and the Incidence of Acute Myocardial Infarction,” August 13, 2020; N Engl J Med 2020; 383:691-693; DOI: 10.1056/NEJMc2015630

4 “Cardiology and COVID-19.” JAMA. 2020;324(12):1131-1132. doi:10.1001/jama.2020.15088

5 Mortality due to cancer treatment delay: systematic review and meta-analysis. BMJ 2020;371.04 November 2020.

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