The Long Road to Recovery, Part IV: Cancer Screening in the U.S. (Munson Healthcare, Michigan)​

For the final installment of our series about the impact of COVID-19 on cancer screening rates across the U.S., we visited ACCC member institution Munson Healthcare in Traverse City, Michigan. COVID-19 came late to Munson Healthcare, which has seen screening rates fall significantly. We talked to Kathleen LaRaia, executive director of oncology services, about the evolving pace of cancer screening in Michigan.

(Previous profiles in this series include Mary Bird Perkins Cancer Center in Louisiana, St. Elizabeth Healthcare in Kentucky, and the Helen F. Graham Cancer Center & Research Institute at ChristianaCare in Delaware.)

During the past 18 years, Michigan has seen an overall downward trend in all-site cancer incidence. Prostate cancer is the most commonly diagnosed cancer among Michigan men, and breast cancer is the most commonly diagnosed cancer in women. Lung cancer is the leading cause of cancer death in the state.

State-wide cancer control priorities target breast, cervical, colorectal, and lung cancers due to the burden of these diseases in Michigan. In its 2020 report on the incidence of cancer in the state, Michigan’s Department of Health and Human Services highlighted “identifying and eliminating disparities within the cancer care continuum” as a state-wide priority. Data show disparities among diverse and minority Michigan populations in incidence and outcomes for colorectal cancer, prostate cancer, breast cancer, and lung cancer.

Among U.S. states, Michigan ranks 20th for incidence and 15th for mortality for lung and bronchus cancer. According to the most recent American Lung Association (ALA) State of Lung Cancer report, in 2021, 8% of Michigan’s residents at high risk for lung cancer (USPSTF 2013 recommendation criteria) were screened, significantly higher than the national rate of 6%. However, the ALA also reports that smoking rates in the state are greater than the national rate of 15%, and the rate of lung cancer diagnosed at an early stage is lower than the national rate. The population of Indigenous Peoples (American Indians/Alaska Natives) in Michigan has the highest rate of new lung cancer cases, 110 per 100,000 population. The ALA report notes that among Indigenous Peoples in Michigan, 16% of lung cancers are diagnosed at an early stage compared to the 23% early-stage diagnosis rate in the state’s White population.

COVID-19 Arrives Late in Northern Michigan

Michigan’s two-peninsula geography is unique—southern Michigan includes the Detroit metro area (home to about half the state’s population) and most of the state’s larger cities, while northern Michigan is more sparsely populated and largely rural. Bordering on four of the five Great Lakes, Michigan is renowned for its inland lakes and unspoiled wilderness areas—most famously in the Upper Peninsula. Scenic areas of spectacular natural beauty and abundant recreational opportunities make northern Michigan a vacation and tourist mecca.

Traverse City is home to Munson Healthcare, a relatively young healthcare system that serves a 30-county area. The flagship Cowell Family Cancer Center in Traverse City opened in 2016 and serves as the hub for Munson’s eight oncology clinics located throughout northern Michigan. “Our population in the Grand Traverse region is about 200,000, and it grows seasonally to 300,000,” said Kathleen LaRaia, executive director of oncology services at Munson Healthcare. “But during the summer, the region attracts over a million tourists annually.”

In response to the federal public health emergency brought on by the pandemic, Michigan instituted COVID-19 safety protocols in March 2020. At that time, COVID-19 rates were surging in Detroit and some areas of the more populous southern part of the state. However, at that time, the pandemic was not yet affecting the Grand Traverse region and the more rural northern areas. Nevertheless, Munson Healthcare followed state protocols and was “very proactive,” said LaRaia. “We stopped all of our elective surgeries, mammography screening, colonoscopies, and low-dose CT scans.” In short, all the usual pathways to cancer screening in the health system were closed. At the end of May 2020, the area had not yet experienced a COVID-19 surge, and cancer screening services were reopened.

Before Munson could resume mammography and other cancer screening services, appointment schedules had to be reconfigured to allow more time for cleaning and social distancing, staff workflows had to be adjusted as hours were extended, plexiglass had to be installed in the reception areas, and a COVID-screening procedure had to be implemented.

But screening suffered. Prior to the March 2020 shutdown of services, “We were diagnosing eight to 12 [breast cancer] patients a week,” LaRaia explained. The cancer program holds a breast tumor conference every Tuesday at which new cases are presented to the multidisciplinary team. “Three to four weeks after we stopped our screening mammograms, there were no more patients for our tumor conference. We actually did not have a tumor conference for five weeks.” Comparing the one-year time period between July 2019 and June 2020 to the one-year time period between July 2020 and June 2021, Munson Healthcare breast cancer screening rates dropped 13%.

By late fall 2020, a COVID-19 surge arrived in Traverse City. “During that first pandemic year, we had the highest volume of cancer patients that we’ve ever served,” LaRaia recalled. The capacity for patients to access care close to home was critical during this time. Michigan’s two NCI-designated cancer centers are located in the southern area of the state, about a four-hour drive from northern Michigan. With the pandemic surging, patients were encouraged to receive their care close to home and were able to avoid disrupted care by continuing their treatment through Munson Healthcare’s hub-and-spoke model of cancer programs.

Impact on Community Outreach

As in other areas of the country, COVID-19 surges during the past two years have led to the cancellation, postponement, or downsizing of planned community outreach and cancer screening events. “In northern Michigan, we have the highest rate of young (i.e., before age 50) female breast cancer incidence in the state,” LaRaia said. The area is also seeing an uptick in young (i.e., before age 50) colorectal cancer incidence.

Community outreach and screening are priorities for the Munson Healthcare cancer program. Although LaRaia had hoped to launch a consumer screening campaign in summer 2021, her plans were modified due to the regional spike in COVID-19 cases. But on Saturday, October 30, 2021, the cancer center was able to safely hold a scaled-down version of its previous breast cancer screening blitz. “We did a similar event in 2019, and I believe we had almost 140 appointments scheduled that day,” LaRaia said. For the event in October 2021, the health system scheduled 45 screenings at several Munson locations. As a result of the screening event, LaRaia said she was able to fill more screening appointments throughout the month and into November: “Out of the 45 screenings, we had three call backs and one biopsy that was benign. That’s still a high percentage rate for such a small number. That’s why it’s so important for us to get out there.”

The pandemic also curtailed a long-planned colorectal cancer awareness campaign. “We had a project scheduled called ‘Rollin’ with the Colon,’” said LaRaia. “We had an inflatable colon that you could walk through as you came into the cancer center. We had a panel of physicians—a GI physician, a colorectal surgeon, a medical and a radiation oncologist, and a genetic counselor ready to present to the community. It was scheduled for March 7, 2020, and we had to cancel.” In the interim, the health system’s multidisciplinary expert team of providers developed a standardized colon cancer screening guideline to support decision-making for consumers and primary care providers in the community. The guideline, which is available on the health system’s website, explains when a home test may be appropriate and when a sigmoidoscopy or colonoscopy may be needed. “It’s guidance for the patient so that, if nothing else, they can start with a home test,” said LaRaia.

Through its website, Munson Healthcare offers online risk-assessment tools for prostate, lung, colorectal, and breast cancers. Consumers can use these to determine whether they are at high risk for the disease. Lung cancer screening information is also easily accessed on the health system’s website, which has an “Ask-a-Nurse” program with contact information so individuals who want more information or have questions but do not have a primary care provider have a place to turn.

Weathering This Winter’s Surge

At the end of 2021, the Traverse City region—like many areas in the U.S.—was in the midst of a significant spike in COVID-19-positive cases. On November 9, 2021, Munson Healthcare announced that it was experiencing a 22% community positivity rate in northern Michigan, adding that the rate was “higher than the state overall [rate] and nearing the highest it’s been at any point during the pandemic."

In a message posted on the health system’s website in November 2021, Munson Healthcare CEO and President Ed Ness explained that Munson was elevating its pandemic response plan to level red, signifying that “we are prioritizing pandemic-related care and will be shifting resources to the highest areas of need.” But Dr. Ness also encouraged people to “not delay necessary care or preventive screenings.”

Although the health system is seeing more admissions than in its previous two surges, Kathleen LaRaia emphasizes Munson’s preparedness. “We have PPE. We know how to treat patients with COVID-19, and we are providing monoclonal antibodies.” LaRaia stresses that the infused monoclonal antibody treatment for COVID-19 is not administered in the cancer center’s infusion area: “We have been creative and found other areas for this so that people can come in, get their treatment, and not expose others.”

Unfortunately, LaRaia believes that it is highly likely that northern Michigan will see an increase in late-stage cancer cases as a result of the COVID-19 pandemic: “We were already an at-risk community prior to the pandemic. We knew we needed to do more community outreach because of our high incidence rate, and so I can only imagine that this has compounded that.”