A little bloating hardly seemed like something to worry about in the middle of a global pandemic.

It started gradually enough that Pat Wales can’t quite nail it down. She felt fine on a vacation to Mexico in late summer 2019, then noticed her abdomen slowly distending in the months after they returned home to Westminster.

Something was off, but then COVID-19 hit, and the problem didn’t seem urgent enough to get a doctor’s attention in the midst of all that.

“I was under the impression that there was no point in seeking an appointment for something as minor as bloating,” she said.

While many relatively benign conditions can cause bloating, Wales, 83, didn’t get good news when she finally saw a doctor in March 2021. She had ovarian cancer, which had progressed to stage 3B, meaning it had spread into other parts of her abdomen, but not to more distant organs. It’s difficult to know at what point the cancer stopped being curable, but an earlier diagnosis might have allowed her to avoid the prospect of having to keep fighting recurrences.

“It’s going to be this endless cycle until I die,” she said.

It’s not clear how many people in Colorado might be in a similar situation, suffering from conditions that might have been manageable or curable but spiraled out of control when their health care was disrupted by COVID-19. Several key types of care still haven’t rebounded to pre-pandemic levels in Colorado, but it could be years before anyone knows whether that led to a measurable increase in premature deaths.

Cancer screenings and routine wellness visits dropped in 2020 both in Colorado and nationwide, and while they rose again in 2021, it wasn’t enough to catch up on all the care that was missed the prior year. While full data isn’t yet available from 2022, experts believe patients haven’t fully caught up on care they postponed.

“Overall, the general pattern is that services have rebounded to pre-pandemic levels,” said Julius Chen, an assistant professor of health policy and management at Columbia University. “We would hope to see more than pre-pandemic levels.”

The extent to which that’s a problem depends on who missed care, and which services they missed. If a generally healthy young person skipped a routine wellness visit, that’s less risky than if someone with high blood pressure and diabetes went without seeing their doctor.

Dr. Teuta Shemshedini, an obstetrician and gynecologist at Boulder Valley Women’s Health Center, said it’s a “fine balancing act” to work through the backlog of people wanting to catch up on care they missed earlier in the pandemic, while leaving space to get those at highest risk in quickly.

At the Women’s Health Center, they’ve added Friday afternoon appointments to serve more people, made it easier to schedule mammograms and Pap smears online and done social media promotions to try to reach people who might be focused on other things, Shemshedini said. The “bottleneck” is starting to clear somewhat, but demand is still high, she said.

“We’re probably not out of it yet, but we’re making some positive moves,” she said.

Colorado cancer screenings dropped sharply

Nationwide, screenings for breast, cervical and colorectal cancer rebounded quickly after the spring 2020 stay-at-home orders, but then dropped again through the end of 2021, according to a study of about 300 million people’s records by Trilliant Health, a health care analytics company.

The state-level data didn’t look as closely at the timeline, but showed Coloradans still weren’t getting screened for cancer at pre-pandemic rates at the end of 2021. Colorado had the fourth-steepest drop in cervical cancer screening rates from the fourth quarter of 2017 to the fourth quarter of 2021, and the sixth-largest drop in breast cancer screening rates in the same period. In both cases, the state moved from the top half of performers in getting its residents screened to the bottom half.

Colorado had one of the smallest drops in screening for colorectal cancer, though, and actually moved up in the rankings.

It’s not clear why the results were so different depending on the type of cancer screening, said Alli Oakes, director of research at Trilliant Health. Even before the pandemic, screening rates were influenced by a complex web of factors, including trust in the health care system, insurance coverage and how easily patients can make and get to appointments, she said.

There could be multiple reasons screenings stayed low in 2021: people may be worried about the cost of care as they deal with other rising prices, they may still be reluctant to get care in person for fear of the virus, or they may be more likely to ignore their doctors’ recommendations if they thought the threat of COVID-19 was overblown, Oakes said.

“We definitely didn’t see the rebound that was needed to make up the screening that was missed in 2020,” she said. “It’s hard to say that it’s all related to COVID, but COVID was a paradigm shift.”

It’s too early to know the exact impact, but some health systems have shown an increase in patients diagnosed with cancers that had already metastasized in 2021, compared to pre-pandemic levels, Oakes said. It’s difficult to know how much of that increase was due to the pandemic, though, because cancer screenings started decreasing in 2017.

Much of the data about the effects of delayed care has come from European countries, which have centralized health care systems. One recent study, from the United Kingdom, found a 26% decrease in lung cancers identified during the first three months of the pandemic, followed by a 2.2% increase in cancers diagnosed at stage four, the most severe stage.

The biggest concern is not the people who delayed their mammograms or colonoscopies by a few months, but the ones who never got around to rescheduling and are years overdue, Chen said. Some people’s tumors grow faster than others, but a multi-year delay increases the odds a cancer will be diagnosed when it’s no longer curable, he said.

At least in the first year of the pandemic, fewer people received cancer care along the Front Range. All cancer-related visits were about 22% lower from March to December 2020 than during the same period in 2019, with the biggest decrease for breast cancer, according to a report from the Colorado Health Institute. Since there’s no particular reason to believe cancer incidence dropped that dramatically, it suggests some people didn’t know they had the disease, or knew and felt they had to delay treatment.

For most of that period, people weren’t prohibited from seeking care. Colorado’s ban on nonemergency procedures, enacted because of concerns the state didn’t have enough personal protective equipment to care for COVID-19 patients and others experiencing emergencies, only lasted from March 23 to April 26, 2020.

Allie Morgan, director over internal research at the Colorado Health Institute, said the stay-at-home order was just one of multiple factors contributing to the drop. Some people who could have gotten care were frightened of getting the virus at their doctor’s office, and others felt they were “doing their part” by not taking up resources for non-emergencies, she said in a webinar.

Unequal drops in care

Visits to all health care providers along the Front Range were down by about 25% from March through December 2020, according to the Colorado Health Institute. Wellness visits had the biggest drop, and fewer people than expected were screened for high blood pressure, diabetes and high cholesterol.

Visits for depression, anxiety and substance use disorders also dropped, as did visits to emergency departments. The numbers include telehealth visits, and without those, the decline would have been even more pronounced, Morgan said.

It’s possible that some of the visits didn’t happen because people weren’t getting routine respiratory viruses or injuring themselves when they were staying at home, said Spencer Budd, a policy analyst at the Colorado Health Institute. That doesn’t explain the extent of the drop, though, he said.

While outpatient visits rebounded to near-normal levels in September 2020, that didn’t make a dent in the backlog from spring and summer, Budd said.

“There wasn’t a surge to make up for missed appointments,” he said.

Providers typically don’t have large numbers of unfilled appointments, so it’s not as simple as rescheduling everyone who would have gotten routine care in April 2020 to come in a few months later, said Dr. Greg Berman, executive medical director of operations at Kaiser Permanente Colorado. It’s been easier for them to catch people up because their system provides most care in-house, meaning a patient who comes in for an eye exam can be flagged and sent for a lab test or blood pressure check during the same visit, he said.

“You’ve already got May and June booked because there’s normal demand,” he said.

Berman said Kaiser Permanente Colorado had about 8% to 10% more visits in 2022 than was typical before the pandemic. Some patients, particularly those with compromised immune systems, still aren’t completely comfortable receiving care in-person, so they’ve expanded phone and video visits to try to reach those people, he said.

“You have to make it super-easy and convenient for your patients,” he said. “We want to close these care gaps.”

The state doesn’t have data on whether the full range of health care rebounded in the second year of the pandemic. An analysis of data from the Colorado All Payer Claims Database found routine wellness visits hadn’t quite reached pre-pandemic levels in 2021, though they came close for people with commercial insurance or Medicare Advantage plans.

The Colorado Health Institute report did raise some concerns about who missed care, at least in the early stages of the pandemic. People over 65 and those diagnosed with asthma, diabetes, high cholesterol or high blood pressure were more likely than other adults to miss care. White and Asian Coloradans saw bigger decreases than people of other ethnicities, and children between 2 and 4 had a bigger drop than older kids.

Some of the difference may simply reflect who was most likely to have appointments in the first place, since healthy young adults tend to see doctors less often than older people, those with chronic conditions and toddlers, who need frequent shots and developmental screenings, Budd said. It’s also possible that older people and those with existing health problems were more worried about the virus and decided to avoid going for in-person care, he said.

Coloradans continue delaying due to costs

As of this spring, some Coloradans still reported they were putting off care. In April 2022, about 45% said reported they had postponed medical or dental care at some point in the previous year, according to the Colorado Health Foundation’s Pulse poll. That was up from summer 2021, when about 39% of people said the same thing.

Coloradans who didn’t have insurance, or were worried about losing it, were more likely to postpone care. So were those who reported they had trouble affording food, people with disabilities and those who said they’d been discriminated against in medical settings. It’s not clear how many people would have said the same thing before the pandemic, because the cost of health care has been a concern for years.

Shemshedini said she’s noticed increasing concerns from patients about the possibility of unexpected health care costs, given that inflation is already squeezing many people’s budgets. And, of course, seeking out routine care isn’t top of mind for everyone, especially people of color, immigrants and LGBTQ people, she said.

“I think we’ve had to be a little more proactive in reaching people,” she said.

Wales, the Westminster woman who delayed seeking medical care that could have identified her cancer sooner, encouraged others to get unusual symptoms checked out — even if they seem minor.

She underwent surgery and chemotherapy in April 2021, and had to have another surgery in mid-January after doctors spotted cancer on her spleen. She expects to start another round of chemotherapy in a few weeks, and knows the cancer will likely return at some point.

“Don’t overlook those little things,” she said.

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