Cancer screenings in the region, and across the state, plunged in 2020 - there were nearly 50,000 less mammograms completed in NSW from January to June; nearly 130,000 fewer cervical screening tests and around 5250 less bowel screening tests returned, than in the same period in 2019.

While GPs remained open during any lockdowns, there was trepidation from many to visit doctors due to fear of COVID infection from other patients. Phone consultations, while a welcome initiative, simply didn't offer the same level of scrutiny as a physical examination.

Meantime the first wave of the COVID-19 pandemic in Australia in early 2020 forced a temporary closure of some screening services, such as BreastScreen Australia, as healthcare providers scrambled to ensure correct infection control procedures were in place.

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Medical co-director of the Illawarra Shoalhaven Local Health District cancer services, radiation oncologist Dr Elias Nasser, fears the real effect of reduced screening will not be apparent for months, if not years.

"We know cancer is a disease that given time can grow locally and cause complications; it can also spread and set out satellites as well - at which point it can become incurable," he said. "If we can detect it in the early stages we can put effective strategies in place that result in cure, in eradication rather than palliation.

"We know people have put off going to see primary healthcare professionals, their GPs, or attending screening services during the pandemic. Our concern is that those people who have delayed attending to their symptoms may present down the track with more advanced cancers than they would have had, had there not been a pandemic.

"There may well be a spike in presentations, in the rate of people being diagnosed, in the coming months."

Professor Philip Clingan, an Illawarra medical oncologist with over 30 years experience, has been the medical director of Southern Medical Day Care Centre in Wollongong for 20 years.

"In the first three months of the outbreak we noticed a huge drop off in screening and referrals," he said. "While this has picked back up, we are obviously worried about those who put off their GP appointments and screening tests, and would urge them to make those visits now."

Illawarra GP, Dr Katherine Michelmore, has also noticed a substantial drop in face-to-face appointments at her Lakeside Medical Practice in Warilla which she puts down to a number of reasons.

"People are very concerned about the possibility of being exposed to someone who has COVID and many have opted to postpone any visits they feel are non-essential," she said.

"Also I think during the pandemic many people have been preoccupied with other issues - stresses over employment, working from home, home schooling and so on - which has meant that they haven't prioritised getting check-ups.

"Telehealth is an excellent addition to our availability but it does mean we don't have the same opportunities to do opportunistic screening - where people come in with one problem but we then recognise they're overdue for certain screening.

"I've certainly done fewer cervical screens for women for instance - and screening is so important. We want to pick up disease while we can do something about it."

Other types of screening, such as The National Bowel Cancer Screening Program, have not seen such massive drop-offs, as the kits are completed at home.

However the Australian government's temporary suspension of all non-urgent elective surgery for several weeks from late March - including some investigative procedures to detect cancer - did mean delays for those who received a positive test result.

"When someone gets a positive result from bowel screening for instance, they need to see a GP to get referred to a specialist for a colonoscopy," Dr Michelmore said.

"Yet due to many procedures needing to be postponed due to the shutdown in non-urgent elective surgery, there has been delays.

"Hospitals and clinics are still trying to deal with the backlog. Also many people are still reluctant to go to hospital to have those procedures due to concerns about being exposed to COVID."

Caitlin Vasica, Cancer Council NSW Screening Project Lead, said the Australian Government had anticipated the drop in screening in the first half of 2020.

They had invested in a $2.2 million Cancer Screening Saves Lives campaign, delivered by Cancer Council, to combat this drop and encourage more people to screen.

"Since COVID-19 began, we've heard many stories of declines in GP visits, hospital admissions and cancer diagnoses. Data released backed those anecdotes, highlighting a decline of diagnostic procedures for cancer during the first COVID-19 lockdown," she said.

"A report by Cancer Australia showed procedures for breast imaging decreased by 37 per cent in March and April 2020. Colorectal investigations were around half (between 55 and 57 per cent) of those in March. These figures point to fewer people following up on potential cancer cases and while numbers have improved since then, they are still lower than we would like to see.

"Some of us may have delayed or neglected our regular health checks. But if we don't buck this trend and see these numbers improve, there is a very real risk that we could have more deaths from cancer caused by the indirect impacts of COVID-19, than by the virus itself.

"We urge NSW residents to stop putting off their health checks. If you have recently been invited to participate in the breast, bowel or cervical screening programs, make your appointments, get it done and tick cancer screening off your to-do list."

Early detection was vital for Shellharbour resident Julie Carter, who was diagnosed with breast cancer in 2012 after discovering a lump. After surgery, and cancer treatment, she was in remission for five years, but is now battling secondary cancer.

"It had spread to my lungs, my abdomen, my neck and my liver," she said. "I had 186 cancer tumours in my body, but I've been fortunate enough to be put on a clinical trial with Prof Clingan - and the number of cancers has already reduced to 40.

"My message to anyone would be, get yourself checked out - early detection saves lives."

Meantime while screening has dropped, the care and treatment delivered to cancer patients has not altered during COVID - although their journey may have changed.

At the Illawarra Cancer Care Centre at Wollongong Hospital, Dr Nasser said phone consultations have increased and changes have been made to the staffing and operation of the facility to ensure the highest level of safety.

"We know that cancer therapies, both chemotherapy and radiation therapy, have an impact of the effectiveness of the immune system - it makes patients more susceptible to infection," he said.

"So cancer patients are more susceptible to developing clinical COVID illness rather than asymptomatic infection due to their inability to fight off the virus.

"So in cancer services we put in a multi-pronged strategy to protect patients, to diagnose those presenting with symptoms and to ensure staff were protected - for their own safety and for the proper functioning of the system.

"We changed the way staff interacted, we tried to minimise any mixing of staff with different shifts and staff effectively quarantined in different parts of the centre.

"In many cases we have reverted to phone consultations, which has been a bit of a struggle but we hope to utilise NSW Health's virtual care system in the near future so we can see people, rather than just talk to them."

It's been business as usual as SMDCC too, though Prof Clingan said there has been an impact on the international cancer trials run there.

"Once people are diagnosed and referred for treatment there have been no delays, and all our staff have been fantastic," he said. "NSW Health have given clear guidelines on infection control, which centres like ours have implemented and we have also used telehealth, for occasional discussions."

For patients like Julie, a combination of phone and face-to-face consultations have worked well - while knowing she is at high risk means she continues to take every precaution.

"I stay home mostly and get shopping home delivered, when I do go out I wear a mask," she said. "I'm coping well; you've got to keep positive and keep going."

The mental health of patients has been a priority for cancer care services, and Dr Nasser said demand for psychologists at the ICCC has spiralled in the past year.

"Cancer patients have this burden of anxiety which is normal because of their diagnosis, because they're undergoing treatment, and they're unsure of what the future holds," he said.

"The added burden of an infection which could be fatal adds to levels of anxiety and that's been reflected in greater call for our services in psychology.

"That's why friends and relatives need to keep in contact with those they know who are battling cancer, and look out for them."

With case numbers low in NSW - and no locally acquired cases for 26 days on Friday - Dr Nasser said it was time for people to make their health a priority again.

"Have a close relationship with your healthcare professionals - get to doctor's appointments because the likelihood of transmission in the Australian context is much less," he said. "And get the COVID vaccine."

Prof Clingan also urged residents, including cancer patients, to take up the COVID vaccine.

"The Clinical Oncology Society of Australia and the American Society of Clinical Oncology are among the bodies who recommend cancer patients should be vaccinated," he said.

"I'm getting vaccinated, I'd encourage everyone to. Australia has done such a great job - we should keep it going."

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