Cancer Screenings Recover From Height of COVID-19 Pandemic, But Disparities Remain

Chris Labaki, MD

Although a substantial decline in cancer screening tests was observed at the height of the COVID-19 pandemic, screening rates have since recovered significantly, reaching levels that exceed even pre-pandemic rates, according to Chris Labaki, MD, and Quoc-Dien Trinh, MD. However, disparities regarding these tests exist, underscoring the need for additional campaigns, outreach efforts, and resources for these underserved communities.¹

“The recovery of cancer screening is assuring overall, but it needs to be maintained. Larger campaigns should be implemented to ensure that we recover as many diagnoses as possible,” Labaki said. “Otherwise, patients may present with more advanced stages of the disease or may eventually be diagnosed at a metastatic stage, which is very unfortunate. As such, it is important to maintain this recovery, and to maintain the implementation of screening tests across the nation.”

Labaki is a postdoctoral genitourinary oncology research fellow at Dana-Farber Cancer institute. Trinh is an associate professor of surgery at Harvard Medical School.

In an interview with OncLive®, Labaki, a postdoctoral genitourinary oncology research fellow at Dana-Farber Cancer institute, and Trinh, an associate professor of surgery at Harvard Medical School, discussed their research on the decline in cancer screenings during the height of the COVID-19 pandemic, the recovery of these tests, and potential existing disparities to be addressed.

OncLive®: What was the rationale to conduct this research?

Labaki: [The] COVID-19 [pandemic] has been shown to affect, to a large degree, cancer screenings in the United States. Many studies have evaluated the impact of the COVID-19 pandemic on cancer screenings in many regions in the United States and have identified a large decrease in many screening types, such as prostate-specific antigen [PSA], mammography, colonoscopy, pap smear, and even low-dose computed tomography [CT] scan, which are the most utilized screening modalities for the most common cancer types.

Our group previously published a study analyzing the impact of the pandemic on cancer screenings, as well as associated diagnosis, [and we] showed similar findings. The rationale behind [the current] study was to evaluate the impact of the pandemic on cancer screening, [particularly] between June 2020 and December 2020, [and determine] whether cancer screening tests have recovered, and whether people are going for screening again.

What were the key objectives? What specific points were of particular interest to you?

Trinh: There are 2 big [ones] with this study. We know for a fact that during the pandemic, less cancer screenings were done. One the one side, institutions had to protect their resources such as personal protective equipment, and there was a lot of uncertainty about transmission. Institutions could not necessarily provide this service [safely at this time]. On the other side, patients were scared. There was concern about coming into the hospital to get testing done. Vaccines were not available at that point in time. As such, unsurprisingly, but also concerningly, we found that there was a significant decrease in cancer screenings during the first wave of the pandemic. As the pandemic continued, hospitals adapted, and patients now have different expectations. They know that life continues and cancer continues. As a result, we were interested in trying to see whether cancer screenings recovered.

The other important thing we were trying to assess is that there has always been concern in this country about inequity and potential racial disparities. Often, in situations where resources are scarce, there is concern that some patients will be left behind. We wanted to know, in our large healthcare system, how we fared [with this]. What results would we see? Is the resumption of cancer screenings happening at the same time for everyone or are there some groups that may be more at risk? [If we noted at-risk groups,] we would need to put more energy toward getting them back to their regularly scheduled cancer screenings.

Could you expand on the design of the study?

Labaki: We examined a long time period on this study, which included 1 year before the pandemic, and 9 months from the start of the pandemic. We then divided this into 7 periods, each of which were 3 months. Of the 7 periods, 4 were defined as pre-pandemic, and 3 were ‘post’ pandemic. One of these would correspond with the first pandemic peak and the last, which was from September 2020 to December 2020, would correspond with the second peak.

We evaluated patients who underwent cancer screening in the Mass General Brigham network, which is one of the largest health care systems in the northeastern United States, and we evaluated the following 5 cancer screening tests: low-dose CT for lung cancer, colonoscopy for colon cancer, PSA for prostate cancer, mammography for breast cancer, and pap smear for cervical cancer.

We included all patients undergoing screening tests, and we also evaluated positive diagnosis tests. The goal was to look at which proportion of these tests came back positive. Finally, we evaluated the racial and socioeconomic characteristics of patients undergoing screening. The socioeconomic characteristics were evaluated using the area deprivation index, which is a geocoding of a patient's zip code. This index links the zip code of each patient to a certain degree of socioeconomic status and has been validated in several studies.

What were the key findings from this research?

Labaki: Overall, we evaluated more than 380,000 patients undergoing screening, across all screening types and all time periods. One of the main findings is that the number of patients undergoing screening from September 2020 to December 2020 was higher than the numbers we saw for each of the pre-pandemic time periods. This indicates that we had a very high recovery of cancer screening tests, as opposed to earlier time periods during the pandemic, meaning from March 2020 to June 2020, and June 2020 to September 2020, where we identified a major decrease in cancer screening tests of up to 80%. We believe that this recovery is reassuring overall; however, for colonoscopy, we did not identify a recovery. Colonoscopy was the only screening modality that did not recover to ‘normal’ pre-pandemic levels. When evaluating diagnosis, all screening tests and their associated positive diagnoses, [except for colonoscopy], had recovered from September 2020 to December 2020, with numbers comparable to those seen before the pandemic.

Trinh: These are interesting findings, and it is also somewhat expected that the recovery would not happen in the same way across all disease states. There is some expectation that certain tests are more complex than others. [For example,] the logistics of getting a colonoscopy done is much more complicated than the PSA test, which is basically just walking into an affiliated center [to get blood drawn] vs showing up to the hospital and getting a colonoscopy. Those findings are not necessarily surprising but documenting and quantifying the problem helps us understand the resources we need to dedicate to address the issue.

One important finding that we had in our study is that [we saw] some racial difference in the recovery of mammographies. It is an unfortunate depiction of things in the United States, and it does mean that we need to make an extra effort to ensure that underserved populations receive the care they deserve. I can say proudly that at Mass General Brigham there is a large-scale United Against Racism initiative where a lot of resources, time, and money are poured into trying to ensure that everyone gets equitable care. Some of these projects are dedicated to cancer screening, including mine, that we are leading for prostate cancer screening, as well as one dedicated to mammography and breast cancer screening. Those are exciting initiatives that arose, throughout the pandemic.

Could you expand on the racial disparities revealed in this study?

Labaki: We analyzed the patient groups in each time period across each screening test, and we tried to see whether the changes we identified for cancer screening recovery or decline during the early time periods of the pandemic were impacting certain ethnic groups [to a higher degree]. For mammography, which is one of the most common screening tests with the highest numbers in our cohort, we identified racial disparities concerning the latest time period of the pandemic. We saw that non-Hispanic Black patients, and Hispanic or Latino patients, had a decreased proportion and decreased numbers for mammography screenings from September 2020 to December 2020. [This was in contrast] with the overall increase we identified during this time period for mammography screening.

This means that while mammography overall is recovering, certain ethnic populations are not experiencing this recovery. They are experiencing lower numbers compared with pre-pandemic time periods, which is worrisome. This [underscores] the need to implement large screening campaigns to include all racial groups within the population.

Trinh: Providing high-quality care to everyone means putting in the extra effort for certain populations that need potentially more resources. It is more than just providing equal access; it is providing more access to populations in need. A good example of that is the increasing use of telemedicine. Telemedicine certainly has played an important role in coordinating care throughout the pandemic, and bringing patients back in for screening tests. However, telemedicine requires technical literacy to access Zoom platforms, to set up the call, and that is not [available] to certain populations. We need to put that extra effort in to get everyone either on board or provide them services, for example, on the telephone if they cannot set up their Zoom platform. That is also an important aspect of providing good care to everyone.

Reference

1. Labaki C, Bakouny Z, Schmidt A, et al. Recovery of cancer screening tests and possible associated disparities after the first peak of the COVID-19 pandemic. Cancer Cell. 2021;39(8):1042-1044. doi:10.1016/j.ccell.2021.06.019