Delays in Cancer Screenings Due to COVID-19 May Result in Trend Toward Excess Deaths

Electra D. Paskett, PhD

Cancer screenings rapidly decreased during the COVID-19 pandemic as health care practices considered not urgent came to a halt. However, as of February 2023, approximately 3 years after the start of the pandemic, cancer screenings still have not reached 100% of expected rates, according to a study published in the Journal of Clinical Oncology.

As a result of stay-at-home orders, which began to take effect in the United States in late March 2020, cancer screenings declined between 86% and 94% in March 2020 compared with prior years. Between March 15, 2020, and June 16, 2020, there were approximately 285,000 breast, 95,000 colorectal, and 40,000 cervical screenings missed. “Unfortunately, I don’t think we’ve gone back up in terms of where we were before the pandemic [with screening],” study author Electra D. Paskett, PhD, said in an interview with OncologyLive®. “The phenomena [of] ‘I missed my mammogram, it’s OK, I feel OK,’ is still continuing. In Ohio, with the state [Comprehensive] Cancer Control Plan, we have a public awareness campaign called Get Back to Basics Ohio, which focuses on encouraging residents of the state to get back to basics in cancer prevention and screening. Every month we vary it by whatever disease month or cancer month it is…we are trying to push people to get back on track.”

Consequently, as diagnoses were less likely to occur during the pandemic and timing plays a key role in outcomes and survival, the study authors estimated that over the course of the next 10 years, approximately 10,000 excess deaths from breast and colorectal cancer swill be reported throughout the United States.

"There are some factors that are different for each of [the screenings], but it’s time and during the pandemic, people didn’t go out and didn’t go to medical facilities and so they got out of the habit of getting their regular screenings and then everything was okay,” said Paskett, who is director of the Division of Cancer Prevention and Control at The Ohio State University College of Medicine, the Marion N. Rowley Chair in Cancer Research, and founding director of the Center for Cancer Health Equity at The Ohio State University Comprehensive Cancer Center—Arthur G. James Cancer Hospital and Richard J. Solove Research Institute in Columbus.

Approximately 3.9 million breast cancer, 3.8 million colorectal cancer, and 1.6 million prostate cancer screenings were missed in the United States because of the pandemic, leading to decreases in diagnoses. As shown in another study by the Massachusetts General Brigham, between March 2020 and June 2020 decreases in diagnoses were 19% to 78%.

“[Patients may have] said, ‘I don’t need to get my mammogram because I feel OK,’ ” Paskett said. “But the point of a screening test is that you get it when you feel OK because when cancer starts it doesn’t [necessarily] impact how you feel. A lot of times you can’t detect an early breast cancer and that’s the point of mammography; to find an early cancer where it can be treated successfully and with less intense methods than later. It’s the same for the other cancers, too. “It’s important for health care providers to encourage their patients to get back on track and get screened,” Paskett said. “We know that recommendation from a health care provider is the No. 1 reason that patients do anything, whether it’s get a mammogram, stop smoking, getting an human papillomavirus [HPV] vaccination, [etc], so providers need to be cued to do that.”

The study authors were part of a National Cancer Institute consortium tasked with looking at the impact of COVID-19 on cancer screening, which included preventive and screening behaviors. Adult patients from Ohio (95.8%) and Indiana (4.2%) who had agreed to be recontacted from previous studies were included in this study.

“The [individuals] we reached out to were either part of a prior study that we had conducted or were part of The James Total Cancer Care [Program] and then we invited caregivers of those participants in James Total Cancer Care if they wanted to participate,” Paskett said. “To get a diverse sample, we used community snowballing techniques so that we have community help workers that work in minority underserved communities, and they could go and recruit participants and then snowball from there.”

The analysis solely included age and sex ranges that were appropriate for each screening: mammogram (women; aged 40-74 years), Papanicolaou test (women; aged 21-65 years), HPV test (women; aged 30-65 years), and colonoscopy/stool blood test (men and women; aged 50-75 years). The average age was 57.3 years, 75% were women, 89.1% were non-Hispanic White, 55.5% had a college or higher degree, 75.2% were married, and one-third of patients lived in rural areas.

Among 7115 individuals, 60% had a screening planned between March 2020 and December 2020, but 11% to 36% delayed their screenings because of the pandemic. Tests that were planned but later delayed included a mammogram (n = 732 of 2986), Papanicolaou test (n = 448 of 1651), HPV (n = 59 of 220), stool blood test (n = 44 of 388), and a colonoscopy (n = 304 of 840).

When compared with those who did not plan a cancer screening (n = 2849; 40%), participants who did plan a screening (n = 4266; 60%) were younger, female, received higher education, had private insurance, and lived in a rural area (P < .001). They were also more likely to be widowed/separated/divorced and had a higher income. Study authors wrote that “age, race/ ethnicity, education, and health insurance were associated with delays in cancer screenings (all P < .05).”

Paskett noted the demographics are reflective of populations that would actively pursue routine screening vs those that would not.

Mammograms

When examining mammogram data, older patients were less likely to delay a planned screening (OR, 0.81; 95% CI, 0.72-0.92) and non-Hispanic Black women had lower odds of delaying the test than non-Hispanic White women (OR, 0.60; 95% CI, 0.39-0.94). Women with at most a high school education were less likely to delay a mammogram than those who had received higher education, as follows: women with some college/associate degree (OR, 1.45; 95% CI, 1.07-1.99), college degree (OR, 1.40; 95% CI, 1.03-1.92), or graduate degree (OR, 1.58; 95% CI, 1.16-2.17) were more likely to delay the screening. Data also showed that participants from Indiana had increased odds of delaying a mammogram compared with those who resided in Ohio (OR, 1.72; 95% CI, 1.21-2.45).

However, an age stratification demonstrated that the only factors associated with lower odds of mammogram delays for women aged 40 to 49 years were race and ethnicity (with non-Hispanic Black women less likely to delay screening). Factors for women aged 50 to 74 years associated with higher odds of a mammogram delay were a younger age (40 to 49 years), had higher education, and resided in Indiana. No significant mammogram delays were associated with marital status, health insurance status, and rural/metropolitan residence.

Papanicolaou Test

Patients of older age were less likely to delay a planned Papanicolaou test (OR, 0.89; 95% CI, 0.79-1.00), and women with private health insurance (OR, 0.37; 95% CI, 0.18-0.74) or combined public and private insurance (OR, 0.44; 95% CI, 0.19-1.00) also had lower odds of delaying the test compared with those without health insurance.

Marital status and rural/urban residence were not associated with mammogram delays; however, education and race were factors in having higher odds of delaying a test. Compared with non-Hispanic White women, Hispanic participants (OR, 2.46; 95% CI, 1.34-4.55) and those who identified as other races (OR, 2.38; 95% CI, 1.41-4.02) were more likely to delay a Papanicolaou test. When evaluating education, participants with an associate degree or some college had higher odds of delaying the test compared with those with high school or less education (OR, 1.53; 95% CI, 1.02-2.31).

Colorectal and HPV Screenings

There was no observed correlation with age, sex, race/ethnicity, health insurance, and rural/urban residence in delaying a colonoscopy. No factors were found to be associated with delays in stool blood tests and they were among the lowest of all the screening tests delayed, at 11.3%.

Individuals with a graduate-level degree had increased odds of delaying planned colonoscopies compared with those with a high school degree or less education (OR, 2.09; 95% CI, 1.23-3.56). There were lower odds for participants who were widowed, separated, or divorced than single individuals in delaying a planned colonoscopy (OR, 0.48; 95% CI, 0.25-0.92).

“Fecal immunochemical tests [FITs] have been validated and they have been shown to reduce death from colon cancer,” Paskett said. “During the pandemic we pushed the clinics we work with to focus on FIT tests because they could call up a patient, explain it, and then if the patient was willing to get it, they could do it in their home and then mail it back. They didn’t have to leave their home and come to a medical facility. We did find some increased use of FIT testing during the pandemic because of that. That’s very good unless you are very high risk for colon cancer; a FIT test is fine as long as you get it every year.”

Investigators found that older patients had lower odds of delaying a planned HPV test (OR, 0.65; 95% CI, 0.46-0.93) and those who identified as other race-ethnicity had higher odds of delaying the HPV test compared with non-Hispanic White individuals (OR, 5.37; 95% CI, 1.44-19.97).

Other Notable Outcomes

Ohio and Indiana are both Medicaid expansion states, and 14.1% of patients had public insurance, 53.7% of patients had private health, and 29.9% had public and private insurance. Patients with public insurance did not experience any differences in screening delays, which may be due to Medicaid expansion. For patients who do not live in states with Medicaid expansion, there are other options that may encourage screening.

“The Breast and Cervical Cancer Early Detection Program is operational in all states and if women qualified by income they can go there and get breast and cervical screening as well as HPV vaccination, and then if [they receive a] diagnosis [of] an abnormality, they can get a diagnostic work-up,” Paskett explained. “Those plans vary a little state by state, but most of the states have those funding and that’s where I would suggest [visiting] other than going to a free clinic.”

Limitations of the study were that it was not nationally representative, and the investigators did not have access to medical records. “We had a biased sample, in terms of who responded to our request,” Paskett said. “It was a cross-sectional design, so we didn’t follow [individuals] longitudinally. It was also self-reported data, which could have some recall bias; [participants] sometimes think that they had their test more recent than they did.”