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Pharmacy Practice in Focus: Oncology
The Impact of COVID-19 on Cervical, Breast Cancer Screenings
Breast cancer screening guidelines using mammography vary among guiding bodies, including the American Cancer Society and the American Academy of Family Physicians.
Routine screening is an important tool for the prevention and early detection of breast and cervical cancer among women. Breast cancer screening guidelines using mammography vary among guiding bodies, including the American Cancer Society and the American Academy of Family Physicians. For women of age 50 to 74 years with average risk factors, the most liberal guidelines recommend biannual mammography.1 Through cervical cancer screening, abnormal cells in the cervix may be identified and treated before they progress to cancer.
The US Preventive Services Task Force recommends women at average risk who are between the ages of 21 to 29 receive cervical cytology alone every 3 years and that women of age 30 to 65 years receive primary high-risk human papillomavirus (hrHPV) testing every 5 years, both cervical cytology and hrHPV testing every 5 years, or cervical cytology alone every 3 years.2 Routine screening for cervical cancer and its precursors has been proven to improve overall cervical cancer outcomes.2
Many factors influence adherence with routine cancer screening. Socioeconomic status, access to care, lack of transportation, and lack of insurance are commonly noted barriers. Perceived barriers to mammography were studied between 2006 and 2011 at the Alvin J. Siteman Cancer Center, a National Cancer Institute (NCI)–designated Comprehensive Cancer Center in Missouri.3 The study was conducted to investigate why women did not get mammograms.
In the study, responses from registrants included fear of cost, mammogram- related pain, and fear of bad news.3 Compounding these barriers, the COVID-19 pandemic in early 2020 resulted in a sharp reduction in cancer screenings across the United States.
During the first months of the pandemic, specifically during the stay-at-home order, several large studies measured a substantial reduction in cervical and breast cancer screenings.4-6 The decline in cervical cancer screening was one of the most significant declines in preventive screening rates in the United States.7 In the years just prior to 2020, there was a slight uptrend in the rates of cervical and breast cancer screenings; however, both declined substantially by spring 2020.8
In both breast and cervical cancer screenings, Epic Health Research Network identified a 94% decline compared with averages before the COVID-19 pandemic, as demonstrated in 2.7 million patient records from 39 organizations spanning 23 states. Additionally, another study identified a 68.2% decline in cervical cancer screenings.7-8 Furthermore, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) observed an 87% and 84% decline in NBCCEDP-funded breast and cervical screenings, respectively, during April 2020 compared with the previous 5-year averages for April.9
However, multiple studies demonstrated some improvement in breast and cervical cancer screening rates by June 2020. Epic Health Research Network data showed that weekly volumes in June remained 29% and 35% lower than pre–COVID-19 levels for breast and cervical cancer screenings, respectively.8 The NBCCEDP research showed that in June 2020, screening rates were 39% and 40% below the 5-year average for that month for breast and cervical cancer screenings, respectively.9
The impact of this decrease in cervical cancer screenings during the beginning of the pandemic remains unknown. From March to June 2020, Epic Health Research Network estimated that 285,000 breast and 40,000 cervical exams were missed or delayed. Additionally, one modeling study using a 70% decline in cervical and breast cancer screening over a 3-month period projected 38,500 women with a delayed cancer diagnosis.10
Although some variation in the United States would be expected, some insight can be gained from a European modeling study that evaluated the impact of 6-month screening delays.11 This model demonstrated that a 6-month screening delay across the population would result in approximately 4 additional cases of cervical cancer per 100,000 women. On the other hand, women who miss an entire 3- to 5-year screening cycle have a 7-fold higher rate of cervical cancer vs those with a 6-month delay. The impact of screening delays for cervical cancer is expected to be greatest among women of age 40 to 49 years, with vaccination against HPV mitigating the effect of the delay in younger women.11
Some reports suggest that screening rates for breast and cervical cancer began to exceed pre-pandemic numbers in late 2020. In one study evaluating
patients in the Massachusetts General Brigham system, screening for breast and cervical cancer from September to December 2020 exceeded pre–COVID-19 levels by 14% and 2%, respectively.12 There was also an increase in positive diagnoses for both breast and cervical cancers during this time.
Despite these improvements in screening rates post pandemic, providers have expressed concerns that we will continue to see an increase in cancers diagnosed at later, less-treatable stages.13 Additionally, recent research has demonstrated that socioeconomic and racial disparities in screening persist.
Members of the Community Oncology Alliance and Avalere Health looked at the impact of the COVID-19 pandemic on cancer screening rates using a multipayer database that included Medicare, Medicaid, and commercial insurance.7 Although there was an increase in breast cancer screenings in the months following the stay-at-home order among all groups, the rate of increase was slower for those with a reduced income level and in certain racial and ethnic minority groups.7 The COVID-19 pandemic highlighted these disparities, giving cancer clinicians a push to focus on improved education and access to care for these groups.
Moving forward, screenings for patients who are overdue must be prioritized.11 Survey research to determine why patients are hesitant to pursue timely screening is ongoing.13 Not only are some patients anxious to go to a health care facility because of the risk of acquiring COVID-19, but others may have lost employment or child care, making it difficult for them to make time for physician appointments and/or pay for health care. Understanding these barriers will help us improve screening rates and potentially mitigate screening declines in the event of a future pandemic.
Improved access to care and increased patient education require coordinated efforts among providers. For a variety of reasons, many patients do not use primary care providers as their first access point to health care.8 Other health care professionals in the community, such as local pharmacists and public health departments, can reinforce the importance of screenings and educate patients.
Furthermore, to reduce issues relating to transportation burdens, coordinating mobile mammography and community outreach projects in underserved areas can bring screenings closer to home. Additionally, grants that provide low-cost or free transportation could also help to remove transportation barriers for patients. Advances in user-friendly, at-home screening tests may also improve cancer screening rates.
Multiple studies have also evaluated the potential impact of at-home HPV tests.14,15 Although these at-home tests appear to be accurate and effective, a statistical difference in the detection of precancer lesions has not been demonstrated.
The COVID-19 pandemic impacted cancer care and cancer screenings more than any event in recent history. Although studies show there is movement toward pre-pandemic cervical and breast cancer screening rates, the disparity among patients of different socioeconomic, racial, and ethnic communities continues. To reduce barriers, health care providers must be innovative and work together to serve these patients.
About The Author
Brooke Peters, PharmD, BCOP, regional clinical pharmacist at
the American Oncology Network, LLC.
Christine Pfaff, RPh, regional director of operations at the American Oncology Network, LLC.
References
1. Breast cancer screening guidelines for women. Centers for Disease Control and Prevention. Reviewed September 22, 2020. Accessed May 18, 2022. https://www.cdc. gov/cancer/breast/pdf/breast-cancer-screening-guidelines-508.pdf
2. Cervical cancer: screening. US Preventive Services Task Force. August 18, 2018. Accessed May 18, 2022. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervical-cancer-screening
3. Fayanju OM, Kraenzle S, Drake BF, Oka M, Goodman MS. Perceived barriers to mammography among underserved women in a breast health center outreach program. Am J Surg. 2014;208(3):425-434. doi:10.1016/j.amjsurg.2014.03.005
4. Chen RC, Haynes K, Du S, Barron J, Katz AJ. Association of cancer screening deficit in the United States with the COVID-19 pandemic. JAMA Oncol. 2021;7(6):878-884. doi:10.1001/jamaoncol.2021.0884
5. Velazquez AI, Hayward JH, Gregory B, Dixit N. Trends in breast cancer screening in a safety-net hospital during the COVID-19 pandemic. JAMA Netw Open. 2021;4(8):e2119929. doi:10.1001/jamanetworkopen.2021.19929
6. Bakouny Z, Paciotti M, Schmidt AL, Lipsitz SR, Choueiri TK, Trinh QD.
Cancer screening tests and cancer diagnoses during the COVID-19 pandemic.
JAMA Oncol. 2021;7(3):458-460. doi:10.1001/jamaoncol.2020.7600
7. Nathoo A, Weng I, Kim J, Ortuno A. Routine chronic disease screenings and oncology biomarker tests plummet during COVID-19. Komodo Health. April 28, 2020. Accessed May 18, 2022. https://knowledge.komodohealth.com/hubfs/white-papers/research-briefs/ Komodohealth-covid19-2020-04-28.pdf
8. Mast C, Munoz del Rio A. Delayed cancer screenings—a second look. Epic Research. July 17, 2020. Accessed May 18, 2022. https://ehrn.org/articles/ delayed-cancer-screenings-a-second-look
9. DeGroff A, Miller J, Sharma K, et al. COVID-19 impact on screening test volume through the National Breast and Cervical Cancer Early Detection
Program, January-June 2020, in the United States. Prev Med. 2021;151:106559. doi:10.1016/j.ypmed.2021.106559
10.Murray, A, Kleinrock, M. Shifts in healthcare demand, delivery and care during the COVID-19 era. IQVIA Institute for Human Data Science. April 29, 2020. Accessed December 20, 2020. https://www.iqvia.com/insights/the-iqvia-institute/covid-19/ shifts-in-healthcare-demand-delivery-and-care-during-the-covid-19-era
11.Castanon A, Rebolj M, Pesola F, Sasieni P. Recovery strategies following COVID-19 disruption to cervical cancer screening and their impact on excess diagnoses. Br J Cancer. 2021;124(8):1361-1365. doi:10.1038/s41416-021-01275-3
12.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
13. Printz C. Cancer screenings decline significantly during pandemic. Cancer. 2020;126(17):3894-3895. doi:10.1002/cncr.33128
14.Arbyn M, Smith SB, Temin S, Sultana F, Castle P; Collaboration on Self-Sampling and HPV Testing. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. BMJ. 2018;363:k4823. doi:10.1136/bmj.k4823
15. Winer RL, Lin J, Tiro JA, et al. Effect of mailed human papillomavirus test kits vs usual care reminders on cervical cancer screening uptake, precancer detection, and treatment: a randomized clinical trial. JAMA Netw Open. 2019;2(11):e1914729. doi:10.1001/ jamanetworkopen.2019.14729
