When the Covid-19 pandemic brought ordinary life to a halt in 2020, routine cancer screenings fell off many people’s list of priorities. Screenings for cervical, breast, and prostate cancer all dropped in the first year of the Covid-19 pandemic, according to a new analysis from the American Cancer Society.
Over the course of 2021, screening levels recovered — but the report’s authors say there’s still reason to be concerned about the impact of missed cancer screenings down the line.
While it’s good that people are resuming their regular visits, the data suggest people haven’t been making up for the missed screens earlier in the pandemic, said Ahmedin Jemal, senior vice president of surveillance and health equity science at the American Cancer Society and the senior author on the study.
“We know there was a deficit during Covid,” he said. “But [visits] should have exceeded the pre-pandemic levels to offset the Covid years, but we haven’t gotten there yet.”
The concern is that some people might have missed out on routine screenings that would have detected an early-stage cancer or precancerous lesion, Jemal said. Cancer is easiest to treat or prevent at these crucial early stages. Without a make-up visit, Jemal warned, some individuals might wait years for their next screening and then discover cancers that have advanced to later stages, when the disease is more difficult to manage.
The analysis compared the amount of breast, cervical, prostate, and colorectal cancer screenings in 2019 and 2021 using data from the U.S. government’s National Health Interview Survey. Overall, the researchers found that 57% of eligible people got breast cancer screenings in 2021, down from 60% in 2019 — an absolute difference of roughly 1.1 million individuals.
For cervical cancer, 45% of eligible people received screenings, compared to 39% in 2019, a decline of about 4.4 million individuals. About 700,000 fewer people reported receiving a prostate cancer screening test, declining from 40% of the eligible pool to 36%. Colorectal screening remained the same, Jemal said, because an increase in home stool tests balanced out a drop in colonoscopies.
STAT spoke with Jemal and Jessica Star, an associate scientist at the American Cancer Society and lead author on the study, about the implications of the changes in cancer screening during the Covid-19 pandemic. This interview has been edited for length and clarity.
What was the most important finding of this analysis?
Jessica Star: Past year breast, cervical, and prostate screening all declined from 2019 to 2021. This was particularly the case for non-Hispanic Asian persons. There were declines in other groups, but non-Hispanic Asians were the only group where we saw declines in all three [categories], and we’ve been seeing the largest declines for non-Hispanic Asian persons.
That’s concerning because they were already susceptible to low screening rates, based on previous literature. So, that should inform some screening campaigns to ensure groups that need screening are receiving it.
The big fear was that we would see more cancer diagnoses at later stages after the pandemic. Has that happened?
Ahmedin Jemal: It will take time to see these consequences. Progression of disease takes years, and screening at regular intervals helps cut those cancers at an early stage. For colorectal cancer and cervical cancer, you can detect lesions before they become cancer. But if you miss that window, they have time to progress to later stages, and people who skipped screening may not get another screening for several more years.
So, those missed opportunities may not turn into late-stage diagnoses in one year or two years, but there might still be cancers that weren’t picked up at the height of the pandemic that may be detected at later stages in the future. I think that’s very important.
We don’t have evidence that this loss in screening led to late-stage diagnosis now, but we’ll need to monitor the stage at diagnosis over the coming years.
Why do you think screening dropped off during the pandemic?
Jemal: There were many factors contributing to that. One is financial issues — we still have close to 30 million people who are uninsured in the United States. At the height of Covid, there were high rates of unemployment, and the majority of insurance is employment-based insurance. So, a lot of people lost their insurance.
Then there’s language barriers and racial discrimination during Covid times; particularly for Asian people, there was heightened discrimination and anti-Asian hate. It’s a possibility that was partly responsible for the large decline in screening for Asian Americans, that Asian people may not have felt safe going out.
Star: I think there may also still be that element of fear about going into a physician’s office. The other thing is that community health doctors may be overburdened and burned out and required to address a lot of issues. Individuals haven’t been going back for screening, but also other preventative services as well, so I’m curious if make-up visits have been deprioritized.
What are some of the key strategies that public health can use to increase screening rates quickly and get people to make up missed screening?
Star: The finding that stool-based screening increased is really important and indicates the utility of home-based screening. It’s important to note that if you have a positive stool test, you need to go in and get a follow-up colonoscopy to complete that screening, and we’ve seen in literature that follow-up colonoscopy screening adherence has been low.
Jemal: We have a test for cervical cancer screening that’s home-based, but not been approved yet. So, the development of new home-based cancer testing is important to maintain screening and cover disruptions of the healthcare system.
In particular, home-based testing went up more among Hispanic and Black individuals, so it’s important in maintaining screening of those that have been historically underserved. The American Cancer Society is also working with community health centers that work with low-income populations, so we’re working to increase screening specifically [in] those populations.
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