Breast cancer and cervical cancer screening fell by more than 80% in a Centers for Disease Control and Prevention (CDC) program for low-income women during the early days of the COVID-19 crisis, according to a recent study. This could lead to more diagnoses at advanced stages of cancer and worse outcomes—especially for women of color.
“This study highlights a decline in cancer screening among women of racial and ethnic minority groups with low incomes when their access to medical services decreased at the beginning of the pandemic,” CDC scientist Amy DeGroff, PhD, MPH, said in a press release. “They reinforce the need to safely maintain routine health care services during the pandemic, especially when the health care environment meets COVID-19 safety guidelines.”
As the COVID-19 pandemic emerged in the United States in the spring of 2020, people were told to stay at home and health facilities shut down. Even as services resumed, many people felt too anxious about the new coronavirus to see providers in person. While many services shifted to telehealth, this is not an option for some types of cancer screening. In an editorial last year in Science magazine, National Cancer Institute (NCI) director Norman Sharpless, MD, estimated that the drop-off in screening and the resulting delays in diagnosis and treatment could lead to nearly 10,000 excess deaths from breast cancer and colon cancer over the next decade.
DeGroff and her colleagues analyzed the impact of COVID-19 on screenings carried out by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), an initiative to provide screening services to women with low incomes and inadequate health insurance.
As described in the journal Preventive Medicine, the researchers looked at changes in the number of screenings through June 2020. NBCCEDP grant awardees complete an annual web-based survey about their program activities and needs; seven additional questions related to COVID-19 disruptions were added to the 2020 survey.
Over the past six years (2015 to 2020), a total of 487,645 women have received breast cancer screening services through NBCCEDP. Of these, 48% were Latina, 28% were white, 15% were Black, 4.3% were Asian or Pacific Islander and 3.5% were American Indian or Alaskan Natives. About 80% lived in metro areas, followed by urban (15%) and rural (2%) areas. During the same period, a total of 353,398 women received cervical cancer screening services. The corresponding racial/ethnic distribution was 52%, 26%, 11%, 4.4% and 4.7%.
DeGroff and her team found that the total number of NBCCEDP-funded breast cancer screening tests declined by 87%, and the number of cervical cancer screening tests fell by 84% in April 2020 compared with the previous five-year averages for the same month.
But there was substantial regional variation in the declines. Screenings dropped most steeply in the region that includes New York City, with a 96% decrease for breast cancer and a 95% decline for cervical cancer screenings—not surprisingly, as this area was hardest hit during the early COVID-19 crisis in the United States.
By race and ethnicity, the drop in breast cancer screenings was steepest for American Indian and Alaskan Native women, falling by 98%. But even the group with the smallest drop—Latina women—saw an 84% decline. Cervical cancer screenings dropped off most among Asian and Pacific Islander women (a 92% decline) and least among Black women (82%).
Screening declined in urban and rural areas alike. Breast cancer screenings fell by 88% in urban areas, by 86% in metro areas and by 89% in rural areas. For cervical cancer screenings, the corresponding decreases were 77%, 85% and 82%, respectively.
These findings are not unique to programs for low-income women. The study authors noted that another analysis of changes in health care delivery during COVID-19 also saw large declines in mammograms (an 87% drop) and Pap tests (an 83% drop) in April 2020 among women with insurance. Likewise, a study of 1.5 million women insured through Kaiser Permanente Southern California also saw about an 80% drop in cervical cancer screening during California’s stay-at-home order.
NBCCEDP screening volume began to recover in May, but it remained well below pre-pandemic levels. At the end of June 2020, the number of breast cancer screenings was 39% below the five-year average for that month while cervical cancer screenings were off by 40%. Recovery was particularly slow in rural areas: breast cancer screenings in June were still 50% below the five-year average.
The researchers noted that many NBCCEDP programs were short-staffed for some time due to personnel being deployed to assist with the COVID-19 response and, in some cases, the need for staff to stay at home due to school and childcare closures. This likely remains the case for some providers even a year and a half into the pandemic.
“CDC encourages health care professionals to help minimize delays in testing by continuing routine cancer screening for women having symptoms or at high risk for breast or cervical cancer,” DeGroff said. “The Early Detection Program can help women overcome barriers to health equity by educating them about the importance of routine screening, addressing their concerns about COVID-19 transmission and helping them to safely access screening through interventions like patient navigation.”