“We must stress that irregular screening can result in a missed opportunity to diagnose cancer when it is small and has not spread. Regular cancer screening is important, and while short delays are acceptable, long delays are not.”—Robert Smith, PhD

Key Points An analysis of private insurance claims from health care before and during the coronavirus disease 2019 (COVID-19) pandemic showed that after a steep decline in the use of mammography and colonoscopy, these 2 screening tests returned to near-normal levels within a few months. Although short pandemic-related delays in cancer screening are acceptable, long delays are not.

At the beginning of the COVID-19 pandemic, the goals of minimizing viral spread in health care settings and focusing health care resources on the care of infected patients led to nonurgent medical services, such as cancer screening tests, being temporarily suspended. As a result, the sheer number of cancer screening tests, such as colonoscopies and mammograms, dropped precipitously. Little was known about the size and duration of the decline, however, and whether it would affect postpandemic adherence to guidelines for these tests.

A new study, appearing in the Journal of General Internal Medicine (2021;36:1829-1831. doi:10.1007/s11606-021-06660-5), reports that the numbers of tests are recovering, approaching pre–COVID-19 levels. The study authors believe that these results suggest that health systems were able to “recalibrate resources and protocols in a relatively short interval.”

“To my knowledge, our study was the first to show a significant rebound in cancer screenings for breast and colorectal cancers,” says lead study author Ryan K. McBain, PhD, MPH, a policy researcher at the RAND Corporation in Boston, Massachusetts. Dr. McBain says that this is a key conclusion because at the beginning of the pandemic, there were concerns about the impact of a large drop in the number of cancer screenings. The study does not, however, address the likely effects of delayed screening on long-term cancer-related morbidity and mortality.

Study Details

For this study, researchers examined weekly medical claims data across all 50 states between January 15, 2020, and July 31, 2020, from health benefits manager Castlight Health. “The information we gathered was based on medical claims filings from adults throughout the United States over this 6-and-a-half-month period,” says Dr. McBain. “This allowed us to examine the interval of 2020 immediately prior to the pandemic (January/February), immediately after the onset (March/April), and through the progression into the spring and summer (May/June/July).”

Study samples included individuals between the ages of 46 and 64 years. Researchers looked at the number of individuals per 10,000 eligible beneficiaries who received cancer screenings. Individuals were grouped by gender and then divided into 2 age groups: 46 to 59 years old and 60 to 64 years old. Using US Census data and USAFacts, a nonprofit organization and website, they also linked claims to demographic characteristics at county levels to determine the weekly prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases per 10,000 people. The researchers estimated changes in screening rates after March 13, 2020, the official date on which COVID-19 was declared a national emergency, versus prior weeks.

Study Results

Before March 13, 2020, the median weekly rate for mammograms was 87.8 women screened per 10,000 beneficiaries. This number declined by 96% in April to 6.9 per 10,000. By the end of July, however, the number increased to 88.2 screenings per 10,000 beneficiaries.

Colonoscopy screenings declined over the same period by 95% from 15.1 per 10,000 beneficiaries in March to 0.9 per 10,000 beneficiaries in April. By the end of July, the number rebounded to 12.6 per 10,000 beneficiaries.

The researchers found a steeper decline in highest income counties in comparison with lowest income counties (in part because highest income counties had higher colonoscopy rates before the pandemic.) They did not find any notable demographic differences for mammography rates.

Study Interpretation

Dr. McBain believes that this study is important for 2 reasons. “First, it quantifies the overall magnitude and duration of declines in cancer screenings for 2 major types of cancer, allowing public health officials and clinicians to have a full picture of the issue.”

Second, the study finds that health systems rapidly responded with protocols and strategies to reopen in a responsible and safe manner. “This highlights the success and resiliency of health systems throughout the country to adjust protocols and recalibrate to deliver important preventive care for a leading cause of morbidity and mortality in the United States,” he says.

Dr. McBain believes that the takeaway message from the study is that health systems were able to respond efficiently during a national emergency in order to resume cancer screenings, an essential component of preventive and primary care. “There are also valuable lessons to be learned from this period about how systems may prepare for future emergencies and adapt to ensure that those patients at highest risk of cancer continue to receive needed check-ups.”

Robert Smith, PhD, senior vice president of cancer screening at the American Cancer Society, says that an important part of the study is the breadth of the number of study subjects: specifically, the study makes use of claims data from a database of nearly 7 million commercially insured adults from all 50 states.

He also issues a caution: “As of now, we will not have data from federally supported population surveys that include questions about breast and colorectal cancer screening for another year or more, so this is a very timely use of big data to answer questions that are more easily answered in countries with national health systems and centralized data collection.” Dr. Smith also notes, “The data apply only to individuals with private insurance, and do not provide any evidence about the decline in cancer screening in adults aged 65 and older, a group covered by Medicare in which the burden of cancer is significant. Did this group rebound as quickly as younger adults? We'll have to wait until data are available to answer this question, and also if adults with private insurance or Medicare increasingly took advantage of the option to be screened for colorectal cancer at home with a stool test.”

Still, says Dr. Smith, the claims data allow for an examination of the effect of the suspension of cancer screening services over time during the pandemic and of the decline and rebound rates overall and by race/ethnicity, income, rurality, and other factors. “Thus, we are able to see the impact on screening rates at the beginning of the pandemic, when hospital systems took steps to redeploy health care professionals to care for the rising number of COVID-19 cases and minimize contagion by suspending cancer screening, and when screening reopened. There has been a great deal of conjecture about whether and when screening rates would rebound. The authors conclude that they have.”

Dr. Smith notes that the data “further confirm earlier reports that showed cancer screening rates plummeted—there really is no better word for it—when screening services were suspended. However, we would expect the current rate to be higher if the backlog was being cleared. In some categorical quartiles the rate is higher, but not by much, and in some quartiles it is lower. This suggests that facilities are operating at previous capacity, but it is fairly likely that although some adults who missed an exam have rescheduled it, many who missed an exam have not, and some who are currently scheduled may not be ready to end medical distancing.”

“We have heard that many facilities went to great lengths to convey that they had taken steps to ensure patient safety and provide confidence that attending screening would not increase risk of viral transmission,” says Dr. Smith. “It is important that patients are confident that the setting they've trusted in the past is just as safe today.”

“Even during the surges that have occurred since last summer, we have heard that health systems have not suspended cancer screening, which is very good news,” adds Dr. Smith. “We sent the wrong signal when we described cancer screening as a nonurgent, nonessential health service.”

Dr. Smith says there is no question that there will be future pandemics and that there may be occasions when preparedness will again lead to the suspension of cancer screening. “Adults need to hear that cancer screening is an essential health service, and that, first, alternative screening tests for colorectal cancer that can be done at home should be utilized during service suspensions, and second, that when services reopen, there is a plan to bring patients who were not able to keep their appointments into adherence. We must stress that irregular screening can result in a missed opportunity to diagnose cancer when it is small and has not spread. Regular cancer screening is important, and while short delays are acceptable, long delays are not.”