Association of Cancer Screening Deficit in the United States With the COVID-19 Pandemic | Breast Cancer | JAMA Oncology | JAMA Network
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    1 Comment for this article
    The “screening deficit” may reduce harms from overdiagnosis and overtreatment
    James Dickinson, MBBS, PhD | Family Medicine and Community Health Sciences, University of Calgary
    Chen et al, provide a measure of “deficits” in Breast, Colorectal and Prostate screening caused by patients staying away from services during the COVID-19 epidemic. They measured only reduced screening, and suggest that this will affect the outcomes that matter for patients: reduced advanced cancer, and deaths from these cancers. Therefore they urge increased vigilance and public health campaigns.

    There is an alternate hypothesis: that much screening is either excessive or ineffective, and may cause overdiagnosis and overtreatment of “disease” that would be better left undiscovered.1 These patients may be harmed by the treatments they receive, and might
    be better off not being screened. These probabilities likely differ for the three cancers chosen. People who have already been screened, and whose risk of important disease is already less, may be affected little by substantial increase in intervals.2

    Rather than simply jumping to remedy the “screening deficits”, the COVID epidemic provides a natural experiment opportunity to assess which screening, for whom, is actually important, and how much harm has been avoided. It may show that longer intervals reduce harm, without increase in mortality. Thus research projects should be planned with open minds to examine all outcomes of this experiment, to provide better information for the future.

    1. Dickinson JA, Pimlott N, Grad R, Singh H, Szafran O, Wilson BJ, et al. Screening: when things go wrong. Can Fam Physician 2018;64:502-8. (Eng),

    2.James A. Dickinson, Guylène Thériault, Harminder Singh, Roland Grad, Neil R. Bell and Olga Szafran. Too soon or too late? Choosing the right screening test intervals Canadian Family Physician February 2021, 67 (2) 100-106; DOI:
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    Original Investigation
    April 29, 2021

    Association of Cancer Screening Deficit in the United States With the COVID-19 Pandemic

    Author Affiliations
    • 1Department of Radiation Oncology, University of Kansas Medical Center, Kansas City
    • 2Scientific Affairs, HealthCore, Inc, Wilmington, Delaware
    • 3Department of Population Health, University of Kansas Medical Center, Kansas City
    JAMA Oncol. Published online April 29, 2021. doi:10.1001/jamaoncol.2021.0884
    Key Points

    Question  What was the association of the COVID-19 pandemic with cancer screening rates across the US?

    Findings  This cohort study found that with sharp declines and subsequent recoveries of breast, colorectal, and prostate cancer monthly screening rates in 2020, there remained an estimated screening deficit of 9.4 million associated with the COVID-19 pandemic for the US population. Screening declines differed by geographic region and socioeconomic status index, and use of telehealth was associated with higher screening rates.

    Meaning  Public health efforts are needed to make up the large cancer screening deficit associated with the COVID-19 pandemic.


    Importance  The COVID-19 pandemic led to sharp declines in cancer screening. However, the total deficit in screening in the US associated with the pandemic and the differential impact on individuals in different geographic regions and by socioeconomic status (SES) index have yet to be fully characterized.

    Objectives  To quantify the screening rates for breast, colorectal, and prostate cancers associated with the COVID-19 pandemic in different geographic regions and for individuals in different SES index quartiles and estimate the overall cancer screening deficit in 2020 across the US population.

    Design, Setting, and Participants  This retrospective cohort study uses the HealthCore Integrated Research Database, which comprises single-payer administrative claims data and enrollment information covering approximately 60 million people in Medicare Advantage and commercial health plans from across geographically diverse regions of the US. Participants were individuals in the database in January through July of 2018, 2019, and 2020 without diagnosis of the cancer of interest prior to the analytic index month.

    Exposures  Analytic index month and year.

    Main Outcomes and Measures  Receipt of breast, colorectal, or prostate cancer screening.

    Results  Screening for all 3 cancers declined sharply in March through May of 2020 compared with 2019, with the sharpest decline in April (breast, −90.8%; colorectal, −79.3%; prostate, −63.4%) and near complete recovery of monthly screening rates by July for breast and prostate cancers. The absolute deficit across the US population in screening associated with the COVID-19 pandemic was estimated to be 3.9 million (breast), 3.8 million (colorectal), and 1.6 million (prostate). Geographic differences were observed: the Northeast experienced the sharpest declines in screening, while the West had a slower recovery compared with the Midwest and South. For example, percentage change in breast cancer screening rate (2020 vs 2019) for the month of April ranged from −87.3% (95% CI, −87.9% to −86.7%) in the West to −94.5% (95% CI, −94.9% to −94.1%) in the Northeast (decline). For the month of July, it ranged from −0.3% (95% CI, −2.1% to 1.5%) in the Midwest to −10.6% (−12.6% to −8.4%) in the West (recovery). By SES, the largest screening decline was observed in individuals in the highest SES index quartile, leading to a narrowing in the disparity in cancer screening by SES in 2020. For example, prostate cancer screening rates per 100 000 enrollees for individuals in the lowest and highest SES index quartiles, respectively, were 3525 (95% CI, 3444 to 3607) and 4329 (95% CI, 4271 to 4386) in April 2019 compared with 1535 (95% CI, 1480 to 1589) and 1338 (95% CI, 1306 to 1370) in April 2020. Multivariable analysis showed that telehealth use was associated with higher cancer screening.

    Conclusions and Relevance  Public health efforts are needed to address the large cancer screening deficit associated with the COVID-19 pandemic, including increased use of screening modalities that do not require a procedure.