Association of Cancer Screening Deficit in the United States With the COVID-19 Pandemic | Breast Cancer | JAMA Oncology | JAMA Network
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Figure 1.  Screening Rates per 100 000 Enrollees per Month in 2018, 2019, and 2020
Screening Rates per 100 000 Enrollees per Month in 2018, 2019, and 2020

PSA indicates prostate-specific antigen.

Figure 2.  Screening Rates per 100 000 Enrollees per Month in 2019 and 2020 by Geographic Region
Screening Rates per 100 000 Enrollees per Month in 2019 and 2020 by Geographic Region
Figure 3.  Screening Rates per 100 000 Enrollees per Month in 2019 and 2020 by Socioeconomic Status Index Quartile
Screening Rates per 100 000 Enrollees per Month in 2019 and 2020 by Socioeconomic Status Index Quartile
Table.  Estimated Cancer Screening Deficits (95% CIs) for the US Population Between January and July 2020, by Age and Sex
Estimated Cancer Screening Deficits (95% CIs) for the US Population Between January and July 2020, by Age and Sex
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Cancino  RS, Su  Z, Mesa  R, Tomlinson  GE, Wang  J.  The impact of COVID-19 on cancer screening: challenges and opportunities.   JMIR Cancer. 2020;6(2):e21697. doi:10.2196/21697PubMedGoogle Scholar
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Song  H, Bergman  A, Chen  AT,  et al.  Disruptions in preventive care: mammograms during the COVID-19 pandemic.   Health Serv Res. 2021;56(1):95-101. doi:10.1111/1475-6773.13596PubMedGoogle ScholarCrossref
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Van Haren  RM, Delman  AM, Turner  KM,  et al.  Impact of the COVID-19 pandemic on lung cancer screening program and subsequent lung cancer.   J Am Coll Surg. 2020;S1072-7515(20)32525-4.PubMedGoogle Scholar
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Whaley  CM, Pera  MF, Cantor  J,  et al.  Changes in health services use among commercially insured US populations during the COVID-19 pandemic.   JAMA Netw Open. 2020;3(11):e2024984. doi:10.1001/jamanetworkopen.2020.24984PubMedGoogle Scholar
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Bakouny  Z, Paciotti  M, Schmidt  AL, Lipsitz  SR, Choueiri  TK, Trinh  Q-D.  Cancer screening tests and cancer diagnoses during the COVID-19 pandemic.   JAMA Oncol. 2021. doi:10.1001/jamaoncol.2020.7600PubMedGoogle Scholar
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Maringe  C, Spicer  J, Morris  M,  et al.  The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study.   Lancet Oncol. 2020;21(8):1023-1034. doi:10.1016/S1470-2045(20)30388-0PubMedGoogle ScholarCrossref
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Sharpless  NE.  COVID-19 and cancer.   Science. 2020;368(6497):1290. doi:10.1126/science.abd3377PubMedGoogle ScholarCrossref
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Smith  RA, Andrews  KS, Brooks  D,  et al.  Cancer screening in the United States, 2019: a review of current American Cancer Society guidelines and current issues in cancer screening.   CA Cancer J Clin. 2019;69(3):184-210. doi:10.3322/caac.21557PubMedGoogle ScholarCrossref
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Siu  AL; US Preventive Services Task Force.  Screening for breast cancer: US Preventive Services Task Force recommendation statement.   Ann Intern Med. 2016;164(4):279-296. doi:10.7326/M15-2886PubMedGoogle ScholarCrossref
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Bibbins-Domingo  K, Grossman  DC, Curry  SJ,  et al; US Preventive Services Task Force.  Screening for colorectal cancer: US Preventive Services Task Force recommendation statement.   JAMA. 2016;315(23):2564-2575. doi:10.1001/jama.2016.5989PubMedGoogle ScholarCrossref
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Grossman  DC, Curry  SJ, Owens  DK,  et al; US Preventive Services Task Force.  Screening for prostate cancer: US Preventive Services Task Force recommendation statement.   JAMA. 2018;319(18):1901-1913. doi:10.1001/jama.2018.3710PubMedGoogle ScholarCrossref
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Bonito  A, Bann  C, Eicheldinger  C, Carpenter  L. Creation of new race-ethnicity codes and socioeconomic status (SES) indicators for Medicare beneficiaries: final report, sub-task 21. AHRQ publication 08-0029-EF. Published 2008. Accessed March 24, 2021. https://archive.ahrq.gov/research/findings/final-reports/medicareindicators/index.html
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Mast  C, Munoz del Rio  A. Delayed cancer screenings—a second look. Epic Health Research Network. Accessed January 12, 2021. https://ehrn.org/articles/delayed-cancer-screenings-a-second-look/
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    3 Comments for this article
    EXPAND ALL
    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: https://doi.org/10.46747/cfp.6702100
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Are we always doing it right?
    Dilipsinh Solanki, MD | TOPA
    Cancer screening almost belongs up there with motherhood, flag and apple pie! Despite pleas and science to back them up, there has been no effort or even desire to loo back at anything for risk v benefits. A few years ago when USPSTF came out with recommendations to streamline mammography schedule based on risk-benefit-cost analysis there was an outcry. It was clearly a result of what WE had created in the minds of people. Even ACS joined only to come out later to largely concur with USPSTF.

    The author has been making pleas elsewhere for increased education and
    efforts by health care institutions. Who would be against that except for the good likelihood that there may be excessive screening of a subset of women with either harm or no benefit.

    A recent good example is PSA. We harmed men by that who would never have been harmed by cancer but like a Federal benefit hard to call it back.

    Will the Authors be following up on those missed screenings and what happened? If they don’t they will be doing a disservice.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Cancer screening strategy under emergencies
    Mitsuaki Oura, MD | Takeda General Hospital
    We have read with great interest the article by Chen et al. reporting the deficit of cancer screening in the United States brought out by COVID-19.
    Not only the lack of resources but the initial panic of COVID-19 would have led to the reluctance of citizens to undergo cancer screening. In fact, the number of infections was soaring, while the number of screening visits recovered as Chen's study showed, and the same trend was observed in Japan.1 Among prostate, breast, and colorectal screening in the US, only colorectal cancer screening showed a delay in recovery in this study. The reason
    for this delay would be different because of the types of screening tests, as explained below.
    This study included mammography for breast cancer, prostate-specific antigen (PSA) test, digital rectal examination, and biopsy for prostate cancer, and stool test, barium enema, virtual colonoscopy, sigmoidoscopy, and colonoscopy for colorectal cancer. Of these, mammography and PSA tests can be performed without a physician and take a short time. In contrast, even though colonoscopy is widely used for screening, the procedure itself requires specialized professionals and takes a long time. Some position statements from endoscopic societies warned about the significant exposure to droplets from patients during maneuvers.2 Recovery in colorectal screening would have delayed due to endoscopic procedures. We would thus be grateful if the authors showed us the changes in the number of each test.
    The delay in recovery of the screening of colorectal cancer cannot be overlooked, because a delay of 4 to 6 months in screening would increase the number of advanced colorectal cancer cases.3 Stool tests would be a good alternative; in Australia, for example, colorectal screening is conducted by sending a stool kit home and sending back, which does not require a visit to a medical institution and is suited to lockdown. The number of tests in 2020 increased from the previous year, and it is suggested that the change in the number of tests was due to the number of stool kits sent rather than to COVID-19.4 Although endoscopy is necessary for definitive diagnosis, it would be also important to fulfill stool kits in preparation for emergencies.
    It would be important to know the exact numbers of each test and widely broadcast the alternative screening ways in emergencies, such as stool kits and breast self-examination.

    References
    1. Japan Cancer Society. 30% decrease in the number of examinees in 2020, about 2100 cancers might have been undetected, according to a survey by 32 branches of the Japan Cancer Society. Published 2021. Accessed May 25, 2021. https://www.jcancer.jp/news/11952
    2. Cadoni S, Ishaq S, Hassan C, et al. Covid-19 pandemic impact on colonoscopy service and suggestions for managing recovery. Endosc Int open. 2020;8(7):E985-E989. doi:10.1055/a-1196-1711
    3. Ricciardiello L, Ferrari C, Cameletti M, et al. Impact of SARS-CoV-2 Pandemic on Colorectal Cancer Screening Delay: Effect on Stage Shift and Increased Mortality. Clin Gastroenterol Hepatol. Published online May 27, 2021. doi:10.1016/j.cgh.2020.09.008
    4. Australian Institute of Health and Welfare. Cancer Screening and COVID-19 in Australia.; 2021. https://www.aihw.gov.au/getmedia/397a22ef-eb50-4337-a576-928db5cdbcb7/aihw-can-137.pdf

    Authors and affiliations
    Mitsuaki Oura, MD, Takeda General Hospital, Fukushima, Japan.
    Hiroaki Saito, MD, Department of Gastroenterology, Sendai Kousei Hospital, Miyagi, Japan.
    Yoshitaka Nishikawa, MD, PhD, Kyoto University School of Public Health, Kyoto, Japan.
    CONFLICT OF INTEREST: Hiroaki Saito MD reported receiving an honorarium from Taiho Pharmaceutical Co Ltd. outside of this work.
    READ MORE
    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. 2021;7(6):878-884. 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.

    Abstract

    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.

    Introduction

    Across the US, the COVID-19 pandemic influenced health care rapidly and dramatically in 2020. As cases rose across the country, many states began to implement stay-at-home orders. In addition, the Centers for Disease Control and Prevention started to issue guidance to help individuals reduce exposure, and particular attention was directed toward older adults and those with comorbidities, who are at higher risk for developing severe complications from COVID-19. As a result, hospitals and clinics across the country dramatically reduced nonemergency clinical appointments. These changes likely had a direct and negative influence on cancer screening.1-5

    Delays in cancer screenings owing to COVID-19 are suspected to lead to additional excess deaths that are directly attributable to the pandemic.6,7 The goal of the current study, using data from a large national commercial insurance carrier that provides coverage for both Medicare-aged and non-Medicare–aged individuals, is to assess the decline and subsequent recovery of monthly breast, colorectal, and prostate cancer screening rates. We also describe differences by geographic region in the US, as well as potential differential association of COVID-19 with cancer screening for individuals in different socioeconomic status (SES) index quartiles. We further compare screening rates in 2020 with 2019 and estimate a total deficit in cancer screening associated with the COVID-19 pandemic for the entire US population.

    Methods
    Data Source and Population

    The HealthCore Integrated Research Database (HIRD) 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.8-10 The database tracks patient health plan enrollment, medical care, and prescription drug utilization data, making it a useful research resource that can be leveraged to identify current use of health care services, including cancer screening and telehealth. The University of Kansas Medical Center Institutional Review Board deemed the study exempt from review and patient informed consent requirements because deidentified data were used and the study did not involve human subjects research.

    From the HIRD, we selected 3 distinct cohorts of enrollees to evaluate monthly screening rates for breast cancer (women only), colorectal cancer (men and women), and prostate cancer (men only). For each year (2018-2020) and month (January-July) in which we evaluated cancer screening, we first identified enrollees who were aged 50 to 79 years (for breast and colorectal cancer screening) or 50 to 69 years (for prostate cancer screening) who had at least 2 years of continuous enrollment prior to the first date of the month of interest (index month) and no medical claims with International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis or personal history codes for the cancer of interest (eTable 1 in the Supplement) during the 2 years preceding the index month. Excluding individuals with a history of the cancer of interest allowed us to more accurately assess cancer screening. The age ranges of the included enrollees for the current analysis are commonly considered to be eligible for screening.11-14 Enrollees meeting these criteria were eligible for inclusion in the evaluation of cancer screening for that index month.

    Data Analysis

    The primary study end point was receipt of cancer screening, defined as the presence of 1 or more claims during the index month with an ICD-10-CM, Current Procedural Terminology, or Healthcare Common Procedure Coding System code specific for the type of cancer screening of interest (breast, colorectal, or prostate; see eTable 1 in the Supplement). Descriptive analyses were used to summarize the characteristics of analyzed cohorts and to calculate monthly rates for each type of cancer screening (per 100 000 enrollees). For each month analyzed, screening rates were compared between 2020 vs 2019 and described as a percentage change. The percentage change in monthly screening rates between 2020 vs 2019 were further analyzed by geographic region, because of differential timing and influence of COVID-19 on different regions, and by SES index quartile, to examine if the association of COVID-19 with cancer screening differed by SES indicators.

    We then used these results to estimate the total deficit in cancer screening in 2020 for the entire US population. To accomplish this, we first estimated the age group–specific (50-59, 60-64, 65-69, and 70-79 years) US population eligible for screening each month. This involved calculating the prevalence of each cancer in each age group using HIRD data, taking 1 − prevalence to achieve the proportion of each group without the specific cancer, and therefore eligible for screening, and multiplying this proportion by the US population in the age group. We then multiplied 2019 screening rates and 2020 screening rates by the population eligible to approximate the number of screenings in each month for each year, took the difference between 2019 and 2020, and summed the differences across January through July for each age group. Finally, we summed January through July differences across age groups to get total deficits in screening for each cancer type for 2020 (compared with 2019).

    For each month (January-July) in 2020, multivariable Poisson regression models were performed using a binary indicator of cancer screening as the dependent variable to identify associations between enrollee characteristics and risk of cancer screening. Separate models were constructed for each type of cancer screening. Covariates included in the regression models included age group, sex (for colorectal cancer screening only), geographic region, SES index quartile, Charlson comorbidity score,15 and the use of telehealth in the same month. The SES index score was calculated using 7 area-level social determinants of health variables, as developed by the Agency for Healthcare Research and Quality,16 and analyzed as quartiles. Use of telehealth was defined as the presence of 1 or more claims in the index month with 1 or more Current Procedural Terminology or Healthcare Common Procedure Coding System codes for telehealth services (eTable 1 in the Supplement). All analyses were conducted using SAS, version 9.4 (SAS Institute) and Excel, version 16.0 (Microsoft Corporation).

    Results

    Characteristics of analyzed individuals are summarized in eTable 2 in the Supplement. Approximately 20% of individuals were in Medicare plans and 80% were in commercial plans. The 4 regions of the country were well represented.

    While monthly screening rates were similar between 2018 and 2019 (Figure 1), breast, colorectal, and prostate cancer screening in 2020 decreased sharply in March through May compared with the same months in 2019, with near complete recovery of monthly screening rates by July for breast and prostate cancers (Figure 1; eTable 3 in the Supplement). Colorectal cancer screening rates remained 13.1% lower in July 2020 compared with 2019. The month of April 2020 had the sharpest drop in screening rates, by 90.8% for breast cancer (decline from 4287 per 100 000 [95% CI, 4258 to 4316] to 394 per 100 000 [95% CI, 385 to 403]), 79.3% for colorectal cancer (decline from 2073 per 100 000 [95% CI, 2058 to 2087] to 430 per 100 000 [95% CI, 423 to 436]), and 63.4% for prostate cancer (decline from 4025 per 100 000 [95% CI, 3993 to 4057] to 1474 per 100 000 [95% CI, 1454 to 1493]), compared with the same month in 2019.

    Despite recovery in monthly screening rates, there remained a deficit in total screening from January through July 2020 compared with 2019. This translated to an estimated absolute deficit across the entire US population in screening for 3.9 million women (breast), 3.8 million men and women (colorectal), and 1.6 million men (prostate) for a total deficit of 9.4 million in 2020 compared with 2019 (Table).

    The magnitudes of decline and subsequent recovery in cancer screening differed by geographic region (Figure 2; eTable 4 in the Supplement). For all 3 cancers, the Northeast region experienced the sharpest decline in March, April, and May; on the other hand, recovery in screening during June and July was slower for the West compared with the Midwest and South.

    Figure 3 and eTable 5 in the Supplement show screening rates by SES index quartiles. For all cancers before the pandemic (in 2019 and January/February 2020), screening rates were higher for individuals in the highest 2 SES index quartiles and lower for individuals in the lowest 2 SES index quartiles. When we compared the average monthly screening rates from the 7-month period of January through July of 2020 vs the same period in 2019, we found that the decline in screening for all 3 cancers in 2020 was largest in magnitude for individuals in the highest SES quartile (eTable 5 in the Supplement, January-July column). This had the effect of narrowing the gap in screening across the 4 SES quartiles in 2020 compared with 2019.

    Multivariable modeling examining covariates associated with screening during each month of 2020 is summarized in eTable 6 in the Supplement. For each cancer, increasing age was associated with less screening. In April, for breast and colorectal cancer screening, individuals in higher SES index quartiles actually had lower screening rates than those in lower SES index quartiles. An additional finding was that individuals who used telehealth had higher rates of screening; this finding was consistent across all 3 cancers.

    Discussion

    In this analysis of administrative claims data that includes approximately 60 million people in Medicare Advantage and commercial health plans, we found an association of sharp declines in breast, colorectal, and prostate cancer screening rates with the COVID-19 pandemic, especially during March through May 2020, with near complete recovery of monthly screening rates by July. Our results are consistent with recent reports,1,2,4,5,17 while revealing additional insights.

    First, to our best knowledge, this is the first study to demonstrate that declines in screening differed by geographic region. For all 3 cancers studied, the Northeast region experienced the biggest declines in March through May of 2020 compared with the same period in 2019, while the South and West regions experienced lower magnitudes of decline. This corresponds to the differential timing of COVID-19 rates across different regions of the country, with New York and other Northeastern states reporting early and higher surges of COVID-19 cases.

    Second, we quantified cancer screening rates by SES index. As expected, prior to the COVID-19 pandemic, there was a measurable disparity in cancer screening rates. For all 3 cancers, screening from January through July 2019 was lower for individuals in the lower 2 SES index quartiles and higher for individuals in the higher 2 SES index quartiles. However, our data suggest that the COVID-19 pandemic had a bigger negative association with cancer screening for individuals in the highest SES index quartile. Specifically, for January through July of 2020 as a whole compared with the same 7-month period in 2019, the declines in cancer screening for the highest SES quartile vs lowest SES quartile were as follows: breast cancer (−30.0% vs −26.1%), colorectal cancer (−30.2% vs −25.6%), and prostate cancer (−18.9% vs −11.5%). This had the effect of closing the gap in cancer screening by SES index. For January through July 2020, the monthly average of cancer screening rates per 100 000 enrollees was nearly identical for individuals in the highest vs lowest SES index quartile for 2 of the 3 studied cancers: breast (2916 vs 2922) and colorectal (1432 vs 1419).

    Third, we estimated the deficit in cancer screening for the US population associated with the COVID-19 pandemic. A recent editorial7 from the National Cancer Institute director clearly defined a concern for increased cancer mortality caused by delayed screening. To inform modeling studies that estimate the magnitude of this mortality impact and to inform health care policies to mitigate this potential increased mortality, accurate estimates on the association of COVID-19 with screening for specific cancers, and in specific populations, are needed. This study provides data to inform these efforts. The current study improves on earlier publications by including a large US population comprising both Medicare-aged and non-Medicare–aged individuals, excluding individuals with prevalent cancers, and analyzing data through the months of screening decline and subsequent recovery. We also restricted the analysis to individuals in age groups that are appropriate for cancer screening. Our results further revealed that the screening deficit was larger for breast and colorectal cancers, which require procedures (commonly, mammography and colonoscopy), compared with prostate cancer screening, which commonly involves a blood test (ie, prostate-specific antigen testing). However, further study is needed to ascertain the reasons for the different screening deficits. While monthly breast and prostate cancer screening rates recovered fully by July 2020, colorectal cancer screening remained 13% below 2019 rates. From a public health perspective, increasing the use of alternatives to colonoscopy for colorectal cancer screening may help mitigate this screening deficit.

    Fourth, we found a novel association between patient use of telehealth and receipt of cancer screening even after adjusting for other covariates, including SES index score. This suggests a potential benefit of telehealth: while the COVID-19 pandemic led to broad cancellations of nonemergency in-person health care appointments, telehealth appointments might have enabled individuals to still receive medical consultation and advice, as well as a plan for rescheduling screening tests.

    Limitations

    There are several limitations to this study, including analysis of only insured individuals, which may skew our population-level estimation of cancer screening deficit associated with the COVID-19 pandemic. Specifically, the analysis may not be representative of underinsured and/or publicly insured individuals and could underestimate the association of SES. Another limitation is the lack of race/ethnicity information for analysis. In addition, while many of the codes used in the analysis were specific for screening tests, some codes did not distinguish between screening vs a test for another clinical indication. Our inclusion of individuals without a history of the cancer of interest partially mitigated the limitation of inaccurately counting a test performed for nonscreening purposes.

    Conclusions

    Breast, colorectal, and prostate cancer screening declined sharply in March through May 2020 throughout the US, but most dramatically in the Northeast region and for individuals in the highest SES index quartile. The estimated screening deficit associated with the COVID-19 pandemic across these 3 cancers for the US population was 9.4 million. This may be a temporary delay; public health efforts are needed to address the large cancer screening deficit, including increased use of screening modalities that do not require a procedure.

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    Article Information

    Accepted for Publication: March 9, 2021.

    Published Online: April 29, 2021. doi:10.1001/jamaoncol.2021.0884

    Corresponding Author: Ronald Chen, MD, MPH, Department of Radiation Oncology, University of Kansas, Kansas City, KS 66160 (rchen2@kumc.edu).

    Author Contributions: Drs Chen and Katz had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: All authors.

    Acquisition, analysis, or interpretation of data: Chen, Haynes, Du, Katz.

    Drafting of the manuscript: Chen, Katz.

    Critical revision of the manuscript for important intellectual content: Haynes, Du, Barron, Katz.

    Statistical analysis: Katz.

    Administrative, technical, or material support: Chen, Haynes.

    Supervision: Chen, Barron.

    Conflict of Interest Disclosures: Dr Chen reported receiving personal fees from AbbVie, Myovant, Bayer, Blue Earth Diagnostics, and Accuray outside the submitted work. Dr Haynes reported being employed by Anthem during the conduct of the study; receiving grants from Patient-Centered Outcomes Research Institute and contracts from the US Food and Drug Administration outside the submitted work. Dr Du reported receiving personal fees (salary) from HealthCore during the conduct of the study. Dr Barron reported being an Anthem employee and stock shareholder. Dr Katz reported receiving personal fees from Kite Pharma and Atara Biotherapeutics outside the submitted work.

    References
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    Cancino  RS, Su  Z, Mesa  R, Tomlinson  GE, Wang  J.  The impact of COVID-19 on cancer screening: challenges and opportunities.   JMIR Cancer. 2020;6(2):e21697. doi:10.2196/21697PubMedGoogle Scholar
    2.
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