Cancer Screening During the 2nd Year of the COVID-19 Pandemic
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Dr. Shannon Westin and her guests, Jessica Star and Dr. Ahmedin Jemal, discuss how the COVID-19 pandemic affected cancer screening in the US in 2021.

TRANSCRIPT The guest on this podcast episode has no disclosures to declare.  Dr. Shannon Westin: Hello, everyone, and welcome to another episode of JCO After Hours*. I am your host, Shannon Westin, the social media editor for the JCO* and Gynecological Oncologist at MD Anderson. And it's my pleasure to welcome you to our next episode, which is “Cancer Screening in the United States During the Second Year of the COVID-19 Pandemic.)” And please note the authors have no conflict of interest.   I'm joined by two of the authors on this important work. First is Jessica Star, who has an MA and an MPH and is Associate Scientist II for Cancer Risk Factors and Screening Surveillance Research at the American Cancer Society. Welcome.  Jessica Star: Thank you for having me.  Dr. Shannon Westin: Of course. And we're also joined by Dr. Ahmedin Jemal, the Senior Vice President for Surveillance and Health Equity Science at the American Cancer Society. Welcome.  We're so excited that you both are here, and I'm hoping that we'll have a really lively discussion about your important work. This paper was published online on February 23, 2023, in the Journal of Clinical Oncology*. So let's level set. We'll start—Jessica, can you talk a little bit about how the COVID-19 pandemic initially impacted cancer screening in the United States?  Jessica Star: So the COVID-19 pandemic disrupted the delivery and receipt of routine preventative services, and that included cancer screening. What we've seen from a lot of 2020 data that has been published is that cancer screening declined during that first year of the COVID-19 pandemic. One of those papers includes a paper by the American Cancer Society led by Stacey Fedewa. And many other studies also reported similar declines, including for breast, cervical, prostate, and colorectal cancer screening. However, some of these papers, by the end of 2020, it appeared that screening rates were starting to rebound back to pre-pandemic rates. And so that was sort of the interest in looking at that 2021 data now. Dr. Shannon Westin: And what did you hypothesize? Did you think that these data were correct? Like, did you think that we were going to start seeing an increase in screening in the second year of the COVID-19 pandemic, or what were your suppositions? Jessica Star: Yes, I think we kind of hypothesized or hoped, based off of what we were seeing from the 2020 data, that we would start seeing more substantial increases as we were getting into 2021. Based off of those declines during the first part of the pandemic, we were really wanting to see individuals coming back into screening now that stay-at-home orders had sort of been reduced and now that individuals were going back to screening more frequently. Dr. Ahmedin Jemal: I might add that the motivation for this screening, in addition to what Jessica said, is that the previous studies were based on representative US populations, either based on claims data or state-specific population-based studies. They were not based on nationwide population-based study. That's why we used the NHIS, National Health Interview Survey, which is a US population-based study, to look at whether screening in 2022 has returned to the pre-pandemic level.  Dr. Shannon Westin: Yeah, why don't we get into a little bit more detail here? I would love—Jessica, can you talk a little bit more about the National Health Interview Survey? I get the idea of why you all used it, but can you tell our listeners just a little bit more about that database? Jessica Star: To go off of what Ahmedin mentioned, The National Health Interview Survey is a nationally representative cross-sectional household survey of the United States population that is generalizable. And that survey is housed by the National Center for Health Statistics in the Centers for Disease Control, and they report on cancer screening biyearly. So we have data from 2019, and we have data from 2021. And the next increment of the National Health Interview Survey that we'll have for cancer screening is in 2023.  Dr. Shannon Westin: And then talk a little bit about which cancer types you all focused on when you're looking into this hypothesis, that potentially screening was being increased.  Jessica Star: So we focused primarily on breast, cervical, colorectal, and prostate cancer screening. And some of the reason behind this was because of data availability. The NHIS only provided those four—receipt of those four screening types, as well as when we were looking at the data previously from that 2020 data, we were seeing a lot that were focusing on some combination of breast, cervical, colorectal, and prostate cancer screening. So we wanted to continue that work into the second year.   Dr. Shannon Westin: And then let's cut to the chase. What did you find? Did you prove or disprove your hypothesis?  Jessica Star: We mostly disproved our hypothesis. Our team found that past-year screening for breast, cervical, and prostate cancer screening decreased in 2021 compared to that 2019 level, with decreases largest primarily among non-Hispanic Asian persons. And this translated to a population-weighted estimate of approximately 1.1 million, 4.4 million, and 700,000 fewer eligible individuals receiving breast, cervical, and prostate cancer screening, respectively. However, we did find that colorectal cancer screening actually remained stable between 2019 and 2021, and part of this can be attributed to an increase in stool testing that offset a decline in colonoscopy testing. Dr. Shannon Westin: Interesting. So people doing things from home allowed them—and I think we all got really good at that during the COVID-19 pandemic, is what actually can we do at home and be functional? That makes sense. Were you surprised at this? I know, as a gynecological oncologist, I was a bit disappointed to see the lack of cervical cancer screening and a bit surprised at the rest. What were your thoughts? Jessica Star: I guess, upon more reflection and seeing that colorectal cancer screening had remained stable and sort of the reason why colorectal cancer screening rates had remained stable, it wasn't entirely surprising. It seems that many people were still hesitant to get screening done in the office or in hospital. And also, considering that many individuals had lost their jobs during the COVID-19 pandemic, many might not have been insured in the same method that they were previously, and so they might have hesitated to be screened as well. Dr. Shannon Westin: That's a great point. Medical coverage is so tightly linked to the work that we're doing. I hadn't even thought about that. That is a great point.   Now, you mentioned briefly about the largest decrease in the non-Hispanic Asian population. Did you see any other kind of associations based on race, ethnicity?  Jessica Star: We did. We also saw some declines for both Hispanic and non-Hispanic Black persons. But we particularly pointed out the decline for non-Hispanic Asian persons because it occurred for all three of the cancer screening types that we saw decline, so for breast, cervical, and prostate cancer screening, whereas for Hispanic and non-Hispanic black persons, they might have had a decrease in one or two screenings but not all three. Dr. Shannon Westin: That's interesting. I bet there's a lot to explore there to try to understand why we would see such discrepancies across the different race ethnicities.  Now, we talked a little bit about how screening might have been improved for colorectal cancer having at home. So what's the lesson here that we can maybe utilize to direct guidance to other screening programs? Jessica Star: The lesson here, which will also have a bit of a caveat to it, is that home-based screening is effective at least getting in that initial screening for when there are healthcare disruptions, whether it's because of the COVID-19 pandemic or even thinking about environmental disasters or all of those different things. But the important thing to note is that once you are screened for colorectal cancer using, for example, like, a home-based stool testing, if you have a positive test, you would need to go in for that follow-up colonoscopy, so you still would need that in-office visit. It does allow a lot of people to get screened, figure out that they're negative, and then not have to proceed any further for those individuals.  Dr. Shannon Westin: Yeah. I wonder, do you have the opportunity to look at data to see how many of those people, if they found something, if they had a positive test then went on to get that next step? I'm sure not from this type of survey.  Jessica Star: Not from this study. From other literature that is already out there, it seems that the estimates are quite low for follow-up colonoscopy. So that's kind of the caveat there is that there would still need to be follow-up to be fully screened if you have an abnormal test. Dr. Shannon Westin: There are some really interesting opportunities to potentially do at-home cervical cancer screening. One of my colleagues is working very hard to try to get that out. And I think you’re bringing up a really big elephant in the room of what will need to be addressed, because it’s going to be something similar where, if you have a positive screening test and then you don’t go to that next step, then you’ve lost the opportunity there. Jessica Star: Yeah. And that's one of the things we did touch on a little bit in the paper, was about cervical cancer screening, since that is an area where there is a home-based option. But since it hasn't yet been approved by the FDA, it hasn't been able to be approved as an appropriate screening method moving forward. But that is definitely an area where we suggest further research sort of comes in to see about allowing cervical cancer screening to also have that home-based option.   Dr. Shannon Westin: So not what we were hoping to see, with the decrease in the screening across three of the major cancer types. What do we do? How do we address these findings? How can we make an impact? Jessica Star: So I think there’s many different areas that can allow for an impact. Clinicians and healthcare professionals should be playing a major role in the return to screening campaigns by recommending screening to each of their eligible patients according to screening guidelines, with that special emphasis on non-Hispanic Asian persons and other historically underserved groups. And I think another area is just continuing to put out research on this topic and continuing to follow up to see about how cancer screenings are continuing to progress as time goes on. This is looking at the second year of the pandemic, and we have data from the first year of the pandemic that's already been published by other people. And we need to sort of keep following it because, in the short term, this problem of delayed cancer screening might lead to late-stage diagnosis, but in the longer term, that can correlate to poor survival and increase mortality as well.  Dr. Ahmedin Jemal: Yeah. I might add one point to what can be done to what already Jessica said. Insurance is a major determinant of access to care, which includes the screening. But we have about 27.5 million, close to 30 million elderly adults who are uninsured. Especially if you look at the expansion of Medicaid, there are 11 states that haven't yet expanded Medicaid. So I think lawmakers can work to expand Medicaid to all populations—to income populations—low-income populations, not all populations. Dr. Shannon Westin: I think you bring up a good point. Policy is really important here, and we've seen this across cancer outcomes. And there's been a lot of really nice data in those states that expand Medicaid that we see improvement in mortality and surgical morbidity and so many things. And so it's a great point. I don't think I've ever heard it referenced towards cancer screening, but there's an opportunity there with policy to improve those numbers as well.  Well, great. I'm so grateful to the two of you. This was—it’s such an important work, and really disproving hypotheses is a good thing, because if we just assumed everything was getting better and didn't act accordingly, then we would be really negatively impacting our patients and potentially with our heads in the sand. So this work was so important, and I'm really grateful for you all to take the time today to have a chat with our listeners.  So listeners, thank you for being here. Again, this was “Cancer Screening in the United States During the Second Year of the COVID-19 Pandemic,” published online February 23, 2023. Thank you for listening to JCO After Hours,* and please do check out our other episodes. And we'll see you next time.  The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. * Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.*