key: cord-0747039-0ukgugbh authors: Puricelli Perin, Douglas M.; Christensen, Tess; Burón, Andrea; Haas, Jennifer S.; Kamineni, Aruna; Pashayan, Nora; Rabeneck, Linda; Smith, Robert; Elfström, Miriam; Broeders, Mireille J.M. title: Interruption of cancer screening services due to COVID-19 pandemic: lessons from previous disasters date: 2021-05-17 journal: Prev Med Rep DOI: 10.1016/j.pmedr.2021.101399 sha: 614990cb11b8661cf2512f1cdfe2819b7fa89e99 doc_id: 747039 cord_uid: 0ukgugbh PURPOSE: To review the scientific literature seeking lessons for the COVID-19 era that could be learned from previous health services interruptions that affected the delivery of cancer screening services. METHODS: A systematic search was conducted up to April 17, 2020, with no restrictions on language or dates and resulted in 385 articles. Two researchers independently assessed the list and discussed any disagreements. Once a consensus was achieved for each paper, those selected were included in the review. RESULTS: Eleven articles were included. Three studies were based in Japan, two in the United States, one in South Korea, one in Denmark, and the remaining four offered a global perspective on interruptions in health services due to natural or human-caused disasters. No articles covered an interruption due to a pandemic. The main themes identified in the reviewed studies were coordination, communication, resource availability and patient follow-up. CONCLUSION: Lessons learned applied to the context of COVID-19 are that coordination involving partners across the health sector is essential to optimize resources and resume services, making them more resilient while preparing for future interruptions. Communication with the general population about how COVID-19 has affected cancer screening, measures taken to mitigate it and safely re-establish screening services is recommended. Use of mobile health systems to reach patients who are not accessing services and the application of resource-stratified guidelines are important considerations. More research is needed to explore best strategies for suspending, resuming and sustaining cancer screening programs, and preparedness for future disruptions, adapted to diverse health care systems. Screening is a key component of the cancer control continuum, and when effectively implemented, can decrease the burden of breast, cervical, colorectal and lung cancers [1] [2] [3] . As COVID-19 reached pandemic levels in March 2020 a reports of the interruption of regular delivery of cancer screening services, including opportunistic and organized cancer screening, pilot and research programs, and diagnostic follow-up emerged from around the world 4, 5 . Several countries took mitigation measures, limiting movement of populations as growing numbers of COVID-19 cases generated pressure on health care systems 4, 6 . Efforts to control COVID- 19 and reduce mortality became the focus of the public health agenda globally, while diverting attention from cancer prevention and control activities. However, cancer remains an important public health issue, accounting for an estimated 9.6 million deaths worldwide in 2018 7 . In addition, early epidemiological evidence suggests that cancer may be an important risk factor for COVID-19-related deaths 8,9 . To limit the spread of coronavirus through healthcare-associated infections and preserve available resources for the COVID-19 response, political and health authorities and administrators in several countries mandated the interruption of non-emergency medical procedures, including routine cancer screening [4] [5] [6] . In the Netherlands, for instance, national screening programs for breast, cervical and colorectal cancers were suspended on March 16, 2020 , and the Netherlands Comprehensive Cancer Organization reported a decrease in cancer diagnosis since the start of the COVID-19 pandemic 10 . In the UK, cancer screening services were suspended and urgent 2-week-wait diagnostic referrals saw a decrease of up to 80% since March 11 . In Hong Kong, colorectal cancer diagnoses fell by 37% in the weeks after the emergence of COVID-19 and an initial model estimated colorectal cancer upstaging for 6.4% of patients at 6 months 12 . In the United States, the National Cancer Institute projected almost 10,000 excess deaths from breast and colorectal cancers in the next ten years associated with delays in screening and treatment due to the COVID-19 pandemic 13 . By June 2020, as COVID-19 containment restrictions were progressively lifted, countries and regions were in various phases of resuming cancer screening services. Although the unprecedented scale of the current health crisis in recent times makes it difficult to find previous situations that were comparable, there have been occasions when natural and human-caused events, such as hurricanes, armed conflicts, and nuclear catastrophes, led to adverse effects on health systems, including interruption of services. Experiences derived from these events may be valuable to address the past and current interruptions of cancer screening services due to COVID-19 as well as to inform best practices for resuming screening and preparing against future interruptions, if necessary. The purpose of this study was to systematically search the available scientific literature to look for lessons that could be learned from previous health services interruptions that affected the delivery of cancer screening services. Hopefully, the results will inform the next steps for cancer screening as services resume and to prepare for potential next rounds of service interruption during the COVID-19 pandemic or for future ones. An electronic search was conducted up to April 17, 2020 , with no restrictions on language or dates. The search strategy was developed with assistance from the Library of Medical Sciences, in the Radboud university medical center, and carried out in PubMed, Google Scholar and Embase using the following keywords and their combinations: "disaster", "mass screening", "cancer" and "time factors" (referring to terms related to the time of interruption, such as "delay", "stop", "discontinue", "after" or "during"). The keyword "mental health" was used to exclude articles from the search results because screening for mental health problems often occurs following a disaster, to punctually address issues that arise post-event and not as an ongoing health service, while the current review focuses on the interruption and restart of health services. The full search strategy can be found in Appendix A. The search resulted in 385 articles and two researchers (D.M.P.P., T.C.) independently performed the selection process, initially reviewing the articles based on their title and abstract. A reversed search on the Web of Science, reviewing the reference list from retrieved articles and literature suggested by experts resulted in eleven more articles. Studies had to include either an interruption in health care services or describe an event that affected screening rates and the health of the population, while providing information on how the health system was able to cope with the event and resume operations. Articles were excluded when information about the provision of health care services was insufficient to offer a picture of the experiences encountered in the setting or when there was no possible parallel with the current COVID-19 pandemic. Any disagreements between the two researchers regarding the selected articles were discussed and a consensus on the final selection was achieved. Twenty-four potential articles were identified based on the titles and abstracts: nine articles were retrieved from PubMed and three from Embase; eight were selected using a reversed search on the Web of Science, and a search in Google Scholar; and, another four were found by reviewing the reference list from retrieved articles and literature suggested by experts. After reading the full-text articles, thirteen were excluded based on the criteria previously described. Therefore, eleven studies were included in the literature review. The selection process of the articles is shown in Figure 1 . focus on infectious disease control, no interruption of screening services (n = 6) assessments of facilities, not the interruption of screening services (n = 2) assessments of cancer risk due to delay in screening, no interruption of screening services (n = 2) assessment of changes in cancer incidence, no interruption of screening services (n = 1) audit of untreated breast cancers, no interruption of screening services (n = 1) preparedness for mental health issues, no interruption of screening services (n = 1) Studies included (n = 11) Duplicates removed (n = 5) Figure 1 . Overview of study inclusion. Relevant information was extracted from each included study, including characteristics that identify the setting as a disaster scenario, and the main findings relative to how it affected the organization or delivery of health services and any plans to resume them. Information from the selected studies were thematically analyzed, independently by two researchers (T.C. and D.M.P.P.) with the assistance of a senior cancer screening researcher (M.J.M.B.). Following the method developed by Braun and Clarke 14 , six stages were adhered to during analysis, i.e., familiarization with the data, coding, developing themes, reviewing themes, defining and naming themes, and final analysis. Consensus was reached through discussion when discrepancies arose. All co-authors recognized the four main thematic categories -coordination, communication, resource availability and patient follow-up -as key for the organization and delivery of cancer screening services. General characteristics of the seven original research studies included in the review are found in Table 1 . Three studies were based in Japan [15] [16] [17] , two in the United States 18, 19 , one in South Korea 20 and one in Denmark 21 . The remaining four studies were reviews that offered a global perspective on interruptions in health services [22] [23] [24] [25] , and their characteristics are described on Table 2 . Eight studies included information about a health services interruption during a natural or human-caused disaster [15] [16] [17] [18] [19] [22] [23] [24] . The remaining three studies provided a perspective of events that may indirectly disrupt the provision of health services, including a maritime incident 20 , a systematic error in screening registration 21 , and a financial crisis 25 . No articles covered an interruption in regular health services due to a pandemic. There were no selection criteria for study design resulting in a wide range of study types, including three narrative reviews 22, 24, 25 , three cohort studies 17, 19, 21 , two cross-sectional studies 18, 20 , one systematic review 23 , one trend analysis 16 , and one case study 15 . The main topics covered in the included studies can be found in Table 3 . Considering the medical subjects covered, two articles were focused on cervical cancer 16 After a disaster, the chaotic environment that often ensues makes it difficult to proceed with regular coordination of the health care activities beyond the immediate response to the event. Therefore, coordination and collaboration across the health care sector, and with other sectors such as the media and local government authorities, are important factors to ensure the continuity or re-establishment of services 18, 22, 24 The ICS b structures the disaster response into five functional sectors -command, operations, logistics, planning and finance -and encompasses core concepts that facilitate a coordinated approach such as a unified command, use of common terminology and integrated communications. Studies suggest that these frameworks could facilitate the development of an integrated, multi-agency, inter-organizational coordinated structure to enhance the effectiveness of the response 22, 24 . Finally, some studies found that new coordinated strategies, such as the quick implementation of mobile health clinics and similar mobile systems are useful to monitor the health of hard-to-reach populations and overcome barriers to accessing health services during and post-disaster 16,23,24 . Studies showed that there are two aspects of communication to be considered in the event of an interruption of health services. From an infrastructure perspective, natural or human-caused disasters may damage the local communications infrastructure and bring down telephone, TV, radio stations or the internet 15 Disasters may lead to loss of infrastructure and human resources, causing a disruption in the regular provision of health services. In Syria, where armed conflict started in 2011, 15,000 doctors were reported as having left the country by 2015, while 45% of public hospitals were reported damaged, with 15% fully damaged and 30% partially damaged by the end of 2017 22 . At MMGH, after the Great East Japan Earthquake, 70% of hospital employees eventually evacuated from the disaster area due to personal concerns. In addition, the lack of adequate resources in terms of food, water and medical supplies soon translated into poorer health services as drug and meal administration to patients were shortened due to lack of medicines and supplies 15 Ozaki et al. (2017) highlighted that the effects of discontinued services on patient follow-up could last long after the disaster, pointing to the importance of strengthening efforts to reach the affected population 17 . The authors found that after the Great East Japan Earthquake, the population in Minamisoma City had a 66% greater risk of experiencing delays of three months or longer in patient care, and 349% greater risk of experiencing delays of 12 months or longer, compared to the pre-disaster population 17 . Minamisoma City continued to provide mammography services throughout the post-disaster period and full oncology services were also re-established after three months. However, simply ensuring the re-establishment of services was not sufficient to decrease the risk of experiencing delays in cancer care. The increased risk persisted for five years after the earthquake, and the authors did not observe any association with factors related to access to cancer care (distance from hospital, referral, etc.) or to the disaster itself (resident of an evacuation zone), and suggested that experiencing psychosocial distress and lack of social support may have played a role in the delays 17 . Moreover, disasters have an impact on decisions to engage with the health system even when the population is not directly affected by the event. For example, the Sewol ferry disaster generated a public trauma in the city of Ansan, South Korea, as 304 passengers died, including 250 students and 11 teachers from a local high school 20 . Ansan residents were not physically affected by the event and the tragedy did not result in a disruption to the provision of health services. However, Kang et al. (2020) reported that, in the 3-year period after the event, people not living in Ansan were 1.41 times more likely to receive cancer screening than those who lived there; no differences were observed in the previous 3-year period 20 . Most natural disasters occur in lowincome countries with vulnerable health care systems, where a coordinated response is less likely to occur because of economic and structural constraints. Recommended the adoption of the Sendai Framework for Disaster Risk Reduction 25 as a preparedness measure to strengthen the resilience of communities and countries. Public awareness and information about how, where, and when to seek medical attention should be made more available to refugees in asylum countries. This could be achieved by improving communication between the health care system and the refugees through publicity and awareness campaigns. At the end of 2017, in Syria, 45% of public hospitals were reported damaged, with 15% fully damaged and 30% partially damaged. Forty-nine percent were reported fully functioning, 25% of hospitals were reported partially functioning, and 26% were reported non-functioning. Only 23% of functional public hospitals in Syria provided cancer treatment services. Settings receiving displaced populations should consider applying resource-stratified Only 46% of patients with cancer in Syria completed radiotherapy treatment without interruption, and 55% of them completed systemic therapy/chemotherapy without interruption. guidelines to manage cancer patients, following the principle of doing the best possible with the resources available. Mobile clinics may help overcome barriers to treatment access in a disaster. Communication infrastructures may be completely collapsed following a disaster, impacting interactions between providers, providers and their patients, and provider agencies and governmental agencies. When assessing challenges of cancer patients, it is important to consider the diverse cancer types as disaster will affect them differently. In 2014-2016 period, after the Sewol Ferry disaster, those who did not live in Ansan (where the ferry disaster took place) received more health screening, more cancer screening, and more vaccination than residents in Ansan. People living in the same area as disaster victims tended to receive fewer health services, even if they did not directly experience the disaster. Kodama et al. (2014) 15 MMGH had disaster plan in place. MMGH did not receive any information on Fukushima Daiichi nuclear power plant accident from the public administration office of the central government until March 18. All communication devices including telephone, cell phones, and internet access were not available between March 11 and March 15. Lack of adequate communication led to worse response planning and increased anxiety among patients and medical staff. 70% of hospital employees chose to evacuate, mostly due to concern about their families and work responsibilities. Shortages happened faster than expected leading to treatment cessation. Delivery of supplies resumed 5 days after the earthquake. Lack of human and material resources, and information after the nuclear accident made it difficult to maintain the health care provider system. Drug and meal administration to patients were shortened as medicine, food and water supplies were halted. Koscheyev et al. (1997) 24 Disaster response is extremely demanding when followed by destruction of the social infrastructure, chaotic situation, inadequate medical supplies and lack of coordination between the various emergency, medical and scientific groups. Three disaster stages are identified: acute (one hour to several weeks), mid-term (months to years), long-term (years to decades). Importance of developing an integrated, multi-agency, inter-organizational structure to enhance the effectiveness of local emergency management directors and need for careful organization and communication among all levels of the chain of command. Having expert and competent personnel in charge of the response under the framework of the incident command system b is recommended in a disaster scenario. Coordinated, comprehensive mobile systems to monitor the health of hard-toreach populations are recommended in disaster planning. Following the Chernobyl nuclear accident, many government officials made decisions with long-term implications that were not optimal from a public health perspective after spending only one or two days at the scene. Contradictory orders given by different officials led to serious mistakes in data gathering and analyses. Availability of physicians and other health care providers for rapid mobilization is often inadequate due to poor planning, insufficient numbers or the sheer magnitude of the disaster. Patient triage can be disrupted by simple mistakes, communication difficulties, transportation problems or incorrect information, on top of high levels of fatigue and stress experienced by health care providers. Population health effects (physical and mental) following the acute emergency period of disasters require closer attention and accurate measurements are needed. However, the immediate research goals to protect the health of the population may be different from the long-term ones, which may lose momentum. Immediate health impact is difficult to be assessed during an acute disaster situation, due to issues such as poor information gathering, poor communication and coordination, and problems of field diagnosis. Prior to women's unsubscription becoming public in October 2013, only 25 cervical cancer-related items were retrieved from media sources mostly regarding human papillomavirus vaccination. Among the 10,094 women within screening age who were unsubscribed from the DNCCSP, 3,804 (37.7%) had been opportunistically tested within 3 years (23to 49-year olds) or 5 years (50-to 64-year olds) despite receiving no invitation. In the six months following the event, 698 items covered the risk of similar events in other programs, patient compensation, and a new law to override the ten-year statute of limitation to the claims. Of 4,783 women within screening age who were re-invited to the DNCCSP, 2,660 (55.6%) received cytology tests within 1 year and 26 (1%) high grade squamous intraepithelial lesions were detected. Among the 8,868 females older than 64 years, a total of 1,124 (12.7%) females received HPV tests, and over 90% of the tests were hrHPV negative. The Danish Patient Compensation Association processed 85 complaints from females diagnosed with cervical cancer, leading to 19 females compensated with a total of €693,000. Only 31 (58.5%) of the 53 reporting hospital laboratories stated that they had received the post-Hurricane Katrina advisory regarding resumption of state laboratory services. From 5958 specimens submitted from hospitals after the hurricane, 1207 (20.3%) screening results had not been received or could not be considered valid due to improper storage or delayed shipment. Staff were evacuated and many could not return for weeks and months, eventually leading to over 70% of newborn screening laboratory staff to resign. Of the 53 hospitals that responded to the full survey, a few reported disruptions in laboratory processing (18.9%), labor and delivery (5.7%), an both (11.3%). Delays in the postal service led to an increase in the number of specimens rejected as a result of being over 14 days old (4% compared to ~0.1% rejection prior to the hurricane). Poorly designed and coordinated screening wastes considerable financial, material and human resources, so during an economic crisis, it is important to focus on aspects Adequate and timely diagnosis and treatment, as well as awareness-raising are aspects needed to establish organized screening. that contribute to optimal organization and implementation of cancer screening. Aspects essential to quality and effectiveness also include financing sustainability; identification, information and invitation of the target population; linkages within the healthcare system (including primary care and oncology); human resource training; laboratory and equipment infrastructure; technical quality; risk communication; monitoring of results among many others that must work together coherently. Miki et al. (2020) 16 After the Great East Japan Earthquake (11 March 2011), cervical cancer screening was resumed in April, 2011. However, in coastal areas restarting screening was delayed from July to December, 2011. In the Miyagi Prefecture, cervical cancer screening was performed in the mobile van or the hospital, with the van covering areas severely affected by the disaster. There were areas where screening rates recovered in the 5 years following the disaster, and others that did not. It was not clear from the study what accounted for these differences, although communication is suggested as an important factor. After the Great East Japan Earthquake, cervical cancer screening rates markedly decreased in the 4 coastal areas affected by tsunami and covered by mobile van: Ogatsu (−5.2%), Onagawa (−7.0%), Karakuwa (−4.8%), and Shizugawa (−4.1%). Patients with locally advanced NSCLC exposed to a hurricane disaster had longer radiation treatment durations and significantly worse overall survival than matched unexposed patients. The adjusted relative risk for death increased with the length of the disaster declaration. There was no significant difference in the proportions of patients presenting with a lump between pre-and post-disaster patients. However, there was a significantly higher proportion of hormone receptor-Breast cancer care was re-established at MMGH on August 2011. Minamisoma City has continuously provided mammography screening to residents throughout the post-disaster period. Alternative mechanisms, rather than changes in healthcare access (since measures did not differ significantly preand post-disaster), may have contributed to patient delay among post-disaster breast cancer patients. positive breast cancer after the disaster, compared with the pre-disaster period. When comparing the overall post-disaster population with the pre-disaster baseline, there was a significant increase in the ageadjusted risk ratio for both total patient delay and excessive patient delay, and this trend continued for five years after the disaster. In the post-disaster period, none of accessand disaster-related factors and sociodemographic factors were significantly associated with experiencing total patient delay, however a significant association was observed with having a family history of any cancer. Although the proportion of those with total patient delay was 18.0% pre-disaster, similar to other settings in high-income countries, it reached 29.9% post-disaster, a level comparable to low-and middleincome countries. Furthermore, 18.6% of all post-disaster patients experienced excessive patient delay, compared to 4.1% predisaster. pandemic. The COVID-19 emergency presents characteristics similar to previous experiences in disaster management, including interruption of health services, weak communication between health care providers and patients and lack of human resources, inadequate infrastructure or lack of supplies immediately after the outbreak and in many cases extending over several months, and the population not seeking health care services once they restarted c . Therefore, the application of these principles and strategies could guide cancer screening practitioners on how to deal with this continuing public health crisis and prepare for future pandemics. Coordination beyond the delivery of cancer screening itself, involving partners across the health sector, is essential to optimize resources and resume services, making them more resilient while preparing for future interruptions. For example, in the Netherlands, since the COVID-19 emergency response led to the reallocation of many cancer screening practitioners, the re-establishment of cancer screening services required coordination with other areas of the health system to bring back enough staff while ensuring the continuity of the emergency response , 27 . In addition, a safe environment for health professionals and the general public is needed for the delivery of cancer screening as the pandemic continues [4] [5] [6] , which requires the coordinated implementation of adequate personal protective equipment and extra sanitation measures, and the assessment of participants for symptoms. These system adaptations call for coordination to ensure that the novel strategies and policies are properly implemented and that there are adequate staff and resources without compromising the response to the COVID-19 pandemic, or future ones. Open communication and coordination among health care providers, health authorities and the public are essential to ensure that all parties understand the needs, challenges and changes generated by this COVID-19 scenario. Furthermore, we highlight the importance of clear communication with the general population, which can be aided through media, public campaigns, community leaders and organizations, about how COVID-19 has affected cancer screening, and the measures taken to mitigate these effects and re-establish the screening services in a safe manner. Such communication efforts may contribute to restoring participation in cancer screening once the programs restart 16, 21, 23 , although the true effectiveness of communication strategies still needs to be tested. Considering the global impact of COVID-19, which led to the interruption of cancer screening in several countries, communication and knowledge exchange at the international level is essential for cancer screening practitioners to share experiences and other resources, learning from each other as they resume screening services and prepare for future disruptions. In dealing with issues of resource availability and patient follow-up, the ongoing COVID-19 pandemic and consequent restrictions put in place worldwide to safeguard the health of the general population present several challenges to cancer screening. For instance, there is a considerable backlog because non-urgent services, including cancer screening, were postponed due to COVID-19 4, 5, 28 . Establishing criteria to prioritize participants is an important part of how programs plan and coordinate the reestablishment of cancer screening services. These delays will not be easy to solve, and may not be solved at all 28 , especially in settings where health care resources were already scarce. Moreover, contact with screening participants becomes more difficult due to the risk of infection, while laboratories are often busy testing COVID-19 samples instead of processing cancer screening samples. From the participant perspective, previous experiences have shown that even after health services are re-established, it may be long before the general population starts accessing them again even when logistical or socio-demographic barriers are absent 17, 22, 23 . In the ongoing COVID-19 pandemic, fear of infection when going for a regular screening or diagnostic visit may contribute to lower participation rates in the years to come. Here, the use of mobile health systems to reach patients who are not accessing services presents an opportunity 16, 23, 24 . One of the limitations of this study is that information about resuming services was limited. There was not enough evidence to determine best practices in resuming cancer screening, which was one of the aims of this study. Furthermore, the focus of our search strategy was on screening, avoiding the inclusion of terms such as 'epidemic' and 'pandemic' because the scope was the disaster literature in general. This may have resulted in missing studies that describe other health services interruptions (e.g., outpatient visits, immunizations, services related to malaria, tuberculosis or HIV, etc.) related to epidemics and other disasters, especially in low-and middle-income countries, such as the Ebola outbreak of 2013-2016 in West Africa 31 . However, our search strategy captured 6 studies related to epidemics, which were excluded due to their focus on infection control and not the interruption of cancer screening services. Finally, grey literature was not included and there may be several strategies and practices being tested while facing the current COVID-19 crisis that were not included in our study. However, the information acquired from the published literature on the interruption and reestablishment of health services described in this study provides important lessons for cancer screening practitioners worldwide. It is important to note that several groups, such as the COVID-19 and Cancer Global Modelling Consortium (https://ccgmc.org/), continue to assess the effects of the COVID-19 on the cancer care continuum. In addition, the International Cancer Screening Network (ICSN) 32,33 has recently performed a survey to understand the immediate effects of COVID-19 on cancer screening worldwide and plan for the best ways forward. It is essential to coordinate these international efforts and establish open channels of communication across these different groups where relevant information could be shared. 33 Moreover, we encourage researchers to further assess best practices in preparing for and responding to the interruption of cancer screening services in the context of a disaster, and how to resume these services. A recent systematic review conducted by Riera and colleagues 34 on COVID-19 disruption to cancer care did not find any studies that addressed the interruption of the diagnostic process or population-based, organized cancer screening programs, indicating that there is a dearth of information even within the present crisis. Coordination and communication while assessing available resources and best strategies to follow-up and monitor patients are essential elements in maintaining and restoring health care services during and after a disaster. Even though the findings gathered in this study are not surprising, they elucidate the importance of applying these fundamental elements of health services in times of crisis. These lessons are crucial in the context of the ongoing COVID-19 pandemic, and future ones, and should be taken into account as cancer screening practitioners re-establish services worldwide and prepare for the next disruption. Furthermore, the international community should work together to exchange information and expertise with the aim of identifying and testing best strategies to resume and sustain cancer screening programs, appropriately adapted to the diverse health care systems. The unprecedented scale of the ongoing pandemic requires a coordinated international effort. By reporting and sharing experiences of how cancer screening is resumed, we can apply lessons earned in other settings and strengthen the response while identifying and preventing potential pitfalls going forward. This project has been funded in part with federal funds from the National Cancer Institute, National Effectiveness of lung cancer screening implementation in the community setting in the United States Report on the implementation of the Council Recommendation on cancer screening. Luxembourg: European Commission European guidelines for quality assurance in breast cancer screening and diagnosis. Fourth edition--summary document International Research Network on COVID-19 Impact on Cancer Care. Impact of the COVID-19 pandemic on cancer care: A global collaborative study The impact of the COVID-19 pandemic on cancer care. Nat Cancer Initial impacts of global risk mitigation measures taken during the combatting of the COVID-19 pandemic Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries Cancer patients have a higher risk regarding COVID-19 -and vice versa? Pharmaceuticals (Basel) Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China Fewer cancer diagnoses during the COVID-19 epidemic in the Netherlands The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study Impacts of the coronavirus 2019 pandemic on gastrointestinal endoscopy volume and diagnosis of gastric and colorectal cancers: A population-based study COVID-19 and cancer. Science Using thematic analysis in psychology Impact of natural disaster combined with nuclear power plant accidents on local medical services: a case study of Minamisoma Municipal General Hospital after the Great East Japan Earthquake Cervical cancer screening rates before and after the Great East Japan Earthquake in the Miyagi Prefecture Breast cancer patient delay in Fukushima, Japan following the 2011 triple disaster: a long-term retrospective study Newborn Screening Assessment Team. Impact of Hurricane Katrina on newborn screening in Association Between Declared Hurricane Disasters and Survival of Patients With Lung Cancer Undergoing Radiation Treatment Impact of disasters on community medical screening examination and vaccination rates: The case of the Sewol ferry disaster in Ansan, Korea An adverse event in a well-established cervical cancer screening program: an observational study of 19,000 females unsubscribed to the program Cancer care for refugees and displaced populations: Middle East conflicts and global natural disasters Cancer patients during and after natural and man-made disasters: A systematic review Lessons learned and unsolved public health problems after large-scale disasters Cancer screening and health system resilience: keys to protecting and bolstering preventive services during a financial crisis The United Nations Office for Disaster Risk Reduction. Sendai Framework for Disaster Risk Reduction The impact of the temporary suspension of national cancer screening programmes due to the COVID-19 epidemic on the diagnosis of breast and colorectal cancer in the Netherlands Epub ahead of print Applying lessons learned from low-resource settings to prioritize cancer care in a pandemic Ethics and Resource Scarcity: ASCO recommendations for the oncology community during the COVID-19 pandemic Utilization of non-Ebola health care services during Ebola outbreaks: a systematic review and meta-analysis Understanding the value of international research networks: An evaluation of the International Cancer Screening Network of the US National Cancer Institute Importance of international networking and comparative research in screening to meet the global challenge of cancer control Delays and Disruptions in Cancer Health Care Due to COVID-19 Pandemic: Systematic Review Web references: a. World Health Organization. WHO Timeline -COVID-19 COVID-19 significantly impacts health services for noncommunicable diseases The authors would like to acknowledge the invaluable assistance from Ms. Alice Tillema, librarian at Radboud university medical center. -"disaster", "mass screening", "cancer" and "time factors"  Coordination, communication, resources and follow-up are key to resume screening.  Preparedness frameworks can guide the response to the current and future pandemics.  Mobile health systems may reach those not accessing screening due to a pandemic.  Clear communication with stakeholders may facilitate screening post-interruption.  Monitor inequalities and use resource-stratified approach to ensure basic services.