key: cord-0816181-nmfcvyln authors: Semprini, J. title: How did the COVID-19 Pandemic impact self-reported cancer screening rates in 12 Midwestern states? date: 2022-04-18 journal: nan DOI: 10.1101/2022.04.13.22273837 sha: 2da49efbaf179bcdbea8af0681cbef81ffe70213 doc_id: 816181 cord_uid: nmfcvyln Objective: In the early months of the COVID-19 pandemic, the U.S. healthcare system reallocated resources to emergency response and mitigation. This reallocation impacted essential healthcare services, including cancer screenings. Methods: To examine how the pandemic impacted cancer screenings at the population-level, this study analyzes 2018 and 2020 Behavioral Risk Factor Surveillance System (BRFSS) data to estimate the change in the proportion of eligible adults reporting a recent cancer screen (mammogram, pap smear, colon/sigmoidoscopy, blood stool test). All analyses accounted for response rates and sampling weights, and explored differences by gender and region across 12 Midwestern states. Results: We found that the proportion of adult women completing a mammogram declined across all states (-0.9% to -18.1%). The change in colon/sigmoidoscopies, pap smears, and blood stool tests were mixed, ranging from a 9.7% decline in pap smears to a 7.1% increase in blood stool tests. Declines varied considerably between states and within states by gender or metro/urban/rural status. Conclusions: The COVID-19 pandemic led to delayed breast, cervical, and colorectal cancer detection services. Policymakers should aim to advance cancer control efforts by implementing targeted screening initiatives. In March 2020, policymakers, healthcare providers, and public health professionals shifted their resources towards COVID-19 prevention and mitigation. The reallocation was a response to the uncertainty of the pandemic's initial projections. [1] [2] [3] Health systems also began instituting policies to protect at-risk adults from adverse COVID-19 outcomes. 2, [4] [5] [6] This required reallocating healthcare capacity, but also limiting exposure to patients and providers by minimizing "non-essential" care. The U.S. healthcare system's response to the COVID-19 pandemic came at the expense of other healthcare services. 7 Early evidence showed dramatic declines in healthcare service utilization. One report found a thirty-percent reduction in individuallevel healthcare consumption. 8 In March and April 2020, most adults reported having difficulties accessing necessary or choosing to delay care. 9 Healthcare providers expected these delays to slow population health and equity efforts. 10 Cancer screenings were among the services delayed due to the pandemic. 10 However, most studies on cancer services in the early months of the pandemic focused on strategies to maintain safe treatment regimens for cancer patients. [11] [12] [13] [14] As data eventually became available, investigators found that cancer screenings declined substantially. 15 Bakouny's report found that, compared to pre-pandemic months, claims for mammograms, pap smears, and colorectal cancer screenings declined 60-80 percent in March/April 2020. It is unknown how screening rates evolved over the rest of the pandemic's first year. 15 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 18, 2022 This study makes many contributions to the evidence on cancer screenings curing the COVID-19 Pandemic. The Bakouny report was conducted in the New England region, with little attention to subgroup analyses. 15 Should healthcare providers in other U.S. states expect 60-80% declines in cancer screenings? Were the changes in screening rates more pronounced in specific subgroup populations? My study aims to examine how cancer screening rates changed in 12 Midwestern states, stratifying analyses by gender and metro/urban/rural status. The most critical gap I address, however, relates to the data. Existing evidence on healthcare service changes during the pandemic relied on claims data, but how well can we use this evidence to implement interventions that get adults back to screening? Claims data doesn't represent the population of adults eligible for screenings, but rather only represents adults accessing the healthcare system. These early claims-based studies can calculate the decline in screenings, but only population-based studies can identify changes in cancer screening rates for adults who delayed or missed care during the pandemic. As we move on from the emergency phase of the pandemic, this study aims to identify which populations' cancer screening rates were most impacted by the pandemic with the goal of informing targeted return to screening initiatives. This study is among the first to analyze the 2020 Behavioral Risk Factor Surveillance System (BRFSS) questionnaire's cancer screening module. 16 BRFSS is a state-based, nationally representative survey implemented by telephone. Each year, BRFSS queries a random sample of adults to represent health risks and behaviors of . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 18, 2022. ; https://doi.org/10.1101/2022.04.13.22273837 doi: medRxiv preprint the U.S. population. On a biannual basis, most states implement a BRFSS questionnaire which asks about cancer screening: mammograms, pap smears, colonoscopies or sigmoidoscopies (colon/sigmoidoscopies), and blood stool tests. All 12 Midwestern states implemented the biannual cancer screening module in 2020. 17 For each of the four cancer screenings, BRFSS asks eligible adults the duration since their last screening. I used these questions to develop binary measures of annual cancer screening behavior and categorized eligible adults as either having completed a respective cancer screen in the past year, or not. The BRFSS survey is implemented in waves and conducted over the course of have yet to be exposed (note: BRFSS briefly stopped surveying activities after the initial emergency towards the end of March 2020). I account for heterogeneous response rates by first calculating the proportion of all eligible adults reporting a recent cancer screen. Then, I account for seasonal survey implementation heterogeneity by differencing out screening behavior and response rate changes from quarter 1 to quarter 4 in 2018. Finally, to compare how these differences varied relative to prepandemic screening rates, I estimate the relative change by dividing the Q4-Q1 difference estimate by the 2020-Q1 baseline screening rate. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 18, 2022 Across all states, the proportion of women completing a recent mammogram declined in 2020. The decline was smallest in Minnesota (-0.9%) and highest in Indiana Table 2 for the full set of results. The change in proportion of women reporting a recent pap smear was mixed across states. In Michigan (+7.9%), North Dakota (+1.3%), and Wisconsin (+4.4%) the proportion of women reporting a recent pap smear increased from quarter 1 to quarter 4 in 2020. The proportion of pap smears declined in the other nine states, with declines ranging from 1.0% in Minnesota to 10.0% in South Dakota. These declines represent a 3.2% and 26.1% relative change in pre-pandemic pap smear rates. When examining rates by regional status, there is less volatility in the changes. For example, the highest observed increase in the proportion of women reporting a recent pap smear was 9.9% in metro Kansas, 13.0% in urban Missouri, and 13.5% in rural Missouri. Conversely, the largest declines were found in metro South Dakota (-14.6%), urban Iowa (-10.8%), and rural South Dakota (-12.2%). Figure 2 and Table 2 report the full set of results. Like the estimates for pap smears, the difference in colon/sigmoidoscopies between quarter 1 and quarter 4 varied by states. The proportion of eligible adults reporting a recent colon/sigmoidoscopy increased from quarter 1 to quarter 4 in Kansas (0.3%), Missouri (1.2%) and South Dakota (1.8%). The proportion declined in nine states, with estimates ranging from 0.5% in North Dakota to 8.9% in Minnesota. These declines represent a 1.9% and 31.6% relative reduction the proportion of adults reporting a colon/sigmoidoscopy. The subgroup analyses reveal that the proportion of . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Contrary to the other screenings, most states were found to have increased the proportion of adults reporting a recent blood stool test. These increases ranged from 0.5% in North Dakota and Kansas to 7.1% in Wisconsin. These respective increases represent a 0.7% and 8.9% change relative to pre-pandemic blood stool test rates. The proportion of blood stool tests only declined from quarter 1 to quarter 4 in Indiana (3.0%), Michigan (4.5%), Minnesota (1.4%) and Missouri (3.4%). These changes in blood stool rates varied across states by metro/urban/rural status. More consistent however, were the results disaggregated by gender. The proportion of adult female respondents having completed a recent blood stool test declined in eight states, ranging from a 0.2% reduction in Illinois to a 7.8% reduction in Michigan. Blood stool rates only increased for female respondents in Iowa (+2.7%), Ohio (+3.1%), South Dakota (+3.4%), and Wisconsin (+5.9%). Conversely, the proportion of male respondents reporting a recent blood stool test only declined in Michigan (-1.0%), Minnesota (-0.9%), and Missouri (-3.4%). In the other nine states, the blood stool test rates increased for . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 18, 2022. ; https://doi.org/10.1101/2022.04.13.22273837 doi: medRxiv preprint male respondents, ranging from 1.0% in North Dakota to 9.5% in South Dakota. See figures and tables 3 and 4 for the full set of results. Policymakers, providers, and public health professionals have already begun to implement return to screening initiatives. 18 This timely research can inform their ongoing efforts. In summary, the proportion of adult women reporting a recent mammogram declined across all 12 Midwestern states. With a few exceptions, the proportion of adults reporting a recent pap smear declined, as did the proportion of adults reporting a recent colon/sigmoidoscopy. Meanwhile, the rate of blood stool tests generally increased, but by a smaller magnitude than the decline in colon/sigmoidoscopies. We should not expect the rise in blood stool tests to offset the declines in colon/sigmoidoscopy rates. There appeared to be greater heterogeneity within states (by metro/urban/rural status) for mammograms than for pap smears. However, the clearest pattern which emerged from the data were the changes in colon/sigmoidoscopy rates for metro and rural respondents, and for adult males. There is also stark heterogeneity across states. This research will be most useful for motivating and informing targeted initiatives. Practitioners and policymakers can use this evidence to identify which screening services declined the most in their state and the population experiencing the greatest declines. Until evidence emerges that screening rates have returned to or exceeded pre-pandemic levels for all groups, stakeholders in these 12 Midwestern states should prioritize the services and populations most impacted by the pandemic. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 18, 2022 reporting a recent cancer screen could have completed the screen anytime between October 1 st , 2019 to December 30 th , 2020. If the screening was completed in 2019, we may be underestimating the decline in screening rates for 2020. We also have no way to know if these recent cancer screens were completed during the end of 2020 and may therefore be missing a signal of "return to screening" behavior. As new data emerge, future research should continue to survey how screening rates evolve over time. Unfortunately, among all population-based survey data, BRFSS provides the most comprehensive cancer screening data, but the cancer module is only implemented biannually. So, the next BRFSS cancer screening module will not be completed until the end of 2022. The data will not be available to researchers until late 2023. 16 Despite this study's limitations, the reliability of the BRFSS data and simple, yet analytically valid design yield baseline estimates for the pandemic's effect on the population's screening rates as Americans emerge from a two-year public health emergency. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 18, 2022. ; https://doi.org/10.1101/2022.04.13.22273837 doi: medRxiv preprint . 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Nat Cancer Cancer Screening Tests and Cancer Diagnoses During the COVID-19 Pandemic Behavioral Risk Factor Surveillance System Survey Data Census Regions and Divisions of the United States Iowa Cancer Registry 2022 The covid-19 pandemic forced adults in all 12 Midwestern states to delay critical cancer screening services. Fewer breast, cervical, and colorectal cancer screenings in 2020 may lead to more cancer diagnoses in the coming years, likely at more advanced and aggressive stages. Policymakers can use evidence from this study to implement targeted screening initiatives and mitigate the pandemic's long-term impact on cancer control systems. It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 18, 2022. ; https://doi.org/10.1101/2022.04.13.22273837 doi: medRxiv preprint