key: cord-0933741-t0vnj6zy authors: Castanon, A.; Rebolj, M.; Pesola, F.; Sasieni, P. title: The impact of COVID-19 disruption to cervical cancer screening in England on excess diagnoses. date: 2020-11-30 journal: nan DOI: 10.1101/2020.11.30.20240754 sha: 2723f7558eaf65715c79c38ecdcf24695b70073f doc_id: 933741 cord_uid: t0vnj6zy Background: Cervical cancer screening services in England have been disrupted by the COVID-19 pandemic. Methods: Using routine statistics we estimate number of women affected by delays to screening. We used published research to estimate the proportion of screening age women with high-grade cervical intraepithelial neoplasia and progression rates to cancer. Under two scenarios we estimate the impact of COVID-19 on cervical cancer over one screening cycle (3y at ages 25-49 and 5y at ages 50-64). The duration of disruption in both scenarios is six months. In the first scenario all women have their screening interval is extended by six months. In the second some women (those who would have been screened during the disruption) miss one screening cycle, but most women have no delay. Results: Both scenarios result in similar numbers of excess cervical cancers: 630 vs. 632 (both 4.3 per 100,000 women in the population). However the scenario in which some women miss one screening cycle creates inequalities - they would have much higher rates of excess cancer: 41.5 per 100,000 screened women compared to those with a six month delay (5.9 per 100,000 screened). Conclusion: To ensure equity for those affected by COVID-19 related screening delays additional screening capacity will need to be paired with prioritising the screening of overdue women. As the pandemic is not yet over, it is currently unknown how quickly primary care and 24 laboratories will be able to restore cervical screening services to pre-pandemic levels, what 25 capacity will be available to address the screening backlog that has accumulated since GP 26 practices closed for non-urgent face to face contact in March 2020 and how many women 27 will be willing to take up their screening invitation in the post-COVID-19 era. Nevertheless, it 28 is possible to estimate the size of the effect that a disruption like this is likely to have on 29 cancer incidence, depending on the screening programme's approach to compensate for the 30 lost opportunity to be screened. Assuming the health service will not be able to increase screening capacity considerably 33 compared with previous years, it will be difficult or impossible to "catch-up" with the backlog is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.30.20240754 doi: medRxiv preprint screening on excess diagnosis of cervical cancers among women of screening age (25-64 38 years) in England. The effect of a delay in attendance to cervical screening is explored under two scenarios. women aged 50-64) only. The length of the disruption is the same in both scenarios, but the 45 proportion of women affected by the delay differs in each scenario. Both scenarios assume 46 that follow-up of women testing positive at screening before the disruption were followed up on time and that follow-up services do not experience delays once the disruption ends. The first scenario considers a rolling delay of six months for all women in England. This 50 means that for a single screening cycle, women would be invited for HPV testing at 3.5 or 51 5.5 years after their previous invitation to cytology screening, depending on their age. They 52 would resume with a standard interval thereafter. The age at which screening is offered 53 would be permanently increased by 0.5 years (up to age 65.5y). Young women entering the 54 programme after the disruption has been resolved would not be affected. The second scenario assumes invitations to screening were likewise disrupted for a six-57 month period and that women who were due a screen during this period do not receive 58 screening during this cycle (i.e. for 3 to 5 years depending on age). Women whose invitation 59 was not affected by COVID-19 disruption would continue to be invited as normal. Both scenarios assume no disruption to screening uptake once screening resumes. Population estimates The age-specific numbers of women screened in England following an invitation for screening (in categories: "call" (first ever invitation to screening), "recall" (second and later routine invitations to screening) and "outside the programme" (predominantly women who 67 were invited but attended 12 months or more after the invitation is issued)) as reported in the 68 NHS Cervical Screening Programme statistics for year 2018-19(7) were used to estimate the 69 numbers of women by age group who would have normally been routinely screened over a is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.30.20240754 doi: medRxiv preprint The national statistics was the source of data for the estimated size of the female population 76 in mid-2019 in England by age group. (8) Population with cervical intraepithelial neoplasia screening in the English HPV primary screening pilot was used, where by far the majority of 82 women were unvaccinated. (9) The pilot reported that 6.6% women at the age of 25-29, 1.6% 83 at the age of 30-49 and 0.5% at the age of 50-64 years had a CIN grade 2 or worse detected 84 following HPV primary screening, either at baseline or at one of two early recalls. The proportion of women estimated to have high-grade CIN was multiplied by the total 87 population affected by the disruption, in order to obtain the number of women in whom CIN2 88 or worse diagnoses were delayed because screening could not take place as scheduled. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.30.20240754 doi: medRxiv preprint undetected CIN would have progressed to cervical cancer during one age-appropriate screening round (supplementary table 2) . Delaying screening for 6 months for the whole population (scenario 1) would result in expected numbers of excess cancers, approximately 630 over one screening round. These When only taking into account the women who were affected by the delay (i.e., those that 124 would normally have participated in screening but were unable to do so, or could only do it 125 with a delay), the excess cervical cancer incidence rates differed vastly between the two 126 scenarios. Those who miss an entire round (scenario 2) would have seven times higher 127 rates of excess cancer compared with those whose screening was delayed by 6 months 128 (41.5 per 100,000 women compared to 5.9 respectively: Table 1 ). The age-specific distribution of excess cancer diagnoses with a 6-month delay can be found 131 in Table 2 , and the results for 3-or 5-year delays are shown in Table 3 . In both scenarios, is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.30.20240754 doi: medRxiv preprint increase in cancer diagnoses is expected (because the test is more sensitive than cytology).(17) Evaluation of screening histories from women diagnosed with cervical cancer once screening services resume will provide the best evidence of the actual impact of is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.30.20240754 doi: medRxiv preprint Increasing the screening capacity alone will not be sufficient. Making sure that women feel 186 confident enough to attend for screening when they are due should be another priority. This 187 is, again, highlighted by the seven-fold higher excess risk of cervical cancer among those 188 who are unable or unwilling to access screening for a whole round, and highlights the 189 importance of messaging to encourage women overdue their screen to attend as soon as 190 possible. Unfortunately, it is often difficult for primary care providers to assess a woman's 191 prior screening history at the time when they are offered a screening appointment. Nevertheless consideration should still be given to strategies that will allow the identification is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.30.20240754 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.30.20240754 doi: medRxiv preprint Human Papillomavirus (HPV) Vaccine Coverage in /09 to 2013/14. A review of the full six years of the three-dose schedule. : Immunisation, Hepatitis and Blood Safety Department NHSE to start issuing cervical screening invitations again from this month. PULSE magazine NHS England is reviewing suspension of national screening programmes: PULSE magazine Implementation of Early Detection Services for Cancer in India During COVID-19 Pandemic The Impact of COVID-19 on Cancer-Screening: Challenges and Opportunities. JMIR Cancer. 2020. 7. NHS Digtal. Cervical Screening Programme Office for National Statistics Primary cervical screening with high risk human papillomavirus testing: observational study Department of Health Prevalence of cervical disease at age 20 after immunisation with bivalent HPV vaccine at age 12-13 in Scotland: retrospective population study What cervical screening is appropriate for women who have been vaccinated against high risk HPV? A simulation study Cervical Cancer Screening in Partly HPV Vaccinated Cohorts -A Cost-Effectiveness Analysis Screeningpreventable cervical cancer risks: evidence from a nationwide audit in Sweden Benefit of cervical screening at different ages: evidence from the UK audit of screening histories Age-specific effectiveness of the Finnish cervical cancer screening programme. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research Long term predictive values of cytology and human papillomavirus testing in cervical cancer screening: joint European cohort study Equality and equity in medical screening: what is fair?