“We must stress that irregular screening can result in a missed opportunity to diagnose cancer when it is small and has not spread. Regular cancer screening is important, and while short delays are acceptable, long delays are not.”—Robert Smith, PhD

Key Points

• An analysis of private insurance claims from health care before and during the coronavirus disease 2019 (COVID-19) pandemic showed that after a steep decline in the use of mammography and colonoscopy, these 2 screening tests returned to near-normal levels within a few months.
• Although short pandemic-related delays in cancer screening are acceptable, long delays are not.

At the beginning of the COVID-19 pandemic, the goals of minimizing viral spread in health care settings and focusing health care resources on the care of infected patients led to nonurgent medical services, such as cancer screening tests, being temporarily suspended. As a result, the sheer number of cancer screening tests, such as colonoscopies and mammograms, dropped precipitously. Little was known about the size and duration of the decline, however, and whether it would affect postpandemic adherence to guidelines for these tests.

A new study, appearing in the Journal of General Internal Medicine (2021;36:1829-1831. doi:10.1007/s11606-021-06660-5), reports that the numbers of tests are recovering, approaching pre–COVID-19 levels. The study authors believe that these results suggest that health systems were able to “recalibrate resources and protocols in a relatively short interval.”

“To my knowledge, our study was the first to show a significant rebound in cancer screenings for breast and colorectal cancers,” says lead study author Ryan K. McBain, PhD, MPH, a policy researcher at the RAND Corporation in Boston, Massachusetts. Dr. McBain says that this is a key conclusion because at the beginning of the pandemic, there were concerns about the impact of a large drop in the number of cancer screenings. The study does not, however, address the likely effects of delayed screening on long-term cancer-related morbidity and mortality.

Study Details

For this study, researchers examined weekly medical claims data across all 50 states between January 15, 2020, and July 31, 2020, from health benefits manager Castlight Health. “The information we gathered was based on medical claims filings from adults throughout the United States over this 6-and-a-half-month period,” says Dr. McBain. “This allowed us to examine the interval of 2020 immediately prior to the pandemic (January/February), immediately after the onset (March/April), and through the progression into the spring and summer (May/June/July).”

Study samples included individuals between the ages of 46 and 64 years. Researchers looked at the number of individuals per 10,000 eligible beneficiaries who received cancer screenings. Individuals were grouped by gender and then divided into 2 age groups: 46 to 59 years old and 60 to 64 years old. Using US Census data and USAFacts, a nonprofit organization and website, they also linked claims to demographic characteristics at county levels to determine the weekly prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases per 10,000 people. The researchers estimated changes in screening rates after March 13, 2020, the official date on which COVID-19 was declared a national emergency, versus prior weeks.

Study Results

Before March 13, 2020, the median weekly rate for mammograms was 87.8 women screened per 10,000 beneficiaries. This number declined by 96% in April to 6.9 per 10,000. By the end of July, however, the number increased to 88.2 screenings per 10,000 beneficiaries.

Colonoscopy screenings declined over the same period by 95% from 15.1 per 10,000 beneficiaries in March to 0.9 per 10,000 beneficiaries in April. By the end of July, the number rebounded to 12.6 per 10,000 beneficiaries.

The researchers found a steeper decline in highest income counties in comparison with lowest income counties (in part because highest income counties had higher colonoscopy rates before the pandemic.) They did not find any notable demographic differences for mammography rates.

Study Interpretation

Dr. McBain believes that this study is important for 2 reasons. “First, it quantifies the overall magnitude and duration of declines in cancer screenings for 2 major types of cancer, allowing public health officials and clinicians to have a full picture of the issue.”

Second, the study finds that health systems rapidly responded with protocols and strategies to reopen in a responsible and safe manner. “This highlights the success and resiliency of health systems throughout the country to adjust protocols and recalibrate to deliver important preventive care for a leading cause of morbidity and mortality in the United States,” he says.

Dr. McBain believes that the takeaway message from the study is that health systems were able to respond efficiently during a national emergency in order to resume cancer screenings, an essential component of preventive and primary care. “There are also valuable lessons to be learned from this period about how systems may prepare for future emergencies and adapt to ensure that those patients at highest risk of cancer continue to receive needed check-ups.”

Robert Smith, PhD, senior vice president of cancer screening at the American Cancer Society, says that an important part of the study is the breadth of the number of study subjects: specifically, the study makes use of claims data from a database of nearly 7 million commercially insured adults from all 50 states.

He also issues a caution: “As of now, we will not have data from federally supported population surveys that include questions about breast and colorectal cancer screening for another year or more, so this is a very timely use of big data to answer questions that are more easily answered in countries with national health systems and centralized data collection.” Dr. Smith also notes, “The data apply only to individuals with private insurance, and do not provide any evidence about the decline in cancer screening in adults aged 65 and older, a group covered by Medicare in which the burden of cancer is significant. Did this group rebound as quickly as younger adults? We'll have to wait until data are available to answer this question, and also if adults with private insurance or Medicare increasingly took advantage of the option to be screened for colorectal cancer at home with a stool test.”

Still, says Dr. Smith, the claims data allow for an examination of the effect of the suspension of cancer screening services over time during the pandemic and of the decline and rebound rates overall and by race/ethnicity, income, rurality, and other factors. “Thus, we are able to see the impact on screening rates at the beginning of the pandemic, when hospital systems took steps to redeploy health care professionals to care for the rising number of COVID-19 cases and minimize contagion by suspending cancer screening, and when screening reopened. There has been a great deal of conjecture about whether and when screening rates would rebound. The authors conclude that they have.”

Dr. Smith notes that the data “further confirm earlier reports that showed cancer screening rates plummeted—there really is no better word for it—when screening services were suspended. However, we would expect the current rate to be higher if the backlog was being cleared. In some categorical quartiles the rate is higher, but not by much, and in some quartiles it is lower. This suggests that facilities are operating at previous capacity, but it is fairly likely that although some adults who missed an exam have rescheduled it, many who missed an exam have not, and some who are currently scheduled may not be ready to end medical distancing.”

“We have heard that many facilities went to great lengths to convey that they had taken steps to ensure patient safety and provide confidence that attending screening would not increase risk of viral transmission,” says Dr. Smith. “It is important that patients are confident that the setting they've trusted in the past is just as safe today.”

“Even during the surges that have occurred since last summer, we have heard that health systems have not suspended cancer screening, which is very good news,” adds Dr. Smith. “We sent the wrong signal when we described cancer screening as a nonurgent, nonessential health service.”

Dr. Smith says there is no question that there will be future pandemics and that there may be occasions when preparedness will again lead to the suspension of cancer screening. “Adults need to hear that cancer screening is an essential health service, and that, first, alternative screening tests for colorectal cancer that can be done at home should be utilized during service suspensions, and second, that when services reopen, there is a plan to bring patients who were not able to keep their appointments into adherence. We must stress that irregular screening can result in a missed opportunity to diagnose cancer when it is small and has not spread. Regular cancer screening is important, and while short delays are acceptable, long delays are not.”

中文翻译：

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大流行恐惧大幅下降后，常规癌症筛查率反弹

“我们必须强调，当癌症很小且尚未扩散时，不定期筛查可能会导致错过诊断癌症的机会。定期的癌症筛查很重要，虽然短暂的延迟是可以接受的，但长时间的延迟是不可接受的。”——罗伯特·史密斯博士

关键点

• 对 2019 年冠状病毒病 (COVID-19) 大流行之前和期间医疗保健私人保险索赔的分析表明，在乳房 X 光检查和结肠镜检查的使用急剧下降后，这 2 项筛查测试在几个月内恢复到接近正常水平.
• 尽管癌症筛查中与大流行相关的短期延迟是可以接受的，但长期延迟则不可接受。

在 COVID-19 大流行开始时，最大限度地减少病毒在卫生保健环境中的传播并将卫生保健资源集中用于受感染患者的护理的目标导致非紧急医疗服务（例如癌症筛查测试）被暂时中止。结果，癌症筛查测试的数量急剧下降，例如结肠镜检查和乳房 X 光检查。然而，人们对下降的规模和持续时间，以及它是否会影响大流行后对这些测试指南的遵守情况知之甚少。

发表在《普通内科杂志》 (2021;36:1829-1831.doi:10.1007/s11606-021-06660-5) 上的一项新研究报告称，检测数量正在恢复，接近 COVID-19 之前的水平. 研究作者认为，这些结果表明卫生系统能够“在相对较短的时间间隔内重新校准资源和协议”。

“据我所知，我们的研究是第一个显示乳腺癌和结直肠癌筛查显着反弹的研究，”主要研究作者、马萨诸塞州波士顿兰德公司的政策研究员 Ryan K. McBain 博士说。麦克贝恩博士说，这是一个关键结论，因为在大流行开始时，人们担心癌症筛查数量大幅下降的影响。然而，该研究并未解决延迟筛查对长期癌症相关发病率和死亡率的可能影响。

学习详情

在这项研究中，研究人员检查了 2020 年 1 月 15 日至 2020 年 7 月 31 日期间所有 50 个州的每周医疗索赔数据，这些数据来自健康福利经理 Castlight Health。“我们收集的信息是基于美国各地成年人在这 6 个半月期间提交的医疗索赔申请，”麦克贝恩博士说。“这使我们能够检查 2020 年大流行之前（1 月/2 月）、发病后（3 月/4 月）以及进入春季和夏季（5 月/6 月/7 月）的时间间隔。”

研究样本包括年龄在 46 至 64 岁之间的个人。研究人员查看了每 10,000 名接受癌症筛查的合格受益人的人数。个体按性别分组，然后分为2个年龄组：46至59岁和60至64岁。使用美国人口普查数据和非营利组织和网站 USAFacts，他们还将声明与县级人口特征联系起来，以确定每 10,000 人中每周严重急性呼吸系统综合症冠状病毒 2 (SARS-CoV-2) 病例的患病率。研究人员估计了与前几周相比，2020 年 3 月 13 日（即 COVID-19 被宣布为国家紧急状态的官方日期）之后筛查率的变化。

研究结果

在 2020 年 3 月 13 日之前，每周乳房 X 光检查的中位数为每 10,000 名受益人筛查 87.8 名女性。这个数字在 4 月份下降了 96%，至每 10,000 人中 6.9 个。然而，到 7 月底，这一数字增加到每 10,000 名受益人 88.2 次放映。

同期结肠镜检查从 3 月份的每 10,000 名受益人 15.1 人下降到 4 月份的每 10,000 名受益人 0.9 人，下降了 95%。到 7 月底，这一数字回升至每 10,000 名受益人 12.6 人。

研究人员发现，与最低收入县相比，最高收入县的下降幅度更大（部分原因是高收入县在大流行之前的结肠镜检查率更高）。他们没有发现乳房 X 光检查率的任何显着人口统计学差异。

学习口译

McBain 博士认为这项研究很重要，原因有二。“首先，它量化了两种主要癌症类型癌症筛查下降的总体幅度和持续时间，使公共卫生官员和临床医生能够全面了解这个问题。”

其次，该研究发现，卫生系统迅速做出反应，以负责任和安全的方式重新开放的协议和策略。“这凸显了全国卫生系统在调整方案和重新校准方面的成功和弹性，以便为美国发病率和死亡率的主要原因提供重要的预防保健，”他说。

McBain 博士认为，该研究的主要信息是卫生系统能够在国家紧急情况下有效应对，以恢复癌症筛查，这是预防和初级保健的重要组成部分。“从这一时期还可以吸取宝贵的经验教训，了解系统如何为未来的紧急情况做好准备并进行调整，以确保那些患癌症风险最高的患者继续接受必要的检查。”

美国癌症协会癌症筛查高级副总裁 Robert Smith 博士表示，该研究的一个重要部分是研究对象的广度：具体而言，该研究利用了来自近 7 个数据库的索赔数据。来自所有 50 个州的百万商业保险成年人。

他还发出警告：“截至目前，我们将不会有来自联邦政府支持的人口调查的数据，其中包括有关乳腺癌和结直肠癌筛查问题的一年或更长时间，因此这是非常及时地使用大数据来回答问题在拥有国家卫生系统和集中数据收集的国家更容易回答。” 史密斯博士还指出，“这些数据仅适用于有私人保险的个人，并没有提供任何证据表明 65 岁及以上成年人的癌症筛查数量下降，这是一个由医疗保险覆盖的人群，其中癌症负担很重。这个群体是否像年轻人一样迅速反弹？我们必须等到数据可用才能回答这个问题，

尽管如此，史密斯博士说，索赔数据允许检查在大流行期间癌症筛查服务暂停的影响以及总体下降和反弹率以及种族/民族、收入、农村和其他因素的影响. “因此，我们能够在大流行开始时看到对筛查率的影响，当时医院系统采取措施重新部署医疗保健专业人员，以照顾不断增加的 COVID-19 病例并通过暂停癌症筛查来最大程度地减少传染，以及当放映重新开放时。关于筛查率是否以及何时会反弹，人们有很多猜测。作者得出结论，他们有。”

史密斯博士指出，这些数据“进一步证实了早先的报告表明，当筛查服务暂停时，癌症筛查率下降了——真的没有更好的词来形容了。” 但是，如果积压被清除，我们预计当前的费率会更高。在某些分类四分位数中，该比率较高，但幅度不大，而在某些四分位数中则较低。这表明设施正在以以前的能力运行，但很有可能的是，尽管一些错过考试的成年人已经重新安排了考试，但许多错过考试的成年人却没有，而一些目前安排好的人可能还没有准备好结束医疗隔离。 ”

“我们听说许多机构竭尽全力地传达他们已采取措施确保患者安全并提供信心，即参加筛查不会增加病毒传播的风险，”史密斯博士说。“让患者确信他们过去信任的环境今天同样安全，这一点很重要。”

“即使在去年夏天以来出现的激增期间，我们也听说卫生系统没有暂停癌症筛查，这是一个非常好的消息，”史密斯博士补充道。“当我们将癌症筛查描述为非紧急、非必要的健康服务时，我们发出了错误的信号。”

史密斯博士说，毫无疑问，未来会出现大流行，而且在某些情况下，准备工作可能会再次导致癌症筛查的暂停。“成年人需要知道癌症筛查是一项必不可少的健康服务，首先，在服务暂停期间应使用可以在家进行的结肠直肠癌替代筛查测试，其次，当服务重新开放时，有一个计划使无法遵守预约的患者遵守。我们必须强调，当癌症很小且尚未扩散时，不定期筛查可能会导致错过诊断癌症的机会。定期的癌症筛查很重要，虽然短暂的延迟是可以接受的，但长时间的延迟却不是。”