June 24, 2022: The Centers for Disease Control and Prevention has listed Fairfield, Hartford, New London, Middlesex, Tolland, and Windham Counties in Low/Green the as part of its COVID-19 Community Levels Map. Only Litchfield, Middlesex and New Haven County are listed in the Medium/Yellow category. Residents who live in the Medium /Yellow counties who are at a high risk for severe illness, should talk to their health care provider about whether to wear a mask and take other precautions. These residents should stay up to date with their COVID-19 vaccines and get tested if they have symptoms. Visit the CDC COVID-19 Community Levels Map for updates.

Connecticut Epidemiologist Newsletter   •   December 2021   •   Volume 41, No.6

Provider perceptions of decreases in cervical cancer screening and follow-up during the COVID-19 pandemic, March-October 2020 


Authors: G. Oliver, BS, M. Brackney, MS, K. Higgins, BS, Connecticut Emerging Infections Program at the Yale School of Public Health; L. Niccolai, ScM, PhD, Yale School of Public Health, Yale University.


Cervical cancer is a preventable disease caused by human papillomavirus (HPV) (1). Early signs of cervical cancer can be identified via screening, and effective treatment can be utilized if precancerous lesions are detected (2). Unfortunately, there is evidence cervical cancer screenings, like most non-urgent medical care, have been reduced during the COVID-19 pandemic (3).  

The objectives of this analysis were to: (1) determine the perception of decreases in the frequency of cervical cancer screening and subsequent follow-up of abnormal screening results due to the COVID-19 pandemic in Connecticut as reported by health care providers, and (2) assess whether changes observed were due to decreases in provider capacity or due to patient scheduling. Medical practices specializing in obstetrics and gynecology (OBGYN) and family medicine or internal medicine (FM/IM) in Connecticut were surveyed. Surveys were sent in October 2020 with up to two subsequent follow-up notifications. Practices who reported conducting screening and follow-up of abnormal results (defined as further screening or treatment) were asked to indicate the impact of COVID-19 on frequency of screening and follow-up during each month, March through October 2020 compared to pre-pandemic levels. Respondents were also asked to identify whether any reduction in screening or follow-up was due to reduced capacity to see patients, patients not scheduling appointments, or both.


Of 151 medical practices surveyed, 39 (26%) responded. All OBGYN practices reported conducting cervical cancer screening and follow-up of abnormal screening results. Among FM/IM providers, 13 (59%) reported conducting cervical cancer screening, and none reported conducting follow-up.


Most OBGYN practices reported the COVID-19 pandemic impacted the number of patients screened (15/17, 88%). The majority observed a decrease in screening in March through June; in April, all practices reported at least “somewhat fewer patients screened” (Figure 1). Most practices (10/15, 67%) reported reductions in screening were due to both patients not scheduling appointments and a reduced capacity of the practice to see patients. Three practices (20%) reported the reduction was due only to reduced capacity and two (13%) reported the reduction was due solely to patients not scheduling. Notably, in May through October, up to 5 (33%) practices in any given month reported more patients screened compared to pre-pandemic levels.


Ten (59%) of the OBGYN practices also reported a reduced number of patients returning for follow-up (Figure 2), typically in March through June and peaking at all ten practices reporting a reduction in April. Six practices (60%) reported the reduction in follow-up was due to both patients not scheduling and reduced practice capacity. Two practices (20%) reported the reduction was due only to reduced capacity and two (20%) reported the reduction was due solely to patients not scheduling. Starting in June and continuing through October, up to two practices (20%) per month began to see a higher number of patients followed up compared to pre-pandemic levels.


Of FM/IM practices conducting cervical cancer screening, 7 (54%) reported the pandemic impacted the number of patients screened. Most practices observed at least “somewhat fewer patients” during all months, and no FM/IM practices reported “more patients screened” compared to pre-pandemic levels. Three practices (43%) reported the reduction in patients screened was due to patients not scheduling. No practices reported the reduction was due exclusively to a reduced capacity. Two practices (29%) reported it was due to “both”, and two (29%) did not respond to the question.


Discussion                                                                                                                                                                   
On March 10, 2020, the Governor of Connecticut declared COVID-19 a Public Health Emergency. Shortly after, on March 20, 2020, the “Stay Safe, Stay Home” policy was implemented, leading to the shutdown of non-essential businesses. Although this policy did not include outpatient medical practices, results show that the volume of cervical cancer screenings and follow-up was impacted at the time of the policy's implementation. Phase 1 Reopening began on May 20, 2020, allowing some non-essential businesses to resume services. This reopening aligned with some providers reporting “more patients screened” compared to pre-pandemic levels beginning in May. However, not all practices reported this increase.


Most OBGYN and FM/IM providers reported the reduction in screening and follow-up during the pandemic was caused in part by patients not scheduling appointments, suggesting future interventions for “catch up” of screening and follow- up will need to go beyond ensuring availability of services. Public health professionals will need to work with medical practitioners to identify and reach patients who have missed screening or follow-up of abnormal results to ensure there are no further delays in care. Risk-based prioritization of screening has also been recommended, for example in settings with limited capacity or significant disruptions to care (4).


There may be an increase in prevalence of precancerous lesions and cervical cancer in the coming years if no interventions are put in place. Burger et al. (5) recently published findings from a model that demonstrate disruptions in screening are expected to result in increases in cervical cancer rates by 2027. Notably, the model suggests interventions should utilize co-testing (cervical pathology with HPV-testing) when appropriate and focus on patients missing follow-up from abnormal primary screening to limit increases in cervical cancer.


Survey results indicate that providers are aware of the disruption caused by COVID-19, and that missed screenings and follow-up were due to patient behavior as well as provider capacity. Providers will be critical stakeholders in getting missed patients back into the clinic, as well as prioritizing resources to focus on those patients most at risk. Public health practitioners must work with medical professionals to ensure this reduction in screening and follow-up does not lead to preventable increases in cervical cancer in the coming years.


References

1. Schiller JT, Davies P. Delivering on the promise: HPV vaccines and cervical cancer. Nat Rev Microbiol. 2004; 2: 343-347.

2. Fontham ETH, Wolf AMD, Church TR, Etzioni R, Flowers CR, Herzig A, Guerra CE, Oeffinger KC, Shih YT, Walter LC, Kim JJ, Andrews KS, DeSantis CE, Fedewa SA, Manassaram-Baptiste D, Saslow D, Wender RC, Smith RA. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA Cancer J Clin. 2020; 70(5): 321-346.

3. Miller MJ, Xu L, Qin J, Hahn EE, Ngo-Metzger Q, Mittman B, Tewari D, Hodeib M, Wride P, Saraiya M, Chao CR. Impact of COVID-19 on cervical cancer screening rates among women aged 21-65 years in a large integrated health care system – Southern California, January 1-September 30, 2019, and January 1-September 30, 2020. MMWR Morb Mortal Wkly Rep. 2021; 70(4): 109-113.

4. Castanon A, Rebolj M, Burger EA, McM de Kok I, Smith MA, Hanley SJB, Carozzi FM, Peacock S, O’Mahony JF. Cervical screening during the COVID-19 pandemic: optimizing recovery strategies. Lancet. 2021; 6(7): E522-E527.

5. Burger EA, Jansen EEL, Killen J, McM de Kok I, Smith MA, Sy S, Dunnewind N, Campos NG, Haas JS, Kobrin S, Kamineni A, Canfell K, Kim JJ. Impact of COVID-19-related care disruptions on cervical cancer screening in the United States. J Med Screen. 2021; 28(2): 213-216.