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Cancer Screening Disparities Before and After the COVID-19 Pandemic

. 2023 Nov 1;6(11):e2343796. doi: 10.1001/jamanetworkopen.2023.43796. Cancer Screening Disparities Before and After the COVID-19 Pandemic

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Cancer Screening Disparities Before and After the COVID-19 Pandemic

Aisha K Lofters et al. JAMA Netw Open. 2023.

. 2023 Nov 1;6(11):e2343796. doi: 10.1001/jamanetworkopen.2023.43796. Affiliations

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Abstract

Importance: Breast, cervical, and colorectal cancer-screening disparities existed prior to the COVID-19 pandemic, and it is unclear whether those have changed since the pandemic.

Objective: To assess whether changes in screening from before the pandemic to after the pandemic varied for immigrants and for people with limited income.

Design, setting, and participants: This population-based, cross-sectional study, using data from March 31, 2019, and March 31, 2022, included adults in Ontario, Canada, the country's most populous province, with more than 14 million people, almost 30% of whom are immigrants. At both dates, the screening-eligible population for each cancer type was assessed.

Exposures: Neighborhood income quintile, immigrant status, and primary care model type.

Main outcomes and measures: For each cancer screening type, the main outcome was whether the screening-eligible population was up to date on screening (a binary outcome) on March 31, 2019, and March 31, 2022. Up to date on screening was defined as having had a mammogram in the previous 2 years, a Papanicolaou test in the previous 3 years, and a fecal test in the previous 2 years or a flexible sigmoidoscopy or colonoscopy in the previous 10 years.

Results: The overall cohort on March 31, 2019, included 1 666 943 women (100%) eligible for breast screening (mean [SD] age, 59.9 [5.1] years), 3 918 225 women (100%) eligible for cervical screening (mean [SD] age, 45.5 [13.2] years), and 3 886 345 people eligible for colorectal screening (51.4% female; mean [SD] age, 61.8 [6.4] years). The proportion of people up to date on screening in Ontario decreased for breast, cervical, and colorectal cancers, with the largest decrease for breast screening (from 61.1% before the pandemic to 51.7% [difference, -9.4 percentage points]) and the smallest decrease for colorectal screening (from 65.9% to 62.0% [difference, -3.9 percentage points]). Preexisting disparities in screening for people living in low-income neighborhoods and for immigrants widened for breast screening and colorectal screening. For breast screening, compared with income quintile 5 (highest), the β estimate for income quintile 1 (lowest) was -1.16 (95% CI, -1.56 to -0.77); for immigrant vs nonimmigrant, the β estimate was -1.51 (95% CI, -1.84 to -1.18). For colorectal screening, compared with income quintile 5, the β estimate for quntile 1 was -1.29 (95% CI, 16 -1.53 to -1.06); for immigrant vs nonimmigrant, the β estimate was -1.41 (95% CI, -1.61 to -1.21). The lowest screening rates both before and after the COVID-19 pandemic were for people who had no identifiable family physician (eg, moving from 11.3% in 2019 to 9.6% in 2022 up to date for breast cancer). In addition, patients of interprofessional, team-based primary care models had significantly smaller reductions in β estimates for breast (2.14 [95% CI, 1.79 to 2.49]), cervical (1.72 [95% CI, 1.46 to 1.98]), and colorectal (2.15 [95% CI, 1.95 to 2.36]) postpandemic screening and higher uptake of screening in general compared with patients of other primary care models.

Conclusions and relevance: In this cross-sectional study in Ontario that included 2 time points, widening disparities before compared with after the COVID-19 pandemic were found for breast cancer and colorectal cancer screening based on income and immigrant status, but smaller declines in disparities were found among patients of interprofessional, team-based primary care models than among their counterparts. Policy makers should investigate the value of prioritizing and investing in improving access to team-based primary care for people who are immigrants and/or with limited income.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Lofters reported receiving grants from the INSPIRE-Primary Health Care (PHC) research program during the conduct of the study and receiving funding from Ontario Health for being the Provincial Primary Care Lead, Cancer Screening from 2018 to 2022 and an unrestricted quality improvement grant from Pfizer’s Rethink Breast Cancer for the Enhancing the Care Experiences of Black Women with Metastatic Breast Cancer project outside the submitted work. Mr Frymire reported receiving nonfinancial support from INSPIRE-PHC for project management support during the conduct of the study. Dr Kiran reported receiving consulting fees and/or speaker honoraria from Ontario Health, the Ontario Medical Association, the Ontario College of Family Physicians, the Canadian Medical Association, and Health Canada. Dr Green reported receiving grants from the Ontario MOH during the conduct of the study; receiving grants from Ontario Health, Ontario College of Family Physicians, and the Canadian Institutes of Health Research (CIHR); and personal fees from the College of Family Physicians of Canada outside the submitted work; and being president-elect of the College of Family Physicians of Canada and a board member of AMS Healthcare Inc (a not-for-profit foundation). Dr Glazier reported receiving grants from the INSPIRE-PHC research program and CIHR during the conduct of the study and receiving personal fees from ICES, CIHR, and the MAP Centre for Urban Health Solutions and being scientific director of the CIHR and research scientist of the MAP Centre for Urban Health Solutions outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. Percentage of Ontario Residents Eligible…

Figure 1.. Percentage of Ontario Residents Eligible and Up to Date on Breast, Cervical, and…

 Figure 1.. Percentage of Ontario Residents Eligible and Up to Date on Breast, Cervical, and Colorectal Cancer Screening at 6-Month Intervals, From 2012 to 2022, Stratified by Neighborhood Income Quintile

Income quintile 1 represents the lowest; quintile 5, the highest.

Figure 2.. Percentage of Ontario Residents Eligible…

Figure 2.. Percentage of Ontario Residents Eligible and Up to Date on Breast, Cervical, and…

 Figure 2.. Percentage of Ontario Residents Eligible and Up to Date on Breast, Cervical, and Colorectal Cancer Screening at 6-Month Intervals, From 2012 to 2022, Stratified by Immigrant Status Similar articles Cited by References
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