Impact of COVID-19-related care disruptions on cervical cancer screening in the United States

Abstract

Objectives: To quantify the secondary impacts of the COVID-19 pandemic disruptions to cervical cancer screening in the United States, stratified by step in the screening process and primary test modality, on cervical cancer burden.

Methods: We conducted a comparative model-based analysis using three independent NCI Cancer Intervention and Surveillance Modeling Network cervical models to quantify the impact of eight alternative COVID-19-related screening disruption scenarios compared to a scenario of no disruptions. Scenarios varied by the duration of the disruption (6 or 24 months), steps in the screening process being disrupted (primary screening, surveillance, colposcopy, excisional treatment), and primary screening modality (cytology alone or cytology plus human papillomavirus "cotesting").

Results: The models consistently showed that COVID-19-related disruptions yield small net increases in cervical cancer cases by 2027, which are greater for women previously screened with cytology compared with cotesting. When disruptions affected all four steps in the screening process under cytology-based screening, there were an additional 5-7 and 38-45 cases per one million screened for 6- and 24-month disruptions, respectively. In contrast, under cotesting, there were additional 4-5 and 35-45 cases per one million screened for 6- and 24-month disruptions, respectively. The majority (58-79%) of the projected increases in cases under cotesting were due to disruptions to surveillance, colposcopies, or excisional treatment, rather than to primary screening.

Conclusions: Women in need of surveillance, colposcopies, or excisional treatment, or whose last primary screen did not involve human papillomavirus testing, may comprise priority groups for reintroductions.

Keywords: COVID-19; cervical cancer screening; simulation modeling.

Figure 1.. Projected impact of COVID-19-related disruptions to different steps in the cervical cancer screening process on the number of cervical cancer cases per 1 million screened women aged 21–84 years over time in the context of primary cytology-based screening (stapled lines) or cotest-based screening (solid lines) for three CISNET-Cervical disease simulation models.

COVID-19-related disruptions varied by the duration of the disruption, (6 months (top panels) or 24 months (bottom panels)) and step(s) in the screening process the disruption(s) impacted: i) primary screening only (PRM), ii) primary screening and surveillance (PRM/SUR), iii) primary screening, surveillance and colposcopy visits (PRM/SUR/COL), or iv) primary screening, surveillance, colposcopy visits and excisional treatments (PRM/SUR/COL/TX). Women aged 21–65 years were screened using cytology with or without an option to switch to cytology and HPV “cotesting” starting at age 30 years. See Supplementary Table 1 for alternative COVID-19-related scenarios and assumptions. Projected 2020 baseline rates per 1 million women in the absence of COVID-19 for Harvard: 79 (cytology) and 26 (cotesting); Policy1-Cervix: 43 (cytology) and 28 (cotesting); MISCAN-Cervix: 48 (cytology) and 37 (cotesting). Note: MISCAN-Cervix simulated disruptions to the primary screening only scenario, while the Harvard and Policy1-Cervix models projected outcomes for disruptions across the multi-step screening process.