Pan-Canadian survey on the impact of the COVID-19 pandemic on cervical cancer screening and management: cross-sectional survey of healthcare professionals

Abstract

Background: The coronavirus disease 2019 (COVID-19) pandemic has caused disruptions to cancer care by delaying diagnoses and treatment, presenting challenges and uncertainties for both patients and physicians. We conducted a nationwide online survey to investigate the effects of the pandemic and capture modifications, prompted by pandemic-related control measures, on cervical cancer screening-related activities from mid-March to mid-August 2020, across Canada.

Methods: The survey consisted of 61 questions related to the continuum of care in cervical cancer screening and treatment: appointment scheduling, tests, colposcopy, follow-up, treatment of pre-cancerous lesions/cancer, and telemedicine. We piloted the survey with 21 Canadian experts in cervical cancer prevention and care. We partnered with the Society of Canadian Colposcopists, Society of Gynecologic Oncology of Canada, Canadian Association of Pathologists, and Society of Obstetricians and Gynecologists of Canada, which distributed the survey to their members via email. We reached out to family physicians and nurse practitioners via MDBriefCase. The survey was also posted on McGill Channels (Department of Family Medicine News and Events) and social media platforms. The data were analyzed descriptively.

Results: Unique responses were collected from 510 participants (November 16, 2020, to February 28, 2021), representing 418 fully and 92 partially completed surveys. Responses were from Ontario (41.0%), British Columbia (21.0%), and Alberta (12.8%), and mostly comprised family physicians/general practitioners (43.7%), and gynecologist/obstetrician professionals (21.6%). Cancelled screening appointments were mainly reported by family physicians/general practitioners (28.3%), followed by gynecologist/obstetrician professionals (19.8%), and primarily occurred in private clinics (30.5%). Decreases in the number of screening Pap tests and colposcopy procedures were consistently observed across Canadian provinces. About 90% reported that their practice/institution adopted telemedicine to communicate with patients.

Conclusions: The area most severely impacted by the pandemic was appointment scheduling, with an important level of cancellations reported. Survey results may inform resumptions of various fronts in cervical cancer screening and management.

Funding: The present work was supported by the Canadian Institutes of Health Research (operating grant COVID-19 May 2020 Rapid Research Funding Opportunity VR5-172666 Rapid Research competition and foundation grant 143347 to Eduardo L Franco). Eliya Farah and Rami Ali each received an MSc stipend from the Department of Oncology, McGill University.

Keywords: COVID-19 pandemic; cervical cancer screening; epidemiology; global health; healthcare practitioners; human; medicine; survey.

Figure 1.. Description of survey elements and administration, and respondent flowchart.

Figure 2.. Cancellations and postponements of screening appointments by province, profession, and place of practice (n=510).

Number of cancellations are shown by (A) province, (B) profession, and (C) place of practice. Number of postponements are shown by (D) province, (E) profession, and (F) place of practice. Answers include responses for questions 6 (cancellations) and 8 (postponements) by questions 2 (province), 4 (profession), and 5 (place of practice). Panels A and D: Territories include Northwest Territories, Nunavut, and Yukon. Other provinces include Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Quebec, and Saskatchewan (and one respondent who preferred not to say). Panels B and E: Primary includes general practitioners/family physicians, nurse practitioners/registered nurses, physician assistants, and a manager of a community health center; secondary (clinical) includes colposcopists and colposcopy registered nurses/registered practical nurses; secondary (cytological) includes cytopathologists/technologists and pathologists; tertiary includes gynecologists/obstetrician-gynecologists, gynecology oncologists, and gynecology nurses. Panels B, C, E, and F: Frequency count exceeded total number of respondents as some reported multiple professions and places of practice. DK: Don’t know; NA: Not applicable to my practice.

Figure 3.. Cancelled (n=325) and postponed (n=382) screening appointments by province that were cancelled or postponed by physician/providers’ institution, by patient, or converted to telemedicine.

Number cancelled by (A) physician or providers’ institution, (B) patient, and (C) converted to telemedicine. Number postponed by (D) physician or providers’ institution, (E) patient, and (F) converted to telemedicine. Answers include responses for questions 7 (cancellations) and 9 (postponements) by question 2 (province). Respondents were asked to ensure that their answers did not exceed 100% for each question. (i.e., for each respondent, A+B+C ≈ 100% and D+E+F ≈ 100%). The x axis represents frequency of responses by province. Territories include Northwest Territories, Nunavut, and Yukon. Other provinces include Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Quebec, and Saskatchewan (and one respondent who preferred not to say). The y axis represents cancelled or postponed screening appointments using a predefined interval scale. DK: Don’t know.

Figure 4.. Cancelled (n=325) and postponed (n=382) screening appointments by profession that were cancelled or postponed by physician/providers’ institution, by patient, or converted to telemedicine.

Number cancelled by (A) physician or providers’ institution, (B) patient, and (C) converted to telemedicine. Number postponed by (D) physician or providers’ institution, (E) patient, and (F) converted to telemedicine. Answers include responses for questions 7 (cancellations) and 9 (postponements) by question 4 (profession). Respondents were asked to ensure that their answers did not exceed 100% for each question. (i.e., for each respondent, A+B+C ≈ 100% and D+E+F ≈ 100%). The x axis represents frequency of responses by profession. Primary includes general practitioners/family physicians, nurse practitioners/registered nurses, physician assistants, and a manager of a community hospital; secondary (clinical) includes colposcopists and colposcopy registered nurses/registered practical nurses; secondary (cytological) includes cytopathologists/technologists and pathologists; tertiary includes gynecologists/obstetrician-gynecologists, gynecology oncologists, and gynecology nurses. Frequency count exceeded total number of respondents as some reported multiple professions. The y axis represents cancelled or postponed screening appointments using a predefined interval scale. DK: Don’t know.

Figure 5.. Cancelled (n=325) and postponed (n=382) screening appointments by place of practice that were cancelled or postponed by physician/providers’ institution, by patient, or converted to telemedicine.

Number cancelled by (A) physician or providers’ institution, (B) patient, and (C) converted to telemedicine. Number postponed by (D) physician or providers’ institution, (E) patient, and (F) converted to telemedicine. Answers include responses for questions 7 (cancellations) and 9 (postponements) by question 5 (place of practice). Respondents were asked to ensure that their answers did not exceed 100% for each question. (i.e., for each respondent, A+B+C ≈ 100% and D+E+F ≈ 100%). The x axis represents frequency of responses by place of practice. Frequency count exceeded total number of respondents as some reported multiple places of practice. The y axis represents cancelled or postponed screening appointments using a predefined interval scale. DK: Don’t know.

Figure 6.. Allowance of in-person consultations during the peak period of the pandemic by province, profession, and place of practice (n=510).

Number of in person consultations is shown by (A) province, (B) profession, and (C) place of practice. Answers include responses for question 11 by questions 2 (province), 4 (profession), and 5 (place of practice). Panel A: Territories include Northwest Territories, Nunavut, and Yukon. Other provinces include Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Quebec, and Saskatchewan (and one respondent who preferred not to say). Panel B: Primary includes general practitioners/family physicians, nurse practitioners/registered nurses, physician assistants, and a manager of a community health center; secondary (clinical) includes colposcopists and colposcopy registered nurses/registered practical nurses; Secondary (cytological) includes cytopathologists/technologists and pathologists; Tertiary includes gynecologists/obstetrician-gynecologists, gynecology oncologists, and gynecology nurses. Panels B and C: Frequency count exceeded total number of respondents as some reported multiple professions and places of practice. DK: Don’t know; NA: Not applicable to my practice.

Figure 7.. Deferral period for postponed screening appointments by province, profession, and place of practice (n=467).

Deferral period for postponed Pap test appointments is shown by (A) province, (B) profession, and (C) place of practice. Deferral period for postponed human papillomavirus (HPV) test appointments is shown by (D) province, (E) profession, and (F) place of practice. Deferral period for postponed HPV/Pap co-test appointments is shown (G) province, (H) profession, and (I) place of practice. Answers include responses for question 19 by questions 2 (province), 4 (profession), and 5 (place of practice). Panels A, D, and G: Territories include Northwest Territories, Nunavut, and Yukon. Other provinces include Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Quebec, and Saskatchewan (and one respondent who preferred not to say). Panels B, E, and H: Primary includes general practitioners/family physicians, nurse practitioners/registered nurses, physician assistants, and a manager of a community health center; secondary (clinical) includes colposcopists and colposcopy registered nurses/registered practical nurses; secondary (cytological) includes cytopathologists/technologists and pathologists; tertiary includes gynecologists/obstetrician-gynecologists, gynecology oncologists, and gynecology nurses. Panels B, C, E, F, H, and I: Frequency count exceeded total number of respondents as some reported multiple professions and places of practice. DK: Don’t know; NA: Not applicable to my practice.

Figure 8.. Cancellations and postponements of colposcopy appointments by province, profession, and place of practice (n=452).

Number of cancellations are shown by (A) province, (B) profession, and (C) place of practice. Number of postponements are shown by (D) province, (E) profession, and (F) place of practice. Answers include responses for questions 25 (cancellations) and 27 (postponements) by questions 2 (province), 4 (profession), and 5 (place of practice). Panels A and D: Territories include Northwest Territories, Nunavut, and Yukon. Other provinces include Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Quebec, and Saskatchewan (and one respondent who preferred not to say). Panels B and E: Primary includes general practitioners/family physicians, nurse practitioners/registered nurses, physician assistants, and a manager of a community health center; secondary (clinical) includes colposcopists and colposcopy registered nurses/registered practical nurses; secondary (cytological) includes cytopathologists/technologists and pathologists; tertiary includes gynecologists/obstetrician-gynecologists, gynecology oncologists, and gynecology nurses. Panels B, C, E, and F: Frequency count exceeded total number of respondents as some reported multiple professions and places of practice. DK: Don’t know; NA: Not applicable to my practice.

Figure 8—figure supplement 1.. Cancelled (n=114) and postponed (n=167) colposcopy appointments by province that were cancelled or postponed by physician/providers’ institution or by patient.

Number cancelled by (A) physician or providers’ institution and (B) patient. Number postponed by (C) physician or providers’ institution and (D) patient. Answers include responses for questions 26 (cancellations) and 28 (postponements) by question 2 (province). Respondents were asked to ensure that their answers did not exceed 100% for each question. (i.e., for each respondent, A+B ≈ 100% and C+D ≈ 100%). The x axis represents frequency of responses by province. Territories include Northwest Territories, Nunavut, and Yukon. Other provinces include Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Quebec, and Saskatchewan (and one respondent who preferred not to say). The y axis represents cancelled or postponed colposcopy appointments using a predefined interval scale. DK: Don’t know.

Figure 8—figure supplement 2.. Cancelled (n=114) and postponed (n=167) colposcopy appointments by profession that were cancelled or postponed by physician/providers’ institution or by patient.

Number cancelled by (A) physician or providers’ institution and (B) patient. Number postponed by (C) physician or providers’ institution and (D) patient. Answers include responses for questions 26 (cancellations) and 28 (postponements) by question 4 (profession). Respondents were asked to ensure that their answers did not exceed 100% for each question. (i.e., for each respondent, A+B ≈ 100% and C+D ≈ 100%). The x axis represents frequency of responses by profession. Primary includes general practitioners/family physicians, nurse practitioners/registered nurses, and physician assistants; secondary (clinical) includes colposcopists and colposcopy registered nurses/registered practical nurses; secondary (cytological) includes cytopathologists/technologists and pathologists; tertiary includes gynecologists/obstetrician-gynecologists, gynecology oncologists, and gynecology nurses. Frequency count exceeded total number of respondents as some reported multiple professions. The y axis represents cancelled or postponed colposcopy appointments using a predefined interval scale. DK: Don’t know.

Figure 8—figure supplement 3.. Cancelled (n=114) and postponed (n=167) colposcopy appointments by place of practice that were cancelled or postponed by physician/providers’ institution or by patient.

Number cancelled by (A) physician or providers’ institution and (B) patient. Number postponed by (C) physician or providers’ institution and (D) patient. Answers include responses for questions 26 (cancellations) and 28 (postponements) by question 5 (place of practice). Respondents were asked to ensure that their answers did not exceed 100% for each question. (i.e., for each respondent, A+B ≈ 100% and C+D ≈ 100%). The x axis represents frequency of responses by place of practice. Frequency count exceeded total number of respondents as some reported multiple places of practice. The y axis represents cancelled or postponed colposcopy appointments using a predefined interval scale. DK: Don’t know.

Figure 9.. Cancellations and postponements of follow-up appointments by province, profession, and place of practice (n=445).

Number of cancellations are shown by (A) province, (B) profession, and (C) place of practice. Number of postponements are shown by (D) province, (E) profession, and (F) place of practice. Answers include responses for questions 31 (cancellations) and 33 (postponements) by questions 2 (province), 4 (profession), and 5 (place of practice). Panels A and D: Territories include Northwest Territories, Nunavut, and Yukon. Other provinces include Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Quebec, and Saskatchewan (and one respondent who preferred not to say). Panels B and E: Primary includes general practitioners/family physicians, nurse practitioners/registered nurses, physician assistants, and a manager of a community health center; secondary (clinical) includes colposcopists and colposcopy registered nurses/registered practical nurses; secondary (cytological) includes cytopathologists/technologists and pathologists; tertiary includes gynecologists/obstetrician-gynecologists, gynecology oncologists, and gynecology nurses. Panels B, C, E, and F: Frequency count exceeded total number of respondents as some reported multiple professions and places of practice. DK: Don’t know; NA: Not applicable to my practice.

Figure 9—figure supplement 1.. Cancelled (n=148) and postponements (n=238) of follow-up appointments by province that were cancelled or postponed by physician/providers’ institution, by patient, or converted to telemedicine.

Number cancelled by (A) physician or providers’ institution, (B) patient, and (C) converted to telemedicine. Number postponed by (D) physician or providers’ institution, (E) patient, and (F) converted to telemedicine. Answers include responses for questions 32 (cancellations) and 34 (postponements) by question 2 (province). Respondents were asked to ensure that their answers did not exceed 100% for each question (i.e., for each respondent, A+B+C ≈ 100% and D+E+F ≈ 100%). The x axis represents frequency of responses by province. Territories include Northwest Territories, Nunavut, and Yukon. Other provinces include Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Quebec, and Saskatchewan (and one respondent who preferred not to say). The y axis represents cancelled or postponed follow-up appointments using a predefined interval scale. DK: Don’t know.

Figure 9—figure supplement 2.. Cancelled (n=148) and postponed (n=238) follow-up appointments by profession that were cancelled or postponed by physician/providers’ institution, by patient, or converted to telemedicine.

Number cancelled by (A) physician or providers’ institution, (B) patient, and (C) converted to telemedicine. Number postponed by (D) physician or providers’ institution, (E) patient, and (F) converted to telemedicine. Answers include responses for questions 32 (cancellations) and 34 (postponements) by question 4 (profession). Respondents were asked to ensure that their answers did not exceed 100% for each question. (i.e., for each respondent, A+B+C ≈ 100% and D+E+F ≈ 100%). The x axis represents frequency of responses by profession. Primary includes general practitioners/family physicians, nurse practitioners/registered nurses, and physician assistants; secondary (clinical) includes colposcopists and colposcopy registered nurses/registered practical nurses; secondary (cytological) includes cytopathologists/technologists and pathologists; tertiary includes gynecologists/obstetrician-gynecologists, gynecology oncologists, and gynecology nurses. Frequency count exceeded total number of respondents as some reported multiple professions. The y axis represents cancelled or postponed follow-up appointments using a predefined interval scale. DK: Don’t know.

Figure 9—figure supplement 3.. Cancelled (n=148) and postponed (n=238) follow-up appointments by place of practice that were cancelled or postponed by physician/providers’ institution, by patient, or converted to telemedicine.

Number cancelled by (A) physician or providers’ institution, (B) patient, and (C) converted to telemedicine. Number postponed by (C) physician or providers’ institution, (D) patient, and (E) converted to telemedicine. Answers include responses for questions 32 (cancellations) and 34 (postponements) by question 5 (place of practice). Respondents were asked to ensure that their answers did not exceed 100% for each question. (i.e., for each respondent, A+B+C ≈ 100% and D+E+F ≈ 100%). The x axis represents frequency of responses by place of practice. Frequency count exceeded total number of respondents as some reported multiple places of practice. The y axis represents cancelled or postponed follow-up appointments using a predefined interval scale. DK: Don’t know.

Figure 10.. Cancellations or postponements of treatment procedures by province (n=431).

Number of cancellations or postponements of (A) cold knife conization, (B) other excisional (e.g., LEEP), (C) ablative procedures, (D) hysterectomy, (E) chemotherapy, and (F) radiation are shown by province. Answers include the responses for question 39 by question 2. Territories include Northwest Territories, Nunavut, and Yukon. Other provinces include Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Quebec, and Saskatchewan (and one respondent who preferred not to say). DK: Don’t know; NA: Not applicable to my practice.

Figure 11.. Cancellations or postponements of treatment procedures by profession (n=431).

Number of cancellations or postponements of (A) cold knife conization, (B) other excisional (e.g., LEEP), (C) ablative procedures, (D) hysterectomy, (E) chemotherapy, and (F) radiation are shown by profession. Answers include the responses for question 39 by question 4. Primary includes general practitioners/family physicians, nurse practitioners/registered nurses, physician assistants, and a manager of a community health center; secondary (clinical) includes colposcopists and colposcopy registered nurses/registered practical nurses; secondary (cytological) includes cytopathologists/technologists and pathologists; tertiary includes gynecologists/obstetrician-gynecologists, gynecology oncologists, and gynecology nurses. Frequency count exceeded total number of respondents as some reported multiple professions. DK: Don’t know; NA: Not applicable to my practice.

Figure 12.. Cancellations or postponements of treatment procedures by place of practice (n=431).

Number of cancellations or postponements of (A) cold knife conization, (B) other excisional (e.g., LEEP), (C) ablative procedures, (D) hysterectomy, (E) chemotherapy, and (F) radiation are shown by place of practice. Answers include the responses for question 39 by question 5. Frequency count exceeded total number of respondents as some reported multiple places of practice. DK: Don’t know; NA: Not applicable to my practice.

Figure 13.. Percentage of patients attending routine screening compared to pre-coronavirus disease 2019 (pre-COVID-19) by province, profession, and place of practice (n=421).

Proportions are shown by (A) province, (B) profession, and (C) place of practice. Answers include responses for question 57 by questions 2 (province), 4 (profession), and 5 (place of practice). Panel A: Territories include Northwest Territories, Nunavut, and Yukon. Other provinces include Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Quebec, and Saskatchewan (and one respondent who preferred not to say). Panel B: Primary includes general practitioners/family physicians, nurse practitioners/registered nurses, physician assistants, and a manager of a community health center; secondary (clinical) includes colposcopists and colposcopy registered nurses/registered practical nurses; secondary (cytological) includes cytopathologists/technologists and pathologists; tertiary includes gynecologists/obstetrician-gynecologists, gynecology oncologists, and gynecology nurses. Panels B and C: Frequency count exceeded total number of respondents as some reported multiple places of practice. DK: Don’t know; NA: Not applicable to my practice.

Figure 14.. Responses to open-ended Q22 by province, profession, and place of practice (n=206).

Opinions and perspectives are shown by (A) province, (B) profession, and (C) place of practice. Answers include responses for question 22 (coronavirus disease 2019 [COVID-19] to encourage/facilitate/accelerate implementation of human papillomavirus [HPV] self-sampling) by questions 2 (province), 4 (profession), and 5 (place of practice). Panel A: Territories include Northwest Territories, Nunavut, and Yukon. Other provinces include Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Quebec, and Saskatchewan (and one respondent who preferred not to say). Panel B: Primary includes general practitioners/family physicians, nurse practitioners/registered nurses, physician assistants, and a manager of a community center; secondary (clinical) includes colposcopists and colposcopy registered nurses/registered practical nurses; secondary (cytological) includes cytopathologists/technologists and pathologists; tertiary includes gynecologists/obstetrician-gynecologists, gynecology oncologists, and gynecology nurses. Panels B and C: Frequency count exceeded total number of respondents as some reported multiple professions and places of practice.

Figure 15.. Responses to open-ended Q23 by province, profession, and place of practice (n=197).

Opinions and perspectives are shown by (A) province, (B) profession, and (C) place of practice. Answers include responses for question 23 (in favor of implementing human papillomavirus [HPV] self-sampling as alternative screening method) by questions 2 (province), 4 (profession), and 5 (place of practice). Panel A: Territories include Northwest Territories, Nunavut, and Yukon. Other provinces include Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Quebec, and Saskatchewan (and one respondent who preferred not to say). Panel B: Primary includes general practitioners/family physicians, nurse practitioners/registered nurses, physician assistants, and a manager of a community health center; secondary (clinical) includes colposcopists and colposcopy registered nurses/registered practical nurses; secondary (cytological) includes cytopathologists/technologists and pathologists; tertiary includes gynecologists/obstetrician-gynecologists, gynecology oncologists, and gynecology nurses. Panels B and C: Frequency count exceeded total number of respondents as some reported multiple professions and places of practice.