Study reveals inequities in breast cancer screening during COVID-19 pandemic

Women of color, rural women disproportionally affected by missed screening mammograms

WASHINGTON STATE UNIVERSITY

Research News

 

SPOKANE, Wash.-- Breast cancer screening took a sizeable hit during the COVID-19 pandemic, suggests new research that showed that the number of screening mammograms completed in a large group of women living in Washington State plummeted by nearly half. Published today in JAMA Network Open, the study found the steepest drop-offs among women of color and those living in rural communities.

"Detecting breast cancer at an early stage dramatically increases the chances that treatment will be successful," said lead study author Ofer Amram, an assistant professor in the Washington State University Elson S. Floyd College of Medicine whose research focuses on health inequities. "Our study findings suggest that health care providers need to double down on efforts to maintain prevention services and reach out to these underserved populations, who faced considerable health disparities even before the pandemic."

The study was conducted by researchers at Washington State University Health Sciences Spokane in partnership with MultiCare, a not-for-profit health care system that encompasses 230 clinics and eight hospitals across Washington state. The research team used medical record data from MultiCare patients who had screening mammograms completed between April and December of 2019 and during the same months in 2020, after the World Health Organization declared COVID-19 a global pandemic in March 2020

The researchers saw the number of completed screening mammograms across Washington state fall from 55,678 in 2019 to 27,522 in 2020, a 49% decrease. When they analyzed the data by race, they saw a similar decrease in screening of 49% for white women but observed significantly larger decreases in non-white women. For example, breast cancer screening declined by 64% in Hispanic women and 61% in American Indian and Alaska Native women. The researchers also looked at geographical location and found that screening mammograms in rural women were reduced by almost 59%, whereas the number of mammograms completed in urban women fell by about 50%.

Additionally, the research team analyzed the data by insurance type and found that compared to women who were on commercial or government-run health insurance plans, screening reductions were greater in women using Medicaid or who self-paid for treatment, which Amram said are indicators of lower socioeconomic status.

"We know that the COVID-19 virus has had disproportionate impacts on certain populations, including racial and ethnic minority groups," said Pablo Monsivais, senior author on the study and an associate professor in the WSU Elson S. Floyd College of Medicine. "What our study adds is that some of the secondary effects of the COVID-19 pandemic are also disproportionately impacting those populations, so it's a double whammy."

While previous studies have looked at missed cancer screening during the pandemic, Monsivais said this study is the first to examine racial and socioeconomic differences, specifically. The research team's goal is to find ways to eliminate barriers to cancer screening, which would help reduce cancer-related health disparities. Their next step is to conduct a follow-up study to identify which social and economic factors interfered with access to cancer screening during the pandemic. In addition to breast cancer, that study will also look at missed colon cancer and lung cancer screening in both women and men.

Factors that may have played a role in reduced cancer screening include job loss, loss of employer-provided health insurance, and caregiver stress due to school- or daycare closures or other circumstances. Fear of contracting COVID-19 may have also played into this, said study co-author Jeanne Robison, an oncology nurse practitioner and lead researcher on this project with MultiCare Cancer and Blood Specialty Centers in Spokane, Washington.

"One of the things we have seen this past year is that women who were pretty good about keeping up with screening remained fearful about going in even after health care facilities had opened back up for routine screening," Robison said. "I've had to talk some of my patients into coming in, however, because even when protocols were in place to safely offer breast cancer screening, there remained a perceived risk."

A drop in primary care visits during the pandemic may have also been a factor, she said, as primary care providers often play a key role in reminding women of the timing and importance of breast cancer screening. And although increased access to virtual visits may have mitigated this drop, there may have been barriers to virtual care delivery that disproportionally impacted certain groups of people, which the researchers' follow-up study will help determine.

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In addition to Amram, Monsivais, and Robison, authors on the paper included Solmaz Amiri and John Roll at the WSU Elson S. Floyd College of Medicine and Bethann Pflugeisen with the MultiCare Institute for Research & Innovation.

The study was supported by a grant from the Andy Hill Cancer Research Endowment Fund.

Socioeconomic and Racial Inequities in Breast Cancer Screening During the COVID-19 Pandemic in Washington State

Ofer Amram, PhD^1,2; Jeanne Robison, PhD^3,4; Solmaz Amiri, DDes¹; et alBethann Pflugeisen, MSc³; John Roll, PhD¹; Pablo Monsivais, PhD, MPH¹

Author Affiliations Article Information

JAMA Netw Open. 2021;4(5):e2110946. doi:10.1001/jamanetworkopen.2021.10946

 May 24, 2021

Introduction

The COVID-19 pandemic has disrupted preventive care, including cancer screening. Studies from the United States and Europe have shown that cancer screening dropped dramatically during the pandemic,^1,2 with breast cancer screening and diagnostic mammograms falling by 58% and 38%, respectively.^1,2 A United Kingdom modeling study estimated that delayed and missed screenings would likely increase breast cancer deaths, a leading cancer among women, by 7.9% to 9.6%.^2,3 The adverse impact of COVID-19 on screening may differ among sociodemographic groups, given the disproportionate impact the pandemic has had on underserved racial and ethnic groups and other vulnerable population groups.⁴ In this report, we used clinical data to examine differences in breast cancer screenings before and during the COVID-19 pandemic overall and among sociodemographic population groups.

Methods

Data

Data included completed screening mammograms within a large statewide nonprofit community health care system in Washington State between April 1, 2018, and December 31, 2020. This health care system included more than 230 primary care, specialty care, and urgent care clinics, and 8 hospitals across Washington State. The MultiCare institutional review board approved this study protocol and granted waivers of individual consent based on removal of individually identifying data. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Measures and Statistical Analysis

Sociodemographic data included patients’ race and ethnicity, insurance, and zip code of residence. Rural-urban commuting area codes differentiated between urban vs rural residence. Inclusion criteria included women who had at least 1 screening mammogram within the health system in 2018 or 2019. Frequency analysis and χ² tests were performed using a significance level of P < .05 to test for differences in screening in 2019 and 2020. Testing was 2-sided. Statistical analysis was performed using R statistical software version 4.03 (R Project for Statistical Computing).

Results

Among the 55 678 screenings in April to December 2019, 45 572 patients were non-Hispanic White (81.8%), 54 620 patients lived in urban areas (98.1%), and 22 761 patients were commercially insured (40.9%); the mean (SD) age was 62.0 (11.3) years. From 2019 to the same period in 2020, there was a 49% decrease in screenings (55 678 screenings in 2019 vs 27 522 screenings in 2020), with some differences apparent in the demographic characteristics between the 2 years (Table). We observed greater and significant reductions in the number of screenings from 2019 to 2020 for women who were Hispanic (1727 vs 619; −64.2%), American Indian/Alaska Native (215 vs 84; −60.9%), mixed race (1892 vs 828; −56.2%), Native Hawaiian or Pacific Islander (365 vs 166; −54.5%), Asian (2779 vs 1265; −54.5%), and Black (2320 vs 1069; −53.9%) compared with women who were White (45 572 vs 23 163; −49.2%) (Figure). Women living in rural areas experienced greater reduction in screenings compared with their urban counterparts. In terms of insurance, women who self-paid for treatment and who were insured by Medicaid experienced the largest reduction in screening, whereas those with commercial insurance or Medicare showed smaller reductions (Table).

Discussion

This study found a substantial overall decline in breast cancer screening in women living in Washington State during the COVID-19 pandemic, as well as inequities in this decline. This study has several limitations. First, the analyses were of aggregate data; we did not link individual records across years. Second, the demographic characteristics of this sample are slightly less diverse and more affluent than Washington State. Third, data reflect patient interactions with a single health care system; we weren’t able to link these interactions to an underlying population base. However, the substantial drop in screenings in 2020 was not likely to be explained by a drop in underlying population base or eligibility; nor was it likely the result of a shift to different health care networks, given that this clinical network is one of the largest health care systems in Washington State.

The larger decline in screening among women from underserved racial/ethnic groups and lower socioeconomic status might be explained by several factors. Increasing unemployment during the pandemic shutdown among those already living in poverty may have further reduced access to health insurance, while school closures led to competing demands at home.⁵ In addition, limited access to health and screening services among rural women may have increased during the pandemic.⁶ To address the decline in breast cancer screening during the pandemic, there is a need to address barriers to screening, especially for higher-risk women. Our findings suggest another inequity in the COVID pandemic due to greater reduction in utilization of cancer screening services for women with lower socioeconomic status, who are in underserved racial/ethnic groups, and live in rural communities.

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Article Information

Accepted for Publication: March 29, 2021.

Published: May 24, 2021. doi:10.1001/jamanetworkopen.2021.10946

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Amram O et al. JAMA Network Open.

Corresponding Author: Ofer Amram, PhD, Washington State University, 412 E Spokane Falls Blvd, Spokane, WA 99202 (ofer.amram@wsu.edu).

Author Contributions: Dr Amram had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Amram, Robison, Amiri, Roll, Monsivais.

Acquisition, analysis, or interpretation of data: Amram, Robison, Amiri, Pflugeisen, Monsivais.

Drafting of the manuscript: Amram, Robison, Amiri, Monsivais.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Amram, Amiri, Monsivais.

Obtained funding: Amram, Amiri, Monsivais.

Administrative, technical, or material support: Robison, Pflugeisen.

Supervision: Amram, Robison.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by a grant from the Andy Hill Care Fund, Washington State’s Cancer Research Endowment. Dr Monsivais received support from the Health Equity Research Center, a strategic research initiative of Washington State University.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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