Cancer Screening Disparities Before and After the COVID-19 Pandemic
Authors: Lofters Aisha K. , Wu Fangyun , Frymire Eliot , Kiran Tara , Vahabi Mandana , Green Michael E. , Glazier Richard H. 
Published: November 2023

ImportanceBreast, cervical, and colorectal cancer–screening disparities existed prior to the COVID-19 pandemic, and it is unclear whether those have changed since the pandemic.ObjectiveTo 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 ParticipantsThis 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.ExposuresNeighborhood income quintile, immigrant status, and primary care model type.Main Outcomes and MeasuresFor 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.ResultsThe 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 RelevanceIn 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.