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Cancer screening disparities before and after the COVID-19 pandemic


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.



Lofters AK, Wu F, Frymire E, Kiran T, Vahabi M, Green ME, Glazier RH. JAMA Netw Open. 2023; 6(11):e2343796. Epub 2023 Nov 20.

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