Examining the association of clinician characteristics with perceived changes in cervical cancer screening and colposcopy practice during the COVID-19 pandemic: a mixed methods assessment
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eLife assessment
This important work provides evidence regarding the impact of the COVID-19 pandemic on cervical cancer screening and precancer treatments in the USA. As there are few screening registries, the study provides solid evidence using a survey of health providers' impressions to assess whether cervical cancer screening services declined during the pandemic. The work will be of interest to public health professionals working in cancer prevention.
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Abstract
The COVID-19 pandemic led to reductions in cervical cancer screening and colposcopy. Therefore, in this mixed method study we explored perceived pandemic-related practice changes to cervical cancer screenings and colposcopies.
Methods:
In 2021, a national sample of 1251 clinicians completed surveys, including 675 clinicians who performed colposcopy; a subset (n=55) of clinicians completed qualitative interviews.
Results:
Nearly half of all clinicians reported they were currently performing fewer cervical cancer screenings (47%) and colposcopies (44% of those who perform the procedure) than before the pandemic. About one-fifth (18.6%) of colposcopists reported performing fewer LEEPs than prior to the pandemic. Binomial regression analyses indicated that older, as well as internal medicine and family medicine clinicians (compared to OB-GYNs), and those practicing in community health centers (compared to private practice) had higher odds of reporting reduced screening. Among colposcopists, internal medicine physicians and those practicing in community health centers had higher odds of reporting reduced colposcopies. Qualitative interviews highlighted pandemic-related care disruptions and lack of tracking systems to identify overdue screenings.
Conclusions:
Reductions in cervical cancer screening and colposcopy among nearly half of clinicians more than 1 year into the pandemic raise concerns that inadequate screening and follow-up will lead to future increases in preventable cancers.
Funding:
This study was funded by the American Cancer Society, who had no role in the study’s design, conduct, or reporting.
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Author Response
Reviewer #1 (Public Review):
As part of a special issue on COVID-19 and cancer, Fuzzell and colleagues report findings from their mixed method study on the impact of the pandemic on cervical cancer screening and colposcopies, consisting of a national (United States) survey (March-August 2021) of 1251 clinicians (675 perform colposcopy) and qualitative interviews (June-December 2021) with 55 of these clinicians. The study looked specifically at perceived pandemic-related practice changes and disruptions over one year into the pandemic after the lockdowns had been lifted.
The overall focus is on three pandemic-related questions (impact on cervical cancer screening practice, colposcopy practice, ability to provide LEEP) that were asked as part of a larger survey related to cervical cancer screening and management of …
Author Response
Reviewer #1 (Public Review):
As part of a special issue on COVID-19 and cancer, Fuzzell and colleagues report findings from their mixed method study on the impact of the pandemic on cervical cancer screening and colposcopies, consisting of a national (United States) survey (March-August 2021) of 1251 clinicians (675 perform colposcopy) and qualitative interviews (June-December 2021) with 55 of these clinicians. The study looked specifically at perceived pandemic-related practice changes and disruptions over one year into the pandemic after the lockdowns had been lifted.
The overall focus is on three pandemic-related questions (impact on cervical cancer screening practice, colposcopy practice, ability to provide LEEP) that were asked as part of a larger survey related to cervical cancer screening and management of abnormal results, details of which are however not fully described in terms of the survey's general aim and items, but seem to have been designed within the context of adherence to guidelines (following Cabana's Guideline Based Practice Improvement Framework).
The authors thank the reviewer for their thoughtful feedback. The surveys topics assessed are now described more fully in the Method, and measures are available upon request. The survey covered several areas related to cervical cancer screening practices and management of abnormal screening results, including presentation of vignettes focused on screening intervals, management or treatment, and screening exit or continuation in relation to 2019 ASCCP risk-based management guidelines adoption, as well as a sub-set of items for clinicians who perform colposcopy. There were also items related to HPV self-sampling, as well as the impact of the COVID-19 pandemic on screening and follow-up (which is the focus of the present manuscript).
Reviewer #2 (Public Review):
Lindsay Fuzzell and her team of researchers have performed an extremely well-executed survey study, which captures a wide spectrum of providers who perform cervical cancer screening in the US. The researchers have captured a vast amount of demographic data in this study in attempting to determine whether cervical cancer screening continued to be reduced in the year immediately after the lockdown period caused by the COVID-19 pandemic.
The authors have uncovered some important and revealing concerns regarding the current state of cancer screening during the public health crisis caused by the COVID-19 pandemic. The most notable implication from their survey was a statistically higher reported reduction in cervical cancer screening in Internal medicine and family medicine providers as well as for community health and safety net clinics. These findings are important as they represent a large portion of primary care and a vulnerable patient population that has been shown to have worse cancer-related outcomes.
This study is more sobering information about the magnitude of ramifications of the COVID-19 pandemic on the US public health system. Decreases in cancer screening may have lasting implications for cancer-related mortality for many years to come. The implications of not going back to pre-pandemic cancer screening rates are daunting, to say the least.
The scope of this survey, the amount of data attained, and the sound methodology of the data acquisition and statistical analysis are the strengths of this study. Weaknesses are inherent to the study relying on survey answers rather than data from cervical cancer screening registries. Reporting biases are complex in surveys and answers given may not reflect the true rates of screening. The authors have also reported a disproportionate and statistically significant reduction in cervical cancer screening for Black and Asian providers. I would conclude more cautiously here with confidence intervals crossing one in both for this statistical analysis.
Overall, this is a survey study with a great magnitude, which has important implications for cancer screening and public health in the US.
The authors thank the reviewer for their kind assessment. The discussion now includes an acknowledgement of the weaknesses inherent with using self-report surveys, namely that self-report surveys have inherent biases and may not be actual representations of screening and colposcopy practices that could be ascertained via medical record or claims databases. Additionally, regarding confidence intervals that cross one, given the few studies that have explored factors associated with clinician perspectives on screening and colposcopy changes due to the pandemic, we desired a more broad-based approach to identifying factors associated with our outcomes of interest, thus electing to utilize p of .10 as significance level. This strikes a balance between the commonly accepted method of using the AIC (Akaike's Information Criterion, which implicitly assumes a significance level of 0.157), and the often-used significance level of 0.05. We now describe the choice of 0.10 in the text. However, we acknowledge that by using 0.10 as a significance level, some 95% confidence intervals for factors we consider significant cross one. We have tempered language in the discussion for findings with p-values between 0.05 and 0.10. Additionally, in examination of the confidence intervals for findings related to race that the reviewer mentions, we identified an error in the labelling of Table 3. Marginally significant findings for Asian clinicians actually apply to mixed race/other clinicians. We have corrected this error in Table 3 and throughout the manuscript. We thank the reviewer for bringing the confidence intervals that cross one to our attention as this triggered an examination of our findings.
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eLife assessment
This important work provides evidence regarding the impact of the COVID-19 pandemic on cervical cancer screening and precancer treatments in the USA. As there are few screening registries, the study provides solid evidence using a survey of health providers' impressions to assess whether cervical cancer screening services declined during the pandemic. The work will be of interest to public health professionals working in cancer prevention.
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Reviewer #1 (Public Review):
As part of a special issue on COVID-19 and cancer, Fuzzell and colleagues report findings from their mixed method study on the impact of the pandemic on cervical cancer screening and colposcopies, consisting of a national (United States) survey (March-August 2021) of 1251 clinicians (675 perform colposcopy) and qualitative interviews (June-December 2021) with 55 of these clinicians. The study looked specifically at perceived pandemic-related practice changes and disruptions over one year into the pandemic after the lockdowns had been lifted.
The overall focus is on three pandemic-related questions (impact on cervical cancer screening practice, colposcopy practice, ability to provide LEEP) that were asked as part of a larger survey related to cervical cancer screening and management of abnormal results, …
Reviewer #1 (Public Review):
As part of a special issue on COVID-19 and cancer, Fuzzell and colleagues report findings from their mixed method study on the impact of the pandemic on cervical cancer screening and colposcopies, consisting of a national (United States) survey (March-August 2021) of 1251 clinicians (675 perform colposcopy) and qualitative interviews (June-December 2021) with 55 of these clinicians. The study looked specifically at perceived pandemic-related practice changes and disruptions over one year into the pandemic after the lockdowns had been lifted.
The overall focus is on three pandemic-related questions (impact on cervical cancer screening practice, colposcopy practice, ability to provide LEEP) that were asked as part of a larger survey related to cervical cancer screening and management of abnormal results, details of which are however not fully described in terms of the survey's general aim and items, but seem to have been designed within the context of adherence to guidelines (following Cabana's Guideline Based Practice Improvement Framework).
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Reviewer #2 (Public Review):
Lindsay Fuzzell and her team of researchers have performed an extremely well-executed survey study, which captures a wide spectrum of providers who perform cervical cancer screening in the US. The researchers have captured a vast amount of demographic data in this study in attempting to determine whether cervical cancer screening continued to be reduced in the year immediately after the lockdown period caused by the COVID-19 pandemic.
The authors have uncovered some important and revealing concerns regarding the current state of cancer screening during the public health crisis caused by the COVID-19 pandemic. The most notable implication from their survey was a statistically higher reported reduction in cervical cancer screening in Internal medicine and family medicine providers as well as for community …
Reviewer #2 (Public Review):
Lindsay Fuzzell and her team of researchers have performed an extremely well-executed survey study, which captures a wide spectrum of providers who perform cervical cancer screening in the US. The researchers have captured a vast amount of demographic data in this study in attempting to determine whether cervical cancer screening continued to be reduced in the year immediately after the lockdown period caused by the COVID-19 pandemic.
The authors have uncovered some important and revealing concerns regarding the current state of cancer screening during the public health crisis caused by the COVID-19 pandemic. The most notable implication from their survey was a statistically higher reported reduction in cervical cancer screening in Internal medicine and family medicine providers as well as for community health and safety net clinics. These findings are important as they represent a large portion of primary care and a vulnerable patient population that has been shown to have worse cancer-related outcomes.
This study is more sobering information about the magnitude of ramifications of the COVID-19 pandemic on the US public health system. Decreases in cancer screening may have lasting implications for cancer-related mortality for many years to come. The implications of not going back to pre-pandemic cancer screening rates are daunting, to say the least.
The scope of this survey, the amount of data attained, and the sound methodology of the data acquisition and statistical analysis are the strengths of this study. Weaknesses are inherent to the study relying on survey answers rather than data from cervical cancer screening registries. Reporting biases are complex in surveys and answers given may not reflect the true rates of screening. The authors have also reported a disproportionate and statistically significant reduction in cervical cancer screening for Black and Asian providers. I would conclude more cautiously here with confidence intervals crossing one in both for this statistical analysis.
Overall, this is a survey study with a great magnitude, which has important implications for cancer screening and public health in the US.
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Reviewer #3 (Public Review):
In this paper, the authors report cervical cancer screening practice during the covid pandemic in the US from the perspective of health professionals (HPs). Two methods were used: survey and regression analysis, and qualitative interviews. Analyses indicated that older, non-White, internal medicine, and family medicine clinicians and those practicing in community health centers had higher odds of reporting reduced screening. Interviews highlighted disruptions of services and a lack of tracking systems.
The strengths of the paper are mainly i) using three different sources of HPs' recruitment and ii) being able to recruit a large number of participants in both survey and interviews and iii) the demographic characteristics of the interviewees were similar to those of the participants of the survey. -
