Population cancer screening programs and early detection
- In Australia, the COVID-19 pandemic has caused disruptions to all three national population cancer screening programs for breast, cervical and bowel cancers.
- The BreastScreen Australia program was temporarily paused across Australia due to workforce and safety considerations,1 and its recommencement has been limited in some areas, particularly related to ongoing physical distancing considerations.
- While the National Cervical Screening Program and the National Bowel Cancer Screening Program continued to operate throughout the pandemic, reduced participation is indicated by a decrease in the use of relevant MBS items for testing and follow-up of positive results.2
- Internationally, reports have emerged of fewer cancer referrals and notifications, including the Netherlands Cancer Registry reporting a decline in cancer incidence of about 25%.3 In Australia, some cancer hospitals also reported reduced referrals of new patients. For example, average daily pathology notifications to the Victorian cancer registry falling by 28% during the March to May national lockdown.4
- In addition to a reduction in screening participation, reductions in cancer referrals reported in some jurisdictions may also have been related to a reduction in incidental findings from other investigations, fewer people attending their GPs for non-COVID related issues, travel restrictions, fears of patients to attend health professional consultations, and a reduction in elective surgery.5,6
Impact of change
- The temporary pause of the BreastScreen Australia program helped to maintain public trust in the program by limiting exposure to SARS-CoV-2 infection in patients and staff, and enabled BreastScreen Australia staff to be redeployed for COVID-19-related care. Similarly, fewer colonoscopies also reduced risk of exposure to patients and staff.
- Disruptions in population screening programs have resulted in a backlog of missed appointments and potentially reduced capacity to deliver follow-up examinations to patients with a positive screening test.
- Potential diagnostic delays due to disruption of screening programs, delayed GP visits and delayed access to diagnostic pathways, have been modelled to result in patients potentially presenting with more advanced diseases (a shift in the disease stage at treatment initiation), the need for more complex treatments, including systemic therapies, and poorer outcomes.6
- The temporary pause in screening may have resulted in some patients moving to the private system, potentially resulting in greater out-of-pocket costs for patients.7 In some areas (for example in Western Australia) agreements were made with private radiology providers and hospitals to offer assessments and procedures to patients, with no out-of-pocket costs where public services were overwhelmed.7
How can the changes be addressed to promote high-value care?
The following strategies were identified in Australian and international literature and by leading Australian cancer experts and consumers. This list is provided to prompt considerations and future strategies to support high-value cancer care in the Recovery phases of the COVID-19 pandemic.
These strategies are listed at the system-, service-, practitioner-, and patient-levels and are intended to be used by a range of cancer control stakeholders across Australia to support high-value cancer care and improve outcomes for people with cancer.
- Prioritising available services for population subgroups who are most likely to benefit. This may involve utilising a risk stratification approach for screening services as they resume, including ‘catch-up plan’ approaches for patients who had missed screening and follow-up appointments.
- Using remote radiology services to facilitate local BreastScreen Australia services and follow-up assessments.
- Increasing strategic communication to target populations to promote participation in population screening programs.7
- Prioritising available services for investigation of symptoms and signs suggestive of cancer and follow-up of positive results, according to evidence-based clinical practice guidelines.
- Encouraging patients to participate in population screening programs and promoting the importance of early detection.
- Encouraging face-to-face consultations where appropriate to investigate ‘red flag’ symptoms.
- Adopting a systematic approach to timely and evidence-based, investigation and referral of symptoms and signs suggestive of cancer.
- Promoting and facilitating access to participation in population screening programs.
- Improving patient health literacy and encouraging patients to see their doctor about ‘red flag symptoms’ suggestive of cancer.
 BreastScreen Australia. COVID-19 Frequently asked questions. Australian Department of Health. Accessed: June 2020; http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/frequently-asked-questions#1
 Department of Health. MBS Online. Accessed August 2020; http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Home
 Kehoe J. More cancer deaths from COVID-19 lockdown. Accessed: August 2020; https://www.afr.com/policy/health-and-education/more-cancer-deaths-from-covid-19-lockdown-20200807-p55jnm
 CovidSurg Collaborative, Nepogodiev D and Bhangu A. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. BJS. 2020. doi:https://doi.org/10.1002/bjs.11646
 Degeling K, Baxter NN, Emery J et al. An inverse stage-shift model to estimate the excess mortality and health economic impact of delayed access to cancer services due to the COVID-19 pandemic. medRxiv 2020.05.30.20117630. doi: https://doi.org/10.1101/2020.05.30.20117630