Vinay Prasad, MD, MPH, breaks down a that examined differences in breast cancer screenings before and during the COVID-19 pandemic overall, and among sociodemographic population groups.
Following is a transcript of his remarks:
Hey, welcome back. Vinay Prasad here for ڴŮ, I'm here with my segment, "Articles You Will Definitely Read (Later)." And I got a new article. It just came out in JAMA Network Open, and it's entitled "Socioeconomic and Racial Inequities in Breast Cancer Screening During the COVID-19 Pandemic in Washington State."
So let's take a look into this study. This is a study that just appears in JAMA Network Open, and the authors look at something very simple. Now we've known all along that COVID-19 can disrupt healthcare systems in several ways.
First they're all the people who suffer from COVID-19. Next, COVID-19 can hit places so hard that they experience healthcare systems being overwhelmed. And in those settings of overwhelmed healthcare systems, other things can fall through the cracks.
The third way COVID-19 can affect healthcare is that COVID-19 and lockdowns meant to reduce the burden of COVID-19 can result in routine care being disrupted.
And that's what the authors of this paper took a look at. They looked at mammographic screening during COVID-19 in Washington state. The authors were interested in what happened to mammographic screening during COVID-19. They plot out how many women underwent mammograms in 2018, 2019, and 2020. And lo and behold, it looks like during COVID-19 there were half as many mammograms performed as in the prior year, a reduction of 49% or roughly half. That is a lot fewer mammograms. And the women who weren't getting the mammograms done, they weren't just the average woman. It was more likely to affect people based on their racial and socioeconomic status.
Specifically, Hispanic women had a greater reduction in mammographic usage during COVID-19. Then we have American Indians. Then we have multiracial. Then we have Asians, then Blacks, and then whites. Whites had the smallest change from 2019. They still had fewer mammograms, but it was less than Hispanics, who underwent the greatest reduction in mammographic screening.
When you look at urban and rural centers in Washington state, you find that it was rural places that had the greatest fall in mammographic screening. And finally, the authors looked at insurance status. And lo and behold, if you had commercial insurance, you did have less mammograms, but if you were self-pay or Medicaid, you had a larger reduction in mammographic screening.
So these were the results. They find a large reduction in mammographic screening due to the COVID-19 pandemic that was likely due, predominantly due, to the response to the COVID-19 pandemic, rather than healthcare systems being overwhelmed. Because in Washington state, there wasn't that long a period of time where we could reasonably say that that was the case. It was likely out of concern of COVID-19 or based on some measures to mitigate COVID-19. There was this large reduction.
Now, what does it all mean? I think that's the tricky part. Now the authors are quick to argue that every time a woman doesn't undergo mammographic screening, that means her likelihood of breast cancer-related death goes up. And I think that might be the case. Although if one were to look at all the randomized controlled trials of mammographic screening, one comes to the rather sobering conclusion that mammograms at best offer a modest reduction in breast cancer-related death, and in a pooled analysis in the Cochrane dataset, there is no sustained reduction in all-cause mortality. There is no reduction in all-cause mortality.
So what do I think this means? I think this is quite an interesting finding. On the face of it, it shows that utilization of a cancer preventive service has dramatically fallen, and it hasn't fallen equally for all people. It's much more likely to drop if you are Hispanic, if you are self-pay, if you are living in a rural center. That's the face of the finding.
What does it mean for the health of these people? I think that's the tougher question. I think many of us thought that the COVID-19 pandemic and this reduction in healthcare utilization would serve as a natural experiment. We'd be able to ask, you know, it's been a long time since those randomized controlled trials of mammographic screening, what is the effect of mammograms in the modern world with modern screening, with modern treatments, modern adjunct care -- is it the same effect size? And we thought COVID-19 would serve as a natural experiment where we'd be able to answer that question.
I think these results give us a little bit of pause. It turns out that the burden, the displacement of healthcare, has not occurred equally across socioeconomic and racial strata. It's occurred more in some socioeconomic groups and in some races. So what does that mean? I think that means it's going to be a lot more difficult to disambiguate the effect of mammographic screening and missing it, from the effect of all the other socioeconomic variables that come into play here.
Specifically, if somebody follows up on this dataset 5 years from now, 10 years from now, and they find that women who didn't get screened had a higher rate of breast cancer death, they're going to have to adjust for the fact that the women who aren't getting screened are disproportionately of some racial groups and disproportionately they have lower socioeconomic status, they have less money. That's why they're self-pay rather than having commercial insurance. And I think that adds a little bit of a wrench into this type of analysis.
So, what do I make of this? I think it is very important. It catalogs the extent to which COVID-19 and the response has disrupted routine healthcare. Am I going to say right now, based on this study, that the women who didn't get mammograms are suffering disproportionately? I'm hesitant to say that because I think the jury is still out on that. And I think what you see is that the healthcare that was disrupted does disrupt more based on socioeconomic and racial lines.
I think it's an interesting paper. It's going to lead to a large body of literature coming this way. We're going to try to figure out how much of these services, these preventive services that are constantly debated, it is contradictory, it is of modest effect size -- how many of these interventions will hold up when you look at what happened during COVID-19? So I think a lot is to come.
In [May] 2020, Gil Welch and I wrote an article on CNN entitled and we prophesied that this exact thing would happen, that you would have a dramatic reduction in routine care, and that would allow you to tease out what is the effect of this routine care.
This new paper gives me a little bit of pause. It makes me think that the disruption in healthcare did not affect all people equally, just as we know COVID-19 didn't affect all people equally. And that will have to be accounted for as we try to make sense of what is the effect size of a reduction in mammographic screening in the modern age.
I'm Vinay Prasad from ڴŮ. And this is a new paper out in JAMA Network Open, and the segment we're going to be running every week is "Articles You Will Definitely Read (Later)." Thank you.
Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of .