LAUSR

By use of self-reported data from the nationally representative Behavioral Risk Factor Surveillance System, Fedewa and colleagues1 document the decrease in cervical and breast cancer screening during 2020, likely secondary to the direct and indirect effects of the COVID-19 pandemic. Decreases in past-year prevalence were greater for segments of the population who, because of structural inequities, were already at higher risk of not undergoing cancer screening before the pandemic and who also were the most likely to experience the adverse consequences of the pandemic (eg, those with lower educational attainment and those who identify as Hispanic).2 These findings raise concerns that the combined effects of the COVID-19 pandemic, both the direct risks associated with COVID-19 incidence and mortality and the indirect risks associated with deferred care for other conditions, could lead to increased all-cause mortality and worsening of health disparities. Although these findings are alarming, 2 other aspects of the findings from Fedewa and colleagues1 suggest possible routes for addressing current and future inequities. First, unlike breast and cervical cancer screening, colorectal cancer (CRC) screening did not decrease significantly, as reductions in colonoscopy were counterbalanced by increased use of home-based stool testing. Moreover, the increased use of stool testing occurred disproportionately in those with lower educational attainment, suggesting that efforts to increase stool testing were reaching those at higher risk for going unscreened and, hence, may serve to reduce future inequities. An important caveat, however, is that the observed increase in stool testing must be sustained on a regular (annual or biennial) basis and be accompanied by high levels of adherence in follow-up colonoscopy after positive stool testing to reduce CRC incidence and mortality. The data available from Behavioral Risk Factor Surveillance System are not sufficient to confirm or refute that concern; however, the available data suggest a loss of adherence to stool testing over time.3 Second, the reductions in past-year screening observed by Fedewa and colleagues1 were not accompanied by similar reductions in up-to-date status, either overall or in subgroup analysis. This observation may be explained by past patterns of more frequent than recommended use of breast and cervical cancer screening compared with US Preventive Services Task Force guideline recommendations (cervical cancer screening every 3 or 5 years and mammography screening every 2 years) such that reductions in testing during 2020 did not also reduce the proportion of respondents being up to date. For CRC, the proportion who were up to date actually increased during 2020, and those groups with lower levels of up-to-date screening in previous surveys (ie, Hispanic individuals, those with lower income or educational attainment, and the uninsured) actually had larger increases than other groups, reducing but not fully closing preexisting disparities in screening. In addition, the overall levels of screening observed in 2020 remain short of the Healthy People 2030 goals: 84.3% up to date for cervical cancer screening, 74.4% for CRC screening, and 77.1% for breast cancer screening with mammography.4 The renewal of the Biden Cancer Moonshot initiative seeks to reduce the death rate from cancer by at least 50% over the next 25 years.5 Importantly, the renewal includes a focus on improving equity in cancer screening use, an investment that could help reduce existing disparities in cancer outcomes while moving the overall screening rates toward national goals. How can these data help guide this and other investments in clinical and policy interventions? Most fundamentally, addressing uninsured status among the 10% of the population younger than 65 years would help improve insurance-related screening disparities (difference in prevalence of up-to-date screening between insured and uninsured individuals, 28.3% for mammography, 18.7% + Related article