Annual Report to the Nation on the Status of Cancer, part 2: Early assessment of the COVID-19 pandemic's impact on cancer diagnosis.

BACKGROUND: With access to cancer care services limited because of coronavirus disease 2019 control measures, cancer diagnosis and treatment have been delayed. The authors explored changes in the counts of US incident cases by cancer type, age, sex, race, and disease stage in 2020. METHODS: Data were extracted from selected US population-based cancer registries for diagnosis years 2015-2020 using first-submission data from the North American Association of Central Cancer Registries. After a quality assessment, the monthly numbers of newly diagnosed cancer cases were extracted for six cancer types: colorectal, female breast, lung, pancreas, prostate, and thyroid. The observed numbers of incident cancer cases in 2020 were compared with the estimated numbers by calculating observed-to-expected (O/E) ratios. The expected numbers of incident cases were extrapolated using Joinpoint trend models. RESULTS: The authors report an O/E ratio <1.0 for major screening-eligible cancer sites, indicating fewer newly diagnosed cases than expected in 2020. The O/E ratios were lowest in April 2020. For every cancer site except pancreas, Asians/Pacific Islanders had the lowest O/E ratio of any race group. O/E ratios were lower for cases diagnosed at localized stages than for cases diagnosed at advanced stages. CONCLUSIONS: The current analysis provides strong evidence for declines in cancer diagnoses, relative to the expected numbers, between March and May of 2020. The declines correlate with reductions in pathology reports and are greater for cases diagnosed at in situ and localized stage, triggering concerns about potential poor cancer outcomes in the coming years, especially in Asians/Pacific Islanders. PLAIN LANGUAGE SUMMARY: To help control the spread of coronavirus disease 2019 (COVID-19), health care organizations suspended nonessential medical procedures, including preventive cancer screening, during early 2020. Many individuals canceled or postponed cancer screening, potentially delaying cancer diagnosis. This study examines the impact of the COVID-19 pandemic on the number of newly diagnosed cancer cases in 2020 using first-submission, population-based cancer registry database. The monthly numbers of newly diagnosed cancer cases in 2020 were compared with the expected numbers based on past trends for six cancer sites. April 2020 had the sharpest decrease in cases compared with previous years, most likely because of the COVID-19 pandemic.

A population study of screening history and diagnostic outcomes of women with invasive cervical cancer.

BACKGROUND: Despite advances to prevent and detect cervical cancer, national targets for screening have not been met in the United States. Previous studies suggested that approximately half of women who developed cervical cancer were not adequately screened. This study aimed to provide an updated examination of women's screening and diagnostic practices five years prior to an invasive cervical cancer diagnosis. METHODS: The study included women age 21 years and older diagnosed with invasive cervical cancer in 2013-2016 from three population-based state cancer registries in the United States. Medical records abstraction identified screening history and diagnostic follow-up. A mailed survey provided sociodemographic data. Screening was a Pap or human papillomavirus (HPV) test between 6 months and 5 years before diagnosis. Adequate follow-up was defined per management guidelines. RESULTS: Of the 376 women, 60% (n = 228) had not been screened. Among women who received an abnormal screening result (n = 122), 67% (n = 82) had adequate follow-up. Predictors of: (a) being screened were younger age, having a higher income, and having insurance; (b) adequate follow-up were having a higher income, and (c) stage 1 cervical cancer were being screened and younger age. CONCLUSION: Unlike other cancer patterns of care studies, this study uses data obtained from medical records supplemented with self-report information to understand a woman's path to diagnosis, her follow-up care, and the stage of her cervical cancer diagnosis. This study provides findings that could be used to reach more unscreened or under screened women and to continue lowering cervical cancer incidence in the United States.

Pursuing Data Modernization in Cancer Surveillance by Developing a Cloud-Based Computing Platform: Real-Time Cancer Case Collection.

Cancer surveillance is a field focused on collection of data to evaluate the burden of cancer and apply public health strategies to prevent and control cancer in the community. A key challenge facing the cancer surveillance community is the number of manual tasks required to collect cancer surveillance data, thereby resulting in possible delays in analysis and use of the information. To modernize and automate cancer data collection and reporting, the Centers for Disease Control and Prevention is planning, developing, and piloting a cancer surveillance cloud-based computing platform (CS-CBCP) with standardized electronic reporting from laboratories and health-care providers. With this system, automation of the cancer case collection process and access to real-time cancer case data can be achieved, which could not be done before. Furthermore, the COVID-19 pandemic has illustrated the importance of continuity of operations plans, and the CS-CBCP has the potential to provide such a platform suitable for remote operations of central cancer registries.

Uterine Cancer Incidence and Mortality - United States, 1999-2016.

Uterine cancer is one of the few cancers with increasing incidence and mortality in the United States, reflecting, in part, increases in the prevalence of overweight and obesity since the 1980s (1). It is the fourth most common cancer diagnosed and the seventh most common cause of cancer death among U.S. women (1). To assess recent trends in uterine cancer incidence and mortality by race and ethnicity, CDC analyzed incidence data from CDC's National Program of Cancer Registries (NPCR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program and mortality data from the National Vital Statistics System (2). Most recent data available are through 2015 for incidence and through 2016 for mortality. Uterine cancer incidence rates increased 0.7% per year during 1999-2015, and death rates increased 1.1% per year during 1999-2016, with smaller increases observed among non-Hispanic white (white) women than among women in other racial/ethnic groups. In 2015, a total of 53,911 new uterine cancer cases, corresponding to 27 cases per 100,000 women, were reported in the United States, and 10,733 uterine cancer deaths (five deaths per 100,000 women) were reported in 2016. Uterine cancer incidence was higher among non-Hispanic black (black) and white women (27 cases per 100,000) than among other racial/ethnic groups (19-23 per 100,000). Uterine cancer deaths among black women (nine per 100,000) were higher than those among other racial/ethnic groups (four to five per 100,000). Public health efforts to help women achieve and maintain a healthy weight and obtain sufficient physical activity can reduce the risk for developing cancer of the endometrium (the lining of the uterus), the most common uterine cancer. Abnormal vaginal bleeding, including bleeding between periods or after sex or any unexpected bleeding after menopause, is an important symptom of uterine cancer (3). Through programs such as CDC's Inside Knowledge* campaign, promoting awareness among women and health care providers of the need for timely evaluation of abnormal vaginal bleeding can increase the chance that uterine cancer is detected early and treated appropriately.

Cervical cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in four US-Affiliated Pacific Islands between 2007 and 2015.

BACKGROUND: Cervical cancer incidence in the US-Affiliated Pacific Islands (USAPIs) is double that of the US mainland. American Samoa, Commonwealth of Northern Mariana Islands (CNMI), Guam and the Republic of Palau receive funding from the Centers for Disease Control (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to implement cervical cancer screening to low-income, uninsured or under insured women. The USAPI grantees report data on screening and follow-up activities to the CDC. MATERIALS AND METHODS: We examined cervical cancer screening and follow-up data from the NBCCEDP programs in the four USAPIs from 2007 to 2015. We summarized screening done by Papanicolaou (Pap) and oncogenic human papillomavirus (HPV) tests, follow-up and diagnostic tests provided, and histology results observed. RESULTS: A total of 22,249 Pap tests were conducted in 14,206 women in the four USAPIs programs from 2007-2015. The overall percentages of abnormal Pap results (low-grade squamous intraepithelial lesions or worse) was 2.4% for first program screens and 1.8% for subsequent program screens. Histology results showed a high proportion of cervical intraepithelial neoplasia grade 2 or worse (57%) among women with precancers and cancers. Roughly one-third (32%) of Pap test results warranting follow-up had no data recorded on diagnostic tests or follow-up done. CONCLUSION: This is the first report of cervical cancer screening and outcomes of women served in the USAPI through the NBCCEDP with similar results for abnormal Pap tests, but higher proportion of precancers and cancers, when compared to national NBCCEDP data. The USAPI face significant challenges in implementing cervical cancer screening, particularly in providing and recording data on diagnostic tests and follow-up. The screening programs in the USAPI should further examine specific barriers to follow-up of women with abnormal Pap results and possible solutions to address them.

Cervical Cancer Screening and Incidence by Age: Unmet Needs Near and After the Stopping Age for Screening.

INTRODUCTION: Leading professional organizations recommend cervical cancer screening for average-risk women aged 21-65 years. For average-risk women aged >65 years, routine screening may be discontinued if "adequate" screening with negative results is documented. Screening is recommended after age 65 years for women who do not meet adequate prior screening criteria or are at special risk. METHODS: Authors examined the most recent cervical cancer incidence data from two federal cancer surveillance programs for all women by age and race, corrected for hysterectomy status. The 2013 and 2015 National Health Interview Surveys were analyzed in 2016 to examine the proportion of women aged 41-70 years without a hysterectomy who reported that they never had a Pap test or that their most recent Pap test was >5 years ago (not recently screened). RESULTS: The incidence rate for cervical cancer among older women, corrected for hysterectomy status, did not decline until age ≥85 years. The proportion not recently screened increased with age, from 12.1% for women aged 41-45 years to 18.4% for women aged 61-65 years. CONCLUSIONS: Even among women within the recommended age range for routine screening, many are not up to date, and a substantial number of women approach the "stopping" age for cervical cancer screening without an adequate prior screening history. Efforts are needed to reach women who have not been adequately screened, including women aged >65 years, to prevent invasive cervical cancer cases and deaths among older women.

National Breast and Cervical Cancer Early Detection Program data validation project.

BACKGROUND: The objectives of this study were to evaluate the quality of national data generated by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP); to assess variables collected through the program that are appropriate to use for program management, evaluation, and data analysis; and to identify potential data-quality issues. METHODS: Information was abstracted randomly from 5603 medical records selected from 6 NBCCEDP-funded state programs, and 76 categorical variables and 11 text-based breast and cervical cancer screening and diagnostic variables were collected. Concordance was estimated between abstracted data and the data collected by the NBCCEDP. Overall and outcome-specific concordance was calculated for each of the key variables. Four screening performance measures also were estimated by comparing the program data with the abstracted data. RESULTS: Basic measures of program outcomes, such as the percentage of women with cancer or with abnormal screening tests, had a high concordance rate. Variables with poor or inconsistent concordance included reported breast symptoms, receipt of fine-needle aspiration, and receipt of colposcopy with biopsy. CONCLUSIONS: The overall conclusion from this comprehensive validation project of the NBCCEDP is that, with few exceptions, the data collected from individual program sites and reported to the CDC are valid and consistent with sociodemographic and clinical data within medical records.

Cancer screening practices among physicians in the national breast and cervical cancer early detection program.

BACKGROUND: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides low-income, uninsured women with screening and diagnostic services for breast and cervical cancer. Our study was conducted to describe the demographic and practice characteristics of participating and nonparticipating physicians, as well as their beliefs, adoption of new screening technologies, and recommendations for breast and cervical cancer screening. METHODS: From a 2006-2007 nationally representative survey, we identified 1,111 practicing primary care physicians who provide breast and cervical cancer screenings and assessed their recommendations using clinical vignettes related to screening initiation, frequency, and cessation. Responses of physicians participating in the NBCCEDP were compared with those from nonparticipating physicians. RESULTS: Of the physicians surveyed, 15% reported participation in the NBCCEDP, 65% were not participants, and 20% were not sure or did not respond to this question. Program physicians were significantly more likely to practice in multispecialty settings, in a rural location, and in a hospital or clinic setting and had more patients who were female and insured by Medicaid or uninsured compared with nonprogram physicians. Beliefs about the effectiveness of screening tools or procedures in reducing breast or cervical cancer mortality were similar by program participation. Adoption of new technologies, including digital mammography and human papillomavirus (HPV) testing, and making guideline-consistent recommendations for screening initiation, frequency, and cessation did not differ significantly by program participation. CONCLUSIONS: Although there may be differences in physician characteristics and practice settings, the beliefs and screening practices for both breast and cervical cancer are similar between program and nonprogram providers.

Examining the association between socioeconomic status and potential human papillomavirus-associated cancers.

BACKGROUND: This study examined the association between county-level measures of socioeconomic status (SES) and the incidence rate of human papillomavirus(HPV)-associated cancers, including cervical, vulvar, vaginal, anal, penile, and oral cavity and oropharyngeal cancers. METHODS: The authors collected data from cancer registries for site-specific invasive cancer diagnoses between 1998 and 2003, inclusive, among adults aged >20 years at the time of diagnosis. County-level variables that included education, income, and poverty status were used as factors for socioeconomic status. Measures of rural-urban status, the percentage of the population that currently smoked, and the percentage of women who reported having ever had a Papanicolaou (Pap) test were also studied. RESULTS: Lower education and higher poverty were found to be associated with increased penile, cervical, and vaginal invasive cancer incidence rates. Higher education was associated with increased incidence of vulvar cancer, male and female anal cancer, and male and female oral cavity and oropharyngeal cancers. Race was an independent predictor of the development of these potentially HPV-associated cancers. CONCLUSIONS: These findings illustrate the association between SES variables and the development of HPV-associated cancers. The findings also highlight the importance of considering SES factors when developing policies to increase access to medical care and reduce cancer disparities in the United States.

Assessment of follow-up for low-grade cytological abnormalities in the National Breast and Cervical Cancer Early Detection Program, 2000-2005.

OBJECTIVE: To assess the management of women in the National Breast and Cervical Cancer Early Detection Program with low-grade squamous intraepithelial lesions (LSIL) before and after the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines for management of abnormal cytology were published in 2002. MATERIALS AND METHODS: We examined the follow-up for 22,342 women with LSIL during 2 periods: 2000-2002 and 2003-2005. RESULTS: The percentage of providers who followed the recommended guidelines with colposcopy for an LSIL Pap test result increased by 9% from the pre-ASCCP to the post-ASCCP period. An increase was seen in every age and racial/ethnic group. Younger women (<30 years) and white women were more likely than comparison groups to be followed by colposcopy rather than a repeat Pap test. CONCLUSIONS: The increase in percentage of women having colposcopy in 2003, 1 year after the new guidelines were published, suggests a change in provider practices consistent with those guidelines.