RESUMEN
Introduction: The COVID-19 pandemic disrupted the preventive services for cervical cancer (CC) control programs in Mexico, which will result in increased mortality. This study aims to assess the impact of the pandemic on the interruption of three preventive actions in the CC prevention program in Mexico. Methods: This study is a retrospective time series analysis based on administrative records for the uninsured population served by the Mexican Ministry of Health. Patient data were retrieved from the outpatient service information system and the hospital discharge database for the period 2017-2021. Data were aggregated by month, distinguishing a pre-pandemic and a pandemic period, considering April 2020 as the start date of the pandemic. A Poisson time series analysis was used to model seasonal and secular trends. Five process indicators were selected to assess the disruption of the CC program, these were analyzed as monthly data (N=39 pre-pandemic, N=21 during the pandemic). HPV vaccination indicators (number of doses and coverage) and diagnostic characteristics of CC cases were analyzed descriptively. The time elapsed between diagnosis and treatment initiation in CC cases was modeled using restricted cubic splines from robust regression. Results: Annual HPV vaccination coverage declined dramatically after 2019 and was almost null in 2021. The number of positive Papanicolaou smears decreased by 67.8% (90%CI: -72.3, -61.7) in April-December 2020, compared to their expected values without the pandemic. The immediate pandemic shock (April 2020) in the number of first-time and recurrent colposcopies was -80.5% (95%CI:-83.5, -77.0) and -77.9% (95%CI: -81.0, -74.4), respectively. An increasing trend was observed in the proportion of advanced stage and metastatic CC cases. The fraction of CC cases that did not receive medical treatment or surgery increased, as well as CC cases that received late treatment after diagnosis. Conclusions: Our analyses show significant impact of the COVID-19 pandemic with declines at all levels of CC prevention and increasing inequalities. The restarting of the preventive programs against CC in Mexico offers an opportunity to put in place actions to reduce the disparities in the burden of disease between socioeconomic levels.
RESUMEN
Cervical cancer (CC) is tightly related to a low Human Development Index. Mexico is an upper-middle-income country with 126 million inhabitants, and its public health system aims to provide universal health coverage. Currently, employment-based social insurance covers approximately 60% of the population, and the scope of the remaining 40% is on course via the "IMSS-Bienestar" Institute. However, the annual government spending on health remains at 3% of the Gross Domestic Product, which is well below the 6% recommended by the Organization for Economic Cooperation and Development. CC is the second in incidence and mortality among women. Regarding primary prevention with the Human Papilloma Virus-vaccine, the current coverage for girls aged 9 to 14 years is only around 7%. Among secondary prevention with screening, the program is yet to cover the total number of women at risk; nevertheless, the age-standardized CC mortality rate has decreased from 12 per 100,000 women in 1979 to 5.7 per 100,000 women in 2020 due in part to increased screening coverage. Still, around two-thirds of patients present with locally advanced disease at diagnosis. Data from our country demonstrate that even socially disadvantaged CC patients achieve "standard" survival outcomes if treatment is granted. Nevertheless, there is a shortage in almost every aspect regarding CC treatment, including oncologists, chemotherapy units, medical physicists, radiation technicians, and both teletherapy and brachytherapy facilities. In conclusion, advances in the public health system in Mexico are urgently required to achieve CC control and reduce the mortality from this neoplasia that mainly targets socially disadvantaged women.
