Opinion: We must catch up on women’s screening tests delayed by COVID

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Our health care system has changed drastically since the dawn of COVID-19. This applies, too, to gynecologists and primary care physicians specializing in women’s health, who have had to adapt to this evolving landscape by working around the various limitations concerning preventive care.

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Up until recently, the saying went “you could never be too rich, too fit or too close to the edge of the examination table.” This was before the pandemic and all that came with it, including lockdowns, doctors being reassigned or changing practices and a limited array of services denying access to basic cervical cancer prevention.

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An astounding number of women don’t have access to the exam table. Some have told me they’ve had a hard time getting a Pap test, which analyzes the cells of the cervix for abnormal cells. Others have shared they were putting their health at risk because of the pandemic and the lack of access to preventive care.

The impact of COVID-19 on screening can be studied by comparing data from pre-pandemic times with data from the pandemic years. In one meta-analysis that includes studies from Canada, Slovenia, Belgium, Italy, Scotland and the United States, the pooled proportion of women screened in 2019 was 9.7 per cent compared with only 4.2 per cent in 2020. In an Ontario study, between March and August 2020, an average of 292 fewer cases of high-grade lesions were diagnosed by Pap smears each month compared with 2019. These shortfalls translate into practice locally as well.

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Cervical cancer takes time to develop, as HPV infection is a slow process. I expect patients will be slowly trickling in now. Some may even present with symptoms of cervical cancer, including abnormal uterine bleeding or bleeding after sex. The worst-case scenario may be that we see more symptomatic patients in the years to come, because of delayed screening.

At-home HPV testing kits and Pap test kits have been in the news lately. Physicians often have mixed feeling about these, and it isn’t common practice to use them. Patients need to be able to reach their cervix. Self-testing may not be a solution for all patients. In a national survey for physicians who do Pap tests, many found that there may be populations not suitable for the at-home tests — for example, post-menopausal women or trans-men with a cervix, and women with a history of trauma — likely due to potential pain or discomfort.

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Pap tests aren’t just for cervical cancer screening. The test is also an opportunity to examine the external genitalia. There are many common infections of the vagina, vulvar issues and vulvar cancers that could be diagnosed during exams as well. Exams are also opportunities for screening for sexually transmitted diseases or for providing contraception and discussing other issues such as cardiovascular disease risk, bone and joint health, and additional cancer screening.

Access to care is a universal right in our country. Yet, people’s views on their general health and their need for screening vary widely. Researchers and experts on health system utilization often note there are factors that either facilitate or impede care. These include factors such as age, ethnicity, language skills, education and whether or not one has private insurance. It might also be helpful to have personal days off, to not be penalized at the workplace for seeing a doctor, and to have additional insurance to cover testing fees. Public awareness campaigns that prioritize women’s health can also help.

The Canadian task force on preventive health recommends that all women who are sexually active and over the age of 24 have routine cervical cancer screening tests every three years. We will have to do more screening after COVID. It will take advocacy, effort and patient education to catch up from the screening delays caused by the pandemic.

Ya Ning Gao is a Montreal physician.