Post-COVID: Breast, prostate, and colorectal cancer screening rates back up in 2023

Authors

Discovery Health Intelligence Team: Claudia Pastellides (Actuary), Lara Wayburne (Senior), Sian-Ailin Da Silva (Statistician), Lizelle Steenkamp (Senior Healthcare Statistician) and Shirley Collie (Chief Health Research Actuary)

Background to this analysis

For the medical schemes administered by Discovery Health, cancer is one of the most prevalent and high-cost conditions claimed for.

For example, when it comes to the Discovery Health Medical Scheme (DHMS), 56,360 scheme members claimed for cancer treatment and maintenance therapy between 1 January and 30 September 2023 alone, at a total cost of R2.9 billion. Also, from 2008 to 2023, the number of medical scheme members who have cancer has grown by 11.7% per annum, with an associated 15.1% per annum cost increase for their treatment.

DHMS offers cancer screening benefits to encourage regular screening and prevention or early detection of cancer. For those diagnosed with cancer, there is access to a comprehensive basket of care through the DHMS Oncology Programme.

It's globally evident that, throughout the pandemic period, routine preventive health checks across the board were postponed or cancelled. Understandably, people feared exposure to COVID-19 at healthcare facilities, alongside the need to prioritise COVID-19 care overall. Analysis of DHMS member data shows this trend too, as in the first year of the COVID-19 pandemic in particular, cancer screening rates declined.

Our investigation

We set out to investigate cancer screening rate trends over time, with a focus on the COVID-19 pandemic period (2020 to 2023).

We included the following cancers in our analysis (some of the most prevalent cancers among DHMS members):

• Breast cancer
• Cervical cancer
• Prostate cancer
• Colorectal cancer

It typically takes three months for claims for medical care to be submitted to Discovery Health for payment. This occurs for several administrative reasons including delays in receiving tests results or delays in scheduling follow-up appointments post screening.

As this article was written at the end of February 2023, we have used an average seasonality factor to adjust for claims that took place in 2023 that have not yet been submitted to the medical scheme.

Cancer screening tren ds over time

1. Breast cancer screening trends

Breast cancer is the most common primary cancer for DHMS members. Approximately 1 700 DHMS members were diagnosed with breast cancer between January and September 2023.

World Health Organisation (WHO) guidelines advise that women aged 40 years or older are eligible for breast cancer screening (mammography) once every two years. Before 2017 the DHMS Screening and Prevention benefit funded mammograms every year for eligible women. In 2017 this was adjusted to funding for screening every two years. We have classified mammogram claims as screening for breast cancer.

Figure 1 shows that mammography rates per eligible person years have been increasing steadily - with a 1.8% increase per annum from 2008 to 2016. In 2017, due to the change in the DHMS mammogram benefit referred to above, we marked a decline in mammography screening rates from 448.4 to 376.0 screens per 1,000 eligible person years.

From 2019 to 2020 (the first year of COVID-19) screening rates decreased by 19.3% - from 340.1 down to 274.6 per 1 000 eligible person years. There was a slight increase in screening rates from 2020 to 2021, and by 2023 screening rates had recovered to levels slightly higher than they were in 2019 - In 2023, screening rates exceeded 2019 rates by 8.1% at 4367.7 screens per 1 000 eligible person years.

Figure 1: Mammograms per 1 000 eligible person years (females aged 40 years or older)

2. Cervical cancer screening trends

Approximately 115 DHMS members were diagnosed with cervical cancer between 1 January and 30 September 2023.

WHO guidelines advise that women aged 30 and older should undergo cervical cancer screening. DHMS members have access to cover for a pap smear once every three years or an HPV test once every five years. We have classified claims for pap smears as screening for cervical cancer.

Among scheme members, cervical cancer screening rates are typically higher than mammograms rates (see Figure 2). Cervical cancer screening rates show a slow and steady decline from 2009 to 2019, with a marked decline in the first COVID-19 year - 2020.

During the pandemic, cervical cancer screening rates decreased by 20% from 2019 to 2020 (from 562.4 in 2019 to 449.9 screens per 1 000 eligible person years in 2020). Slight recovery in screening rates for cervical cancer is evident in between 2021 and 2023.

Unlike mammography, cervical cancer screening rates had, by 2023, not recovered from the decrease experienced through the pandemic period (2020 to 2023) and have remained below pre-COVID-19 levels at 9% lower than 2019 screening rates.

Figure 2: Cervical screenings per 1 000 eligible person years (females)

3. Prostate cancer screening trends

Prostate cancer is the second most common primary cancer for DHMS members in general and the most common primary cancer among male members.

41,816 DHMS members were diagnosed with prostate cancer in between 1 January and 30 September 2023. Male DHMS members have cover for annual prostate cancer screening. We have classified claims for prostate specific antigen (PSA) tests as screening for prostate cancer.

The US Centres for Disease Control and Prevention (US CDC) recommends prostate screening for men aged from 55 to 69.

Figure 3 shows that prostate cancer screening rates have, from 2008 to 2019, been increasing year-on-year - with an annualised increase of 1.1% per annum.

In 2020, the first year of the pandemic, prostate screening rates fell by 10.7% compared to 2019 rates - from 577.5 to 515.5 screens per 1 000 eligible person years. There was some recovery in screening rates in 2021 before rates increased to 637.6screens per 1 000 eligible person years in 2023 - 10.4% higher than pre-pandemic levels.

Figure 3: Prostate screening rates per 1 000 eligible person years (males)

4. Colorectal cancer screening trends

After breast cancer and prostate cancer, colorectal cancer is the third most prevalent cancer among DHMS members. There were approximately 726 new colorectal cancer registrations between 1 January and 30 September 2023.

According to the WHO, people aged 50 years or older are eligible for colorectal cancer screening. DHMS members from 45 to 75 years old have access to cover for bowel cancer screening every two years.

We have classified claims for faecal occult blood (chemical or monoclonal antibody) tests as screening for colorectal cancer.

Figure 4 shows that colorectal cancer screening showed a steady increase year-on-year from 2008 to 2019. Then, from 2019 to 2020, screening rates decreased by 15.2% - from 29.5 to 25.0 per 1 000 eligible person years. Between 2021 and 2023, colorectal cancer screening rates recovered to above pre-COVID-19 levels, with a 24.4% increase in 2023 compared to 2019.

Figure 4: Colorectal screening rates per 1 000 eligible person years (aged 50 years or older)

Conclusion

Keeping to routine cancer screening is essential to cancer prevention and early detection. However, the COVID-19 pandemic's pressures caused significant declines in cancer screening rates, particularly in the 2020 period (the first year of the pandemic).

Screening rates for cervical cancer showed the largest absolute reduction from 2019 to 2020 - 112.5 screens per 1 000 eligible person years, as well as the highest percentage reduction of 20% reduction from 2019.

On a positive note, by 2022 screening rates for prostate, colorectal and breast cancers had returned to rates slightly higher than those seen pre-COVID-19 (in 2019 and prior).

By the end of 2023, screening rates for cervical cancer remained 9% lower than 2019 rates - at 512 screens per 1000 eligible person years.

Further investigation is needed to determine the reasons for the differences noted above.

Interested in knowing more or reporting on these findings?

Please contact us on MEDIA_RELATIONS_TEAM@discovery.co.za to request any updated data available since publication and to obtain any further context required.

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