Cancer-associated mortality is the second leading cause of death in the United States [1,2]. Cancer screening tests are recommended to prevent cancer-associated mortality by detecting precancerous and cancerous lesions in early stages [3]. The most common routine cancer screenings include breast, colorectal, and cervical [4].

The COVID-19 pandemic disrupted the use of preventive health care services [5]; there was an abrupt decline in cancer screening services throughout 2020 [6]. A report from May 2020 suggested there was a 94% drop in cancer screening tests across the United States, primarily due to disruptions in access to screening tests [7]. Although there was an increase in the number of cancer screening tests beginning in late 2020, screenings remained 29% to 36% lower than in the prepandemic era [8].

The reduction in cancer screenings and other preventative and diagnostic care have been attributed to both health care provider and patient constraints [9-12]. Health care provider constraints included restrictions on elective procedures [9] and a shortage of health care staff due to redeployment to help with pandemic-related care [9,10]. Even when health care providers have increased availability of preventive care and cancer screenings, many patients face constraints. Patient constraints include loss of income and employer-based insurance coverage [11] and fear of contracting COVID-19 during in-person health care visits [12].

The decline in cancer screening resulted in fewer cancer diagnoses in 2020 [13,14] and raises concerns that missed screenings and delayed cancer diagnoses will likely lead to late stage diagnosis and higher cancer-related mortality [7,14]. For example, a study (n=5167) reported a 13.5% (P=.03) decrease in colorectal cancer diagnoses during March 2020 to December 2020 compared to the number of patients diagnosed before the pandemic, and the same study showed the average number of stage three colorectal cancer cases (advanced stage cancers) diagnosed per month increased by 68.4% (P<.001) [15].

Health care providers must consider ways to increase cancer screening. Therefore, we conducted a scoping literature review to assist health care providers in identifying approaches for prioritizing and increasing cancer screening during the uncertainty of the COVID-19 pandemic. In this review, we focused on the most common cancer screenings: breast, cervical, and colorectal.

We used the scoping review framework outlined by Arksey and O’Malley [16] to identify and gather evidence from all sources in the field. The framework is comprised of four stages: (1) identification of relevant literature on multiple databases, (2) screening of identified literature and selection of relevant studies, (3) extraction of data, and (4) summarization and reporting of the findings [16]. The research questions of this review are what methods are recommended for risk stratification and triage of patients for cancer screenings, and what alternative cancer screening methods are recommended?

The articles included two primary categories of recommendations: (1) risk stratification and triage to prioritize screenings and (2) alternative methods to conduct cancer screenings (Table 1).

The number of cancer screenings missed during the COVID-19 pandemic will likely lead to a sharp increase in the number of late-stage cancer diagnoses and increased cancer mortality [14]. As health care providers look for ways to focus their cancer screening efforts, this review provides insights into risk stratification and triage approaches and alternative screening approaches that can be adopted to reduce the impact of COVID-19 on cancer mortality.

Risk stratification and triage approaches focused on prioritizing patients based on personal characteristics, medical history, cancer screening history, and communities facing highest cancer disparities [6,9,17-32]. The literature suggests that older patients at higher risk should be given priority since the risk of cancer increases with age [17,26].

Prioritizing high-risk patients based on the past screening history could help the health care provider prioritize care based on the probability of patients developing cancerous lesions. Several studies have shown that prioritizing high-risk patients based on past medical history is important [6,9,17-32], and studies have reported the effectiveness of the personalized screening approach, demonstrating that the one-size-fits-all approach may not be the best strategy [37-40]. In addition, using algorithms and artificial intelligence to categorize and triage high-risk patients will help navigate large data sets and assist physicians in the decision-making process [24,28].

Alternative cancer screening approaches focused on tests that do not require a clinic or hospital visit can be used to collect samples at home. These alternative methods allow initial screening outside the traditional clinical environment, take fewer clinical resources, and reduce exposure risk to patients. Alternative at-home screening modalities exist for cervical cancer screening [41-43] and colorectal cancer [26]. Studies have evaluated the efficacy of detecting cervical intraepithelial lesions using self-collected samples with samples collected in the doctor’s office and concluded that self-sampling is a safe and effective alternative to screen for cervical cancers [42,43]. Similar to cervical cancer, colorectal cancer screenings can be effectively conducted using noninvasive stool-based test kits at home [44,45]. Studies have shown that stool-based test kits can help reach underresourced communities and increase colorectal cancer screening uptake [46]. Although the stool-based tests have a high false-positive rate [47], patients testing negative can be assured that they do not have colorectal cancers [26].

Follow-up for abnormal results from at-home tests can be provided and help focus limited clinical resources. Although there are not at-home alternatives for mammography, mobile units can provide a way to reach the community [28,30] and reduce exposure risk.

Although the COVID-19 pandemic had devastating effects on population health globally, it could be an opportunity to adapt and evolve our cancer screening recommendations. Disruption often creates innovation, and focus on alternative methods for cancer screenings may help reach rural and underresourced areas after the pandemic has ended.