Cervical cancer continues to be a serious public health concern, particularly in low- and middle-income nations, where it plays a substantial role in the morbidity and mortality of cancer in women. Itis the fourth most common cancer in women worldwide. About 90% of the 342,000 cervical cancer fatalities that occurred in 2020 took place in low- and middle-income countries (LMICs) [1]. Cervical cancer burden reduction techniques that have been shown to work include routine screening and early detection through programs like Pap smears and human papillomavirus (HPV) testing [2]. Cervical cancer is frequently detected only in advanced stages and with severe symptoms, and the population in LMICs has limited access to detection techniques. Furthermore, there may be limited access to malignant lesion treatment (chemotherapy, radiation, and surgery), which raises the death rate from cervical cancer in these nations [1]. A 9-week delay in treatment was expected to result in a 2.52% lifetime increase in cervical cancer-related fatalities; if treatment was further postponed for six months, the increase rose to 3.8% [3]. According to a World Health Organization (WHO) prediction, nearly two-thirds of cervical cancer occurrences will occur in LMICs, and up to 44.4 million cases might be diagnosed worldwide between 2020 and 2069 if successful interventions are not implemented [4]. Global health systems have been greatly impacted by the unexpected onset of the coronavirus disease 2019 (COVID-19) pandemic in January 2020 [5]. On March 11, 2020, the World Health Organization (WHO) proclaimed COVID-19 a pandemic due to its widespread distribution [6]. The National Health Service Scotland declared in March 2020 that screening services for breast, colon, and cervical cancer will no longer be offered [7]. In order to conserve resources and stop the spread of COVID-19, many regular and non-urgent services have been discontinued in the majority of countries [8]. Essential health services have been impacted in 90% of nations globally since the COVID-19 outbreak, according to the WHO's first interim report of the Pulse Survey on Continuity of Essential Health Services during the COVID-19 pandemic, which was published in August 2020 [9].Reduced access to preventive services and delays in diagnosis were caused by lockdowns, transit restrictions, fear of catching the virus, and reallocation of health resources [10]. Cervical cancer screening rates have significantly decreased throughout the epidemic, according to several research. For example, a research conducted in the United States found that cervical screening decreased by more than 80% in the first few months of the pandemic as compared to pre-pandemic values [11]. Similar patterns have been noted in other nations, underscoring the crisis's worldwide influence on vital cancer prevention programs [12]. Future incidence of advanced-stage cervical cancer cases could increase as a result of delayed screening and diagnosis, potentially undoing the gains of the past few decades. Comprehending the magnitude of this influence is essential for formulating recovery plans and preparing for upcoming public health crises. AIM: To investigate how the COVID-19 pandemic has affected cervical cancerscreeningand diagnosis.

To assess the effect of the COVID-19 pandemic on cervical cancer screening and diagnosis, a cross-sectional observational study was carried out. The study was conducted over a period of one yearin the department of Obstetrics and Gynecology in Kasturba Medical College, Manipal. Study Population: Women between the ages of 21 and 70 who qualified for routine cervical cancer screening in accordance with National or WHO recommendations were included in the study. Based on the time period, participants were divided into two groups: Pre-pandemic period: [e.g., October 2019 – March 2020] Pandemic period: [e.g., April 2020 – September 2020] Inclusion criteria: • Women who underwent HPV DNA test or Pap smear test during the study period • Who provided consent for the study Exclusion criteria: • Women who have already been diagnosed with cervical cancer. • Incomplete screening or medical information • Who not provided consent for the study Data collections: Socio-demographic details(age, parity, socio-economic status) and clinical presentation were recorded. The following data were collected: Number of cervical screening tests (pap smear/HPV DNA) performed monthly. Number and stages of new cervical cancer diagnosed Changes in the number of cervical cancer screening test performed before and during COVID-19 pandemic. Change in the number of new cervical cancer diagnosed. Stage at diagnosis before versus during the pandemic. Statistical analysis: descriptive data were used to summarize demographic and clinical characteristics. Categorical variables were expressed as frequencies and percentages, continuous variables as means and standard deviation (SD). A p value <0.05 considered as statistically significant

Table 1: Pre COVID 19 pandemic cervical screening among study population Month (N=6) PAP Smear (N=2345) Cervical biopsy (N=46) HPV DNA (N=105) Colposcopy (N=32) OCTOBER 2019 635 11 8 6 NOVEMBER 2019 615 11 15 8 DECEMBER 2019 150 5 16 3 JANUARY 2019 332 6 25 4 FEBRUARY 2020 385 13 29 11 MARCH 2020 228 0 12 0 Table 2: Post COVID 19 pandemic cervical screening among study population Month (N=6) PAP smear (N=399) Cervical biopsy (N=22) HPV DNA (N=5) Colposcopy (N=2) APRIL 2020 1 1 0 0 MAY 2020 9 1 0 0 JUNE 2020 62 3 0 0 JULY 2020 86 7 0 0 AUGUST 2020 74 5 0 1 SEPTEMBER 2020 167 5 5 1 Table 3: Age distribution of patients screened for cervical cancerPre and Post Covid Age (yrs) Pre Covid Post Covid No. of patients (N=2391) No. of patients (N=428) < 20 96 (4%) 8 (2.5%) 20-39 710 (29.7%) 141 (33.3%) 40-59 1295 (54.16%) 218 (51.19%) 60-79 271 (11.34%) 64 (15.47%) >80 19 (0.8%) 0 (0%) The common presenting complaints in women undergoing Pap smear were, most of them came forRoutine cervical screening (37%) followed by Abdominal Pain (16.2%), Heavy Menstrual Bleeding (10.9%), Discharge PV (6%), Bleeding PV (6%), Dysmenorrhea (4.7%), Burning Micturition (3.8%), Mass PV (2.8%) and post menopausal bleeding was in 2.3% cases Number of Pap smear showing LSIL, HSIL in pre covid- 11and inpost covid- 2 Cervical cancer patients in pre covid- 23and post covid- 14. There is 39.2% decrease in the number of cervical cancer getting diagnosed from pre covid times to post covid times.

Globally, the COVID-19 pandemic has profoundly interrupted cervical cancer screening programs. All the qualified studies included for the quantitative analysis were from developed countries having organized cancer screening programs. The reduced screening coverage will be translated as a higher incidence of invasive cancers in the coming decades. In our study majority of the patients were in age between 40 –59 yrs with average age was 53.72 yrs, these finding correlates with the Miller et al, [13] and Amram O, et al [14]. This age group constituted a group of vulnerable women with an increased frequency of high-grade cytological abnormalities Clinical presentation of patients who tested positive for cervical cancer, maximum patients were presented for routine checkup. The common compliant were post menopausal bleeding, abdominal Pain, heavy Menstrual Bleeding, discharge PV and bleeding PV, our results similar to many other studies like: Chen R, et al [15] and Peng S, et al [16]. Among cervical cancer screening, most common methods were Pap smear followed by cervical biopsy, HPV DNA and colposcopy in the current study, in agreement with the N. Wentzensen et al [17] We have found that the significant decrease in the number of Pap smear testing in Post covid time period compared to pre covid time period, in consistence of TR Martins, et al [18] and Sabeena, et al [19].There was 39% decrease in the number of cervical cancer getting diagnosed from pre covid times to post covid times. This study observed that Pap smear in pre covid was significantly higher as compared to Pap smear in post covid, our result comparable with the Frederik A. et al [20] and Masson H, et al [21]. Public health measures to deal with the huge cancer screening deficits should be undertaken. During the current COVID-19 pandemic cancer screening and timely management have to be maintained while protecting thepatients and care givers [22].

The impact of the COVID-19 pandemic on cervical cancer screening has been particularly significant. COVID 19 has drastically reduced the footfall of patients in the hospital which has evidently hampered screening and diagnosis of Cervical Cancer. This will not only add burden of diagnosis and management in coming period, but also cause delayed diagnosis of disease at an advanced stage, hence concerned authorities should formulate policies and organize programs for screening of cervical cancer in pandemic.

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