Two recent studies have elucidated the effects of the COVID-19 pandemic on colorectal cancer screenings and diagnostic colonoscopies in Central Indiana. The findings—reported by Kumar et al in PLOS One and Richter et al in Preventive Medicine Reports—contribute to the compendium of knowledge on preventive health uptake and subsequent treatment in various populations during the pandemic.
Background
Colorectal cancer is currently the second most common cancer type among U.S. male and female patients combined and the second-leading cause of cancer-related mortality. The American Cancer Society estimated that the disease will cause about 52,900 deaths in the United States in 2025. Regular colorectal screenings are effective at preventing or catching colorectal cancer at an earlier, more curable stage.
Fecal immunochemical tests (FIT) are capable of detecting hidden blood in the stool. FIT/DNA tests examine stool for both occult blood and biomarkers for DNA mutations associated with colorectal cancer.
Diagnostic colonoscopy is often performed because of symptoms such as rectal bleeding or abdominal pain, as a result of signs like anemia or unintentional weight loss, or following a positive screening test. A short interval between the screening procedure and a diagnostic colonoscopy is preferable in order to find a lesion early, before it advances in stage.
Overview of Both Studies
In both studies, the investigators utilized de-identified electronic health record data from public and private health-care systems between January 2019 to June 2021.
“We [conducted] this study because we wanted to know what was happening in our part of the country and because we had not seen studies from other geographic areas on this specific, most important aspect of colorectal cancer screening—which is follow-up on a positive, noninvasive test,” detailed senior study author of both studies Thomas F. Imperiale, MD, a researcher-clinician at the Regenstrief Institute and the Indiana University School of Medicine. “[T]he few studies we did find reported similar delays, but hadn't looked, as we did, much beyond the peak of the pandemic period,” he stressed.
First Study Methods and Findings
In the first study, the investigators examined noninvasive and colonoscopy screening trends during the COVID-19 pandemic by assessing 16,939 FIT tests, 2,942 FIT/DNA tests, and 38,332 screening colonoscopies.
The investigators revealed that the overall colonoscopy volume declined by about 19% in 2020 compared with in 2019. However, the volume returned to baseline in 2021, with no difference in early- vs late-stage colorectal tumors detected.
“As we found, health services don't necessarily have to come to a stop during events that tax the health-care system. When it comes to colorectal cancer screening, the alternatives to colonoscopy came more into the public eye during the pandemic, especially the early months when [individuals] were concerned about leaving their homes,” noted Dr. Imperiale. “The effect of the pandemic on colorectal cancer screening, especially colonoscopies, was profound at two multifacility health-care systems in Central Indiana over a 30-month period prior to and during the first 18 months of [the] COVID-19 [pandemic]. There were … no screening colonoscopies performed during April of 2020, reflecting the illiquid nature of screening and the acuity of the pandemic, which dictated the need for the apportioning of resources to other health-care needs, but this rebounded within a few months,” outlined Dr. Imperiale. “Noninvasive testing done at home declined as well but rebounded faster—both FIT and FIT/DNA tests,” he added.
Second Study Methods and Findings
In the second study, the investigators evaluated the interval between a positive noninvasive screening test and subsequent diagnostic colonoscopies during the COVID-19 pandemic.
The investigators discovered that although the timeliness of completion of a diagnostic colonoscopy was similar among patients who tested positive on FIT and FIT/DNA screenings, those who used FIT/DNA screening tests were more likely to adhere to follow-up with a diagnostic colonoscopy compared with those who used FIT.
“Although there was a mild delay in follow-up diagnostic colonoscopy after a positive noninvasive screening in 2020 compared with 2019 and 2021, it wasn't concerning. We found that the proportion of [patients] completing colonoscopy did not differ numerically. It was still over 70% over the 2.5-year period, which is quite good,” highlighted Dr. Imperiale. “Follow-up diagnostic colonoscopies were a priority during the pandemic for both patients and health-care systems in Central Indiana as other studies have shown nationally,” he stated.
Conclusions
The findings from both studies may be relevant to discussions of the pandemic’s influence on the future incidence rates of colorectal cancer. The investigators indicated that the COVID-19 pandemic temporarily disrupted colorectal cancer screenings and had a minimal impact on diagnostic colonoscopies during the COVID-19 pandemic.
“Future studies should focus on evaluating the effectiveness of remote monitoring technologies and telehealth interventions to facilitate colorectal cancer screening, because this is unlikely to be the last pandemic,” Dr. Imperiale suggested. “To be able to offer preventive services to [patients] who do not want or are unable to physically see [a physician], we can rely on telehealth as we did during the pandemic. We need to further develop or at least maintain this technology so that telehealth options are available for the next pandemic or the next time it becomes necessary to modify our health-care practices,” he underscored.
In addition to the need for novel strategies mitigating the impact of future disruptions on health-care services, the investigators called for public health campaigns and initiatives that promote the use of noninvasive testing while maintaining adequate access to diagnostic colonoscopy for patients with positive screening results.
Disclosure: The research in both studies was supported by the Advanced Scholars Program for Internists in Research and Education within the Department of Medicine at the Indiana University School of Medicine and by the Regenstrief Institute. For full disclosures of the study authors, visit journals.plos.org and sciencedirect.com.
