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COVID-19

Colorectal Cancer Screening and Prevention in the COVID-19 Era

  • 1Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
  • 2Division of Gastroenterology, University of Washington School of Medicine. Seattle, Washington
  • 3Division of Gastroenterology, University of California, San Francisco
  • 4Center for Vulnerable Populations, University of California, San Francisco

On March 18, the Centers for Medicare & Medicaid Services issued guidance that all nonurgent surgeries and medical procedures be delayed during the COVID-19 pandemic. This recommendation was made to conserve personal protective equipment, a critical resource in the care of patients with COVID-19. Although the necessity of this recommendation is clear, progress must continue to be made on other serious non–COVID-19 challenges in public health.

Among the procedures being delayed are colonoscopies, the most commonly used test to screen for and prevent colorectal cancer. As the second highest cause of cancer deaths in the United States, colorectal cancer is largely preventable through screening. However, nearly 23 million adults aged 50 to 75 are past due for screening, and an estimated 53 000 Americans will die from colorectal cancer this year. To reduce colorectal cancer mortality, the National Colorectal Cancer Roundtable, a coalition established by the American Cancer Society and the Centers for Disease Control and Prevention, launched this year its “80% in Every Community” campaign, which aims to increase colorectal cancer screening rates substantially in all US communities. Since the Centers for Medicare and Medicaid Services recommendation to delay nonurgent procedures in mid-March, adult primary care and gastroenterology visits have declined by 49% and 61%, respectively, which makes achieving colorectal cancer screening goals even more challenging.

Delaying colorectal cancer screening for the 23 million adults who are past due will lead to delayed diagnoses and cancer deaths. Delays in screening will widen persistent racial, ethnic, and socioeconomic mortality disparities as rising unemployment in disadvantaged populations stifles already limited access to care. Delays will also overwhelm health care systems burdened by long screening backlogs when elective procedures resume.

To address this problem, health care organizations can leverage mailed fecal immunochemical tests (FIT) outreach programs. As states continue shelter-in-place ordinances that keep Americans at home, many health care providers have moved to telemedicine appointments for clinic visits. Primary care physicians and gastroenterologists should similarly advocate for implementing mailed FIT outreach in their health care systems to reduce colorectal cancer mortality.

FIT is an inexpensive, at-home colorectal cancer screening method that checks for blood in stool and can be returned by mail.1 A meta-analysis that examined test characteristics found FIT had a pooled sensitivity of 79%, specificity of 94%, and overall diagnostic accuracy of 95% for colorectal cancer.2 Prior research found that FIT outreach costs approximately $23 per person and $112 per additional person screened.3 To further decrease costs, health care systems can consider using third-party vendors who can increase the scale of FIT distribution at a lower price.

Mailed FIT outreach is an evidence-based strategy that addresses barriers to colorectal cancer screening at the patient level by providing convenient at-home testing, at the provider level by addressing clinic visit time limitations, and at the health system level by maximizing the reach of screening.3 Mailed FIT outreach also allows populations to be segmented into higher and lower risk for colorectal cancer based on FIT results. Identifying a high-risk population that will need colonoscopies earlier will facilitate a smooth transition to resuming elective procedures and preserve personal protective equipment for the more urgent COVID-19 response. In Australia, Canada, the Netherlands, and the United Kingdom, FIT and other stool-based tests are the cornerstone of colorectal cancer screening. All eligible adults are offered a FIT through an organized, population-level screening program, and colonoscopies are made available to those with an abnormal result.4

FIT is not a perfect intervention, but it has the advantages of enabling effective screening in remote health care settings at a low cost, making it very useful during times of mandated social distancing. The 2 most common arguments against adopting FIT are that it does not reliably identify small polyps and that it is a 2-step screening process that requires individuals with an abnormal result to complete a follow-up colonoscopy to remove large polyps or detect early-stage colorectal cancer. The benefits, however, are that FIT does not require intensive patient bowel preparation, does not require sedation or a designated driver to transport the patient home, and can reduce disparities in colorectal cancer screening because of its low cost and ease of access.

To ensure that mailed FIT outreach does not increase existing colorectal cancer screening disparities, implementation strategies should proactively apply a health equity lens in the following ways: (1) prioritize mailed FIT outreach for individuals who are not up to date with screening, (2) ensure mailed FIT outreach includes all individuals within a health care system regardless of health plan or associated incentives, and (3) support passing federal policy that waives co-insurance for follow-up colonoscopy completion after abnormal FIT results.

Primary care physicians and gastroenterologists can maintain momentum in decreasing colorectal cancer mortality within health care organizations by taking the following steps:

  1. Advocate for establishing mailed FIT outreach programs, with an eye toward health equity, that can be executed by medical administration with modest physician oversight (Gupta et al, unpublished data, 2020).

  2. Set clear expectations that follow-up colonoscopies for abnormal FIT results will receive priority scheduling after the moratorium on screening colonoscopies is lifted.

  3. Create workflows to track patients with abnormal FIT results until colonoscopy is completed.5

  4. Increase gastroenterology staffing to accommodate the expected surge in procedural demand.

  5. Offer evening or weekend colonoscopy sessions to enable patients and gastroenterologists to alleviate colorectal cancer screening and surveillance backlogs.

In the midst of a pandemic, we cannot and should not abandon disease prevention. Preventable chronic diseases, including colorectal cancer, are still responsible for most deaths worldwide.6 Creative solutions are needed to survive and thrive after the COVID-19 pandemic. In cancer prevention, colorectal cancer is one of the few cancers for which there are multiple screening options. Now is the time for the United States to use the full arsenal available to combat this disease, because prevention is always better than cure.

Article Information

Corresponding Author: Rachel Issaka, MD, MAS, 1100 Fairview Ave N, M3-B232, Seattle, WA 98109 (rissaka@fredhutch.org).

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Issaka receives funding from the National Institutes of Health/National Cancer Institute (K08 CA241296). Dr Somsouk is supported by the Dean M. Craig Endowed Chair of Gastrointestinal Medicine and the SF Cancer Initiative. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the funders.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
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Inadomi  JM.  Screening for colorectal neoplasia.   N Engl J Med. 2017;376(2):149-156. doi:10.1056/NEJMcp1512286PubMedGoogle ScholarCrossref
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Lee  JK, Liles  EG, Bent  S, Levin  TR, Corley  DA.  Accuracy of fecal immunochemical tests for colorectal cancer: systematic review and meta-analysis.   Ann Intern Med. 2014;160(3):171. doi:10.7326/M13-1484PubMedGoogle ScholarCrossref
3.
Somsouk  M, Rachocki  C, Mannalithara  A,  et al.  Effectiveness and cost of organized outreach for colorectal cancer screening: a randomized, controlled trial.   J Natl Cancer Inst. 2020;112(3):305-313. doi:10.1093/jnci/djz110PubMedGoogle ScholarCrossref
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Rabeneck  L, Chiu  HM, Senore  C.  International perspective on the burden of colorectal cancer and public health effects.   Gastroenterology. 2020;158(2):447-452. doi:10.1053/j.gastro.2019.10.007PubMedGoogle ScholarCrossref
5.
Issaka  RB, Rachocki  C, Huynh  MP, Chen  E, Somsouk  M.  Standardized workflows improve colonoscopy follow-up after abnormal fecal immunochemical tests in a safety-net system.   Dig Dis Sci. 2020. doi:10.1007/s10620-020-06228-zPubMedGoogle Scholar
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Mortality  GBD; GBD 2015 Mortality and Causes of Death Collaborators.  Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015.   Lancet. 2016;388(10053):1459-1544. doi:10.1016/S0140-6736(16)31012-1PubMedGoogle ScholarCrossref
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