Plunging Colonoscopy Rates May Signal Crisis Ahead

Jennifer A. Christie, MD; Carol A. Burke, MD; Klaus Mergener, MD, PhD


July 22, 2020

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This transcript has been edited for clarity.

Jennifer A. Christie, MD: There has been a significant impact on gastroenterology in the past few months because of the coronavirus. Komodo Health, a large medical claims database, reports that the number of colonoscopies dropped by nearly 90% by mid-April of this year. What that leads to is that we've made 32% fewer colon cancer diagnoses by mid-April compared with last year at that time.

Carol A. Burke, MD: The patient populations that were most vulnerable to being affected during the COVID-19 pandemic were those with rectal bleeding, changes in bowel habits, unanticipated weight loss, anemia, or inflammatory bowel disease. These people needed to be seen and were afraid to come in. So, quite frankly, it's important that we get colorectal cancer screening done. If you're a few months delayed, it's not so important. But when it comes to individuals who have had active disease symptoms and needed to come in but didn't, it's very important.

Screening Impacts

Klaus Mergener, MD, PhD: The pandemic definitely has had an impact on ethnic groups in regard to colorectal cancer screening. We know that even before COVID-19, the rate of colorectal cancer is higher in certain ethnic groups, specifically in Blacks compared with Whites.

Christie: The African American and Hispanic communities have been devastated by COVID-19. Patients may be caring for themselves in quarantine or caring for others. They may have lost loved ones. I personally know multiple people, including patients and friends, who have suffered and even died from COVID-19.

Burke: Specific ethnic groups have been harder hit with COVID-19–related morbidity and mortality, including the African American population. When it comes to colorectal cancer screening, we know that White individuals often choose invasive methods like colonoscopy, whereas other ethnicities, including Hispanics and African Americans, often choose noninvasive methodologies like the fecal immunochemical test (FIT). For individuals who needed colorectal cancer screening, I think many institutions may have proceeded with their usual practice of sending either FITs or multitarget stool DNA tests to them. It did not require any contact with the healthcare system since it's sent through the mail.

Christie: In this climate of a pandemic, I think coming in for a screening colonoscopy is really not on their priority list — certainly not high on that list. When it comes to having an invasive procedure, the other factor to consider is the setting, where patients are not sure about whether (a) it is needed and (b) the environment is safe and the providers have their best interest at heart.

Alternatives to Colonoscopy

Mergener: In regard to screening for colorectal cancer, many of us in gastroenterology believe that colonoscopy is the gold standard. In the current situation, if we cannot do colonoscopy, I personally prefer to recommend FIT. We have a lot of data over many years on this test, and we know that the overall accuracy for FIT is very decent. It is also a low-cost test.

Burke: I work in the Cleveland Clinic, and our primary care doctors use colonoscopy and FIT as the preferred strategies. We have not seen a substantial decrease in the use of FIT during this time.

Christie: We've also used the stool DNA tests, like Cologuard. It's more costly to perform but can detect colon cancers early.

Burke: The important thing is that individuals who have a positive result on either FIT or Cologuard are the ones who need to come to the front of the line and have their diagnostic colonoscopy, as opposed to individuals undergoing screening who are at average risk and asymptomatic.

The Role of Telemedicine in Screening

Mergener: With the current lockdown, we switched to telemedicine for essentially all of our services in gastroenterology, including talking to patients about colorectal cancer screening.

Burke: I love virtual visits. Patients can access me pretty much anywhere at any time on their phone or on their computer. Originally we were using platforms that included Google Duo or FaceTime. Now we have a different platform that includes Zoom and goes right into the electronic medical record. We're up to 75%-85% of our visits being virtual visits. Many of our patients and providers want to continue with virtual visits.

Christie: However, there is something very different and unique about telemedicine, in that you can't give patients that reassuring squeeze on the shoulder or, depending on how close you are to patients, give that hug to let them know that it's going to be okay.

Burke: With virtual visits, you get a window into an individual's life. They have their pets. You can see around them. When it comes to some of the functional bowel disorders, you can also get an idea of what's going on in the home environment. It's different from a patient entering a sterile room in a completely different environment. I think access to care has been enhanced substantially via telemedicine. Virtual visits are here to stay.

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