Stool-Based Tests Boosted Declining Screening Rates for Colorectal Cancer During Pandemic

By Brandon May

April 30, 2021

NEW YORK (Reuters Health) - Many healthcare centers saw colorectal cancer (CRC) screening rates decline during the COVID-19 pandemic, but changes to hospital protocols and increased use of non-invasive screening tests appear to have helped CRC screenings climb back up to pre-pandemic levels, according to new U.S. research.

There has been widespread concern over the pandemic's impact on preventive services worldwide, and the downstream effects this will have on public health.

Following advice from the United States Surgeon General in March of 2020 that hospitals and ambulatory surgical centers delay nonurgent procedures, the University of California Los Angeles (UCLA) health system temporarily ceased elective endoscopies and encouraged use of stool-based CRC screening instead. The university resumed elective endoscopies in May after new safety protocols were put into place.

To gauge the effects of these changes on screening rates and modalities, Dr. Anthony Myint and colleagues of the UCLA retrospectively analyzed electronic health record data of UCLA primary-care patients who completed a colon-cancer screening test between March and May 2020.

During the period from late January to mid-March 2020, before the pandemic, UCLA reported an average of 382 screening tests each week. This rate dropped to 74 per week during the endoscopy-cessation period (P<0.01), the researchers report in Gastroenterology.

Colonoscopies had the largest decline, from 223 per week to 11, while fecal immunochemical testing (FIT) fell from 154 to 61.

In the months after UCLA resumed elective endoscopies, the average rate of colonoscopies climbed back up toward pre-pandemic levels, but remained significantly lower at 174 per week. The use of non-invasive tests exceeded or matched pre-pandemic use, however, with FIT reaching 162 per week (P=0.54) and stool DNA going from 0 to 6 per week (P<0.01).

The findings fuel concerns over the decreased use of preventive care during the pandemic. In June of last year, the National CRC Roundtable estimated there were 18,800 missed or delayed colon-cancer diagnoses during and immediately after the onset of the pandemic, which could lead to more than 4,500 excess deaths over the next decade.

Dr. Myint told Reuters Health by email that in addition to fear of infection, many patients have been faced with several competing demands over the past year that may have contributed to the decline in screening rates. These demands include caring for children and changes to employment.

"Nationwide, Americans have de-emphasized preventive care and services as they cope with the global pandemic," he said. He added that he and his colleagues predict that there may "be increased cases of CRC, increased deaths from CRC, and more individuals presenting with late and incurable disease due to the COVID-19 pandemic and delays or omission of screening."

But it's not all bad news. As the researchers write in their report, their "work highlights the potential of stool-based CRC screening modalities as a useful alternative to colonoscopy in the midst of the ongoing COVID-19 pandemic."

They note that "FIT screening is inexpensive and widely available. Additionally, given the growing utilization of contactless services, an added benefit of stool-based screening is that it does not require physical patient-provider contact, which is highly desirable for patients and helps reduce risk of COVID-19 in health centers."

In addition to the use of non-invasive tests, several other strategies have been put in place to help improve rates of CRC screening across the U.S.

Dr. Mark Pochapin, director of the division of gastroenterology and hepatology at NYU Langone Health, in New York City, told Reuters Health by email that he and his colleagues have found "it very important to communicate with our patients the stringent safety measures that have been put in place in our doctors' offices and endoscopy units to assure them that they can receive their colonoscopy in a safe environment."

Dr. Pochapin, who wasn't involved in the new study, added that it has been useful to also communicate with patients that all healthcare professionals and staff have been tested for COVID-19.

He noted that national gastroenterology societies were largely responsible for getting screening rates back to pre-pandemic levels. These organizations, said Dr. Pochapin, worked to collect real-time data on COVID-19 and its transmission to develop guidelines for operating an endoscopy unit during the pandemic.

"Using these national guidelines, as well as those of our respective institutions, many were able to resume colonoscopy screenings quickly, once the number of hospitalized patients with COVID-19 had decreased," Dr. Pochapin said.

SOURCE: Gastroenterology, online April 15, 2021.