Colorectal Cancer Screening During the Pandemic

Delaying or avoiding routine medical care is a major health issue that may have consequences in terms of excess deaths attributed directly, or indirectly, to the COVID-19 pandemic.¹ An example is delayed screening for malignancies, including colorectal cancer (CRC).² Effective screening methods make CRC one of the most preventable cancers.³ However, screening rates and diagnoses of CRC have decreased dramatically during the pandemic.^1,5-8

This article will discuss CRC, the effect the COVID-19 pandemic on screening and diagnosis, and how the laboratory can help provide options for safe CRC screening during the pandemic. While pandemics will end, cancer deaths will not; continued screening guides actions that can help stop CRC disease progression.

CRC Epidemiology, Progression, Screening, Types, and Risk Factors

CRC is the fourth most commonly diagnosed cancer in the United States and is one of the most common causes of cancer-related death.³ In 2020 around 148,000 adults were diagnosed with CRC, and an estimated 53,000 persons died from CRC.⁹

CRC is one of the most preventable cancers.³ Most CRCs begin as adenomatous polyps that progressively enlarge, become dysplastic, and eventually become malignant.¹⁰ This process can take 10 or more years.¹⁰ As most early-stage cancers are curable and disease progression is slow,¹¹ screening programs help reduce

• Incidence of CRC by allowing identification and removal of adenomatous polyps
• Deaths
  • The 5-year relative survival is approximately 90% when CRC is confined to the primary site but just 14% for individuals with distant metastasis.¹²
  • Compared with no endoscopic screening, a colonoscopy is associated with a 67% reduction in the risk of death from CRC.¹³

The most important risk factor for CRC is age: approximately 80% of CRCs occur in persons 55 years of age or older, although the incidence in younger persons is increasing.¹² Another risk factor is family history; individuals with a first-degree relative with CRC have an approximately 2-fold greater risk than the average-risk population.¹¹ Approximately 10% are due to inherited (genetic) syndromes (eg, familial adenomatous polyposis [FAP] and Lynch syndrome).¹⁴ Other risk factors for CRC, such as being overweight or obese, are modifiable.³

The Pandemic’s Impact on CRC Screening and Diagnosis

To avoid potential viral exposure during the COVID-19 pandemic, government and professional organizations advised hospitals and ambulatory care centers to delay nonurgent medical office visits, procedures, and surgeries, including suspension of colonoscopies for CRC.^7,8,15 This guidance had an effect on new CRC diagnoses. Data from a nationwide laboratory showed that the average weekly rate of newly identified CRCs decreased by approximately one-third for March 1 to April 18, 2020 compared to the previous 14 months.⁴

Substantial decreases in CRC screening and colonoscopy rates have also been reported during the pandemic⁵: more than one-third of adults have not received recommended screenings for their associated age and risk factors, and 43% have missed routine preventive appointments.¹⁶ COVID and Cancer Research Network (CCRN) data indicate a significant decrease in all cancer-related patient encounters, with the potential for an increase in patients with later-stage cancer diagnoses.¹⁷

Medically Underserved Populations

CRC disproportionately impacts medically underserved populations such as African Americans, Hispanics, and Native Americans, who have higher incidence of CRC and higher rates of CRC-related death and yet have CRC-screening rates far below those of white non-Hispanic populations.¹⁵ During the pandemic, CRC screening in underserved populations is estimated to have decreased by up to 86%.¹⁵ Screening rates are also low in uninsured and underinsured individuals who are more likely to present with advanced-stage disease and have higher mortality rates.¹⁸

The COVID-19 pandemic has resulted in delays in CRC screening at locations that serve the aforementioned populations, such as community health centers. These delays have the potential to lead to later stage disease at diagnosis and increased CRC mortality, exacerbating existing health disparities.¹⁸

Screening Methods: FIT

A fecal immunochemical test (FIT) is the most widely used test for population CRC screening (see Sidebar for other options and recommendations³). In the context of the pandemic, an advantage of FIT is that it does not require an in-person visit to a healthcare provider. FIT results can help identify individuals at risk for invasive CRC. Notably,

• For asymptomatic FIT-positive persons 50 to 75 years of age the risk is around 4% to 5%—20 times higher than that in the general population.^3,5
• Timely colonoscopy is recommended if the FIT yields a positive result.^3,5
• A delay to colonoscopy after an abnormal FIT result is associated with a higher risk of CRC and advanced disease stage.¹⁵
• Even moderate delays (months) between a positive screening test and follow-up diagnostic testing could significantly reduce the life-years gained from cancer screening.²

CRC Screening Recommendations During the Pandemic

A number of recommendations have been proposed to address CRC screening during the pandemic, including

• Increased use of remote testing such as mailed FIT for CRC screening to reduce the need for in-person visits^2,8,18
• Increased screening outreach programs to target high-risk populations²
• Expanded use of risk stratification tools to identify persons at highest risk of CRC and most likely to benefit from screening and persons at lowest risk who are unlikely to benefit from screening²
• Cancer screening practices based on COVID-19 prevalence to maximize screening rates in areas of low viral prevalence²
• Guideline-driven infection control measures to maximize the safety of patients and medical staff, and effective communication to decrease patient concerns regarding screening²

Gastroenterological professional organizations have also published guidelines for the prioritization and performance of colonoscopies and other procedures, as well as for maintaining healthcare staff safety during the pandemic.¹⁹

Screening Options for CRC

CRC screening options include direct visualization methods, such as colonoscopy, and stool-based tests. Colonoscopy allows direct visualization and subsequent removal of lesions in the colon. Stool-based testing detects occult blood related to polyp growth, as well as other conditions (eg, diverticulitis). For persons with average risk of CRC, the American Cancer Society (ACS) recommends screening average-risk adults aged 45 years and older with 1 of the following options³:

• Fecal immunochemical test (FIT) every year
• High-sensitivity, guaiac-based fecal occult blood test (gFOBT) every year
• Multitarget stool DNA test every 3 years
• Colonoscopy every 10 years
• Computed tomography colonography every 5 years
• Flexible sigmoidoscopy every 5 years

In addition, ACS recommends that³

• All positive results from non-colonoscopy screening tests be followed up with a colonoscopy
• Average-risk adults with a life expectancy of more than 10 years continue CRC screening through age 75
• Screening decisions for individuals 76 through 85 years old be based on patient preference, life expectancy, health status, and screening history
• CRC screening be discouraged for individuals older than 85 years

Importantly, these ACS guidelines apply to individuals with an average risk of developing CRC. Persons at increased risk for CRC, such as those with a family history of CRC, polyps, and certain hereditary syndromes, should begin screening earlier.¹²

How the Laboratory Can Help

Quest Diagnostics offers the Fecal Globin by Immunochemistry (InSure^®) (test code 11290). The test only requires that a patient collect a water-based sample from the toilet after a single bowel movement by gently brushing the stool with the supplied brush. The patient then dabs the brush on the test card and mails the card to the lab. Annual FIT has been reported to be more effective and less costly than stool DNA testing every 3 years.²⁰

To help improve the CRC screening rate, Quest can now provide text or email reminders to the patient when the InSure ONE order is placed electronically. Quest will remind the patient at 1 week and again at 2 weeks if the test card has not been returned to the lab. A reminder can also be sent to the healthcare provider at 25 days if the test card has not been received.

Quest also provides electronic delivery of test results, which facilitates their documentation. To find out more about InSure ONE, or to request kits, contact Quest at 1.866.MYQUEST (1.866.697.8378).

References

1. Czeisler MÉ, Marynak K, Clarke KEN, et al. Delay or avoidance of medical care because of COVID-19–related concerns—United States, June 2020. MMWR Morb Mortal Wkly Rep. 2020;69(36):1250-1257. doi:10.15585/mmwr.mm6936a4

2. National Cancer Institute’s PROSPR Consortium; Corley DA, Sedki M, et al. Cancer screening during the Coronavirus Disease-2019 pandemic: a perspective from the National Cancer Institute's PROSPR Consortium. Gastroenterology. 2020;S0016-5085(20)35317-8. doi: 10.1053/j.gastro.2020.10.030

3. Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018;68(4):250-281. doi:10.3322/caac.21457

4. Kaufman HW, Chen Z, Niles J, et al. Changes in the number of US patients with newly identified cancer before and during the Coronavirus Disease 2019 (COVID-19) pandemic. JAMA Netw Open. 2020;3(8):e2017267. doi:10.1001/jamanetworkopen.2020.17267

5. Cheng SY, Chen CF, He HC, et al. Impact of COVID-19 pandemic on fecal immunochemical test screening uptake and compliance to diagnostic colonoscopy. J Gastroenterol Hepatol. 2020;10.1111/jgh.15325. doi: 10.1111/jgh.15325

6. Patel S, Lorenzi N, Smith T, et al. Critical insights from patients during the COVID-19 pandemic. NEJM Catalyst. 2020. doi:10.1056/CAT.20.0299

7. Cancer screening during the COVID-19 pandemic. American Cancer Society. Revised July 2, 2020. Accessed January 13, 2021. https://www.cancer.org/healthy/find-cancer-early/cancer-screening-guidelines/cancer-screening-during-covid-19-pandemic.html

8. Shaukat A, Church T. Colorectal cancer screening in the USA in the wake of COVID-19. Lancet Gastroenterol Hepatol. 2020;5(8):726-727. doi: 10.1016/S2468-1253(20)30191-6

9. American Cancer Society. Cancer Facts & Figures. American Cancer Society; 2020. Accessed January 13, 2021. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2020/cancer-facts-and-figures-2020.pdf

10. Hadjipetrou A, Anyfantakis D, Galanakis CG, et al. Colorectal cancer, screening and primary care: a mini literature review. World J Gastroenterol. 2017;23(33):6049-6058. doi:10.3748/wjg.v23.i33.6049

11. Rex DK, Boland CR, Dominitz JA, et al. Colorectal cancer screening: recommendations for physicians and patients from the U.S. Multi-Society Task Force on colorectal cancer. Gastroenterology. 2017;153(1):307-323. doi:10.1053/j.gastro.2017.05.013

12. Cancer stat facts: colorectal cancer. National Cancer Institute: Surveillance, Epidemiology, and End Results Program. Accessed January 13, 2021. https://seer.cancer.gov/statfacts/html/colorect.html

13. Doubeni CA, Corley DA, Quinn VP, et al. Effectiveness of screening colonoscopy in reducing the risk of death from right and left colon cancer: a large community-based study. Gut. 2018;67(2):291-298. doi:10.1136/gutjnl-2016-312712

14. Recio-Boiles A, Cagir B. Colon cancer. In: StatPearls [Internet]. StatPearls Publishing; 2020. Updated August 10, 2020. Accessed January 13, 2021.  https://www.ncbi.nlm.nih.gov/books/NBK470380/

15. Balzora S, Issaka RB, Anyane-Yeboa A, et al. Impact of COVID-19 on colorectal cancer disparities and the way forward. Gastrointest Endosc. 2020;92(4):946-950. doi:10.1016/j.gie.2020.06.042

16. Mitchell EP. Declines in cancer screening during COVID-19 pandemic. J Natl Med Assoc. 2020;112(6):563-564. doi:10.1016/j.jnma.2020.12.004

17. London JW, Fazio-Eynullayeva E, Palchuk MB, et al. Effects of the COVID-19 pandemic on cancer-related patient encounters. JCO Clin Cancer Inform. 2020;4:657-665. doi:10.1200/CCI.20.00068

18. Nodora JN, Gupta S, Howard N, et al. The COVID-19 pandemic: identifying adaptive solutions for colorectal cancer screening in underserved communities. J Natl Cancer Inst. 2020;djaa117. doi:10.1093/jnci/djaa117

19. Vecchione L, Stintzing S, Pentheroudakis G, et al. ESMO management and treatment adapted recommendations in the COVID-19 era: colorectal cancer. ESMO Open. 2020;5(suppl 3):e000826. doi:10.1136/esmoopen-2020-000826

20. Ladabaum U, Mannalithara A. Comparative effectiveness and cost effectiveness of a multitarget stool DNA test to screen for colorectal neoplasia. Gastroenterology. 2016;151(3):427-439.e6. doi:10.1053/j.gastro.2016.06.003.

Models used for illustrative purposes only.

Published date: Mar 2021