Among the routine medical procedures initially deferred due to COVID-19, screenings for colorectal cancer (CRC) were drastically reduced after nonurgent endoscopies were temporarily suspended during the early part of the pandemic.1

Rates of screening colonoscopies in the United States reportedly declined by almost 90% by mid-April 2020 compared with the previous year, and new CRC diagnoses decreased by more than 32% in the same time period.2

As of December 2020, some findings showed that colonoscopy screenings still lagged by 15% compared with the same period in 2019, indicating a “substantial but incomplete rebound in care delivered,” according to the Health Care Cost Institute.3 Overall, their data demonstrated a 25% reduction in colonoscopies performed during 2020 compared with 2019.

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This pause in colonoscopies threatens to derail the substantial improvements that have been made in CRC outcomes during the past 50 years, including a 51% reduction in CRC mortality observed from 1970 to 2016 that is largely attributed to increased screening rates.2

In addition, the deferral of screenings because of COVID-19 is likely widening racial and other disparities in CRC. “These effects are particularly noticeable in medically underserved communities where CRC morbidity and mortality are highest,” as noted in a paper published in October 2020 in Gastrointestinal Endoscopy.4

Throughout the pandemic, some facilities have turned to at-home methods for CRC screening, such as fecal immunochemical testing (FIT) and multitarget stool DNA (mt-sDNA) tests to help fill the gaps in screening.5

A modeling study published in April 2021 in JAMA Network Open linked the increased use of FIT during the pandemic to increased numbers of CRC screenings (roughly 600,000) and a greater number of early CRC diagnoses (approximately 70%) compared with scenarios in which FIT was not used.

We learned more about the past, present, and potential future landscape of CRC screening in a recent interview with Joseph Feuerstein, MD, gastroenterologist at the Center for Inflammatory Bowel Disease at Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard Medical School in Boston, Massachusetts, and Robert Smith, PhD, cancer epidemiologist and senior vice president of cancer screening at the American Cancer Society (ACS) in Atlanta, Georgia.

What were the alternate methods used for CRC screening earlier in the pandemic when in-person health care visits were drastically reduced?

Dr Feuerstein: This was a very challenging time. Studies have shown that many visits for colon cancer screening were missed or deferred. Some modeling studies indicate it could take over 40 months to catch up on missed colon cancer screening procedures from the pandemic.7

During the pandemic, very few routine screening colonoscopies were performed. In lower-risk and average-risk patients, some practitioners opted for FIT testing or fecal DNA testing (eg, Cologuard). These tests are really only appropriate in the setting of average-risk individuals; ie, those with no prior history of adenomas, no family history of advanced polyps, and no family history of colon cancer, etc.

One issue with using these tests during the pandemic was the fact that a positive test still might not get an urgent evaluation due to limited resources. This was a big challenge.

Dr Smith: CRC screening methods generally can be grouped into 2 categories. [The first is] stool tests, which include guaiac-based fecal occult blood tests (gFOBT), FIT, and mt-sDNA tests. [The second is] structural exams, which allow for visualizing the inside of the colon, include colonoscopy, flexible sigmoidoscopy, and CT colonography, which utilizes x-ray imaging.

Colonoscopy is the most widely used CRC screening test in the United States, and recently published data from private insurance claims showed that colonoscopy screening rates declined sharply after the pandemic was announced in March 2020 but, as of July 2020, had nearly returned to previous levels.8 During the suspension of screening, patients could easily have done a stool test at home, including those who were due for a colonoscopy.