What is the current state of CRC screening now that restrictions have loosened, and how might changes caused by the pandemic affect the approach to CRC screening in the long term?
Dr Feuerstein: Overall, most practices have fully restarted colon cancer screening procedures. The challenge, though, is that not all programs have been able to increase their total number of procedures to deal with the backlog in procedures that have been deferred. Some practices have increased their procedure volume dramatically by adding sessions on weekends and earlier or later in the day.
Now is probably the time to better assess the colon cancer screening strategies and determine which patients are most appropriate for colonoscopy as their primary screening modality and which patients are appropriate for FIT and mt-sDNA tests (and which are not).
One important factor is that the latest guidelines suggest that we should be doing more appropriate shared decision-making with our patients when deciding on which colon cancer screening modality should be used. This creates many challenges, as this is typically done by the referring primary care provider. Being knowledgeable in the risks and benefits of each procedure is therefore of utmost importance.
Dr Smith: It is possible that more adults will begin utilizing stool testing based on convenience, but in addition, the evidence shows that many adults prefer stool testing over colonoscopy. This is why ACS guidelines endorse patients being offered a choice between a visual exam or a stool test. 9 We may see that the experience during the pandemic will lead to greater uptake of stool testing going forward.
Are there other recommendations for clinicians screening patients as they resume in-person visits?
Dr Feuerstein: This is an area in which we need to emphasize the safety and efficacy of all the screening modalities and provide accurate shared decision-making with our patients. The strongest data [remain] for colonoscopy as the primary screening modality for colon cancer screening.
However, both FIT and mt-sDNA testing have a role. More recent guidelines from the ACG [American College of Gastroenterology] published in 2021 provide more robust data for FIT over mt-sDNA, but they both require a discussion that if there is a positive result, then colonoscopy is still needed and should be done expeditiously.10
It is also imperative that practitioners have a system by which patients are placed into a recall system to allow for appropriate recall for subsequent colon cancer screening.
Dr Smith: It is very likely that some adults are still medically distancing; ie, are hesitant to return to routine health care visits. Health services are still requiring masks and questioning all patients about recent exposures, symptoms, etc.
It is important for adults to hear that providers have created a safe environment and that the risks of returning to routine health services are minimal. More to the point, regular cancer screening is important and, if delayed, it is important to reschedule appointments at the earliest convenience.
What are the remaining needs in this area in terms of education, outreach, or research?
Dr Feuerstein: There are major gaps in overall education and outreach for colon cancer screening. Significant disparities in care remain, and programs need to focus on improving cancer screening rates among minority groups.
Dr Smith: There will be other pandemics, and we likely will see additional surges of COVID-19. We need to identify ways to avoid suspending cancer screening and where it is possible for cancer screening to be done at home. This is currently possible for CRC screening and eventually will be possible for cervical cancer screening with HPV self-sampling.
If cancer screening does need to be suspended, we need to meet the needs of patients at high risk and ensure that we catch up as quickly as possible [with] those screening appointments that were postponed. Cancer screening should not be thought of as elective or nonessential. The ACS is committed to delivering these messages to the public.
- Myint A, Oliva H, Lee S, et al. S0318 – Impact of the COVID-19 pandemic on colorectal cancer screening rates and modalities in a large integrated health system. Am J Gastroenterol. 2020;115:S154-S155. doi:10.14309/01.ajg.0000703320.30592.7b
- Periyanaayagam U, Dwter A, Kim J, Garcia R, Worrall S, Davis A. New colorectal cancer diagnoses fall by one-third as colonoscopy screenings and biopsies grind to a halt during height of COVID-19. Fight Colorectal Cancerwebsite.Published May 2020. Accessed May 25, 2021. https://fightcolorectalcancer.org/wp-content/uploads/2020/05/COVID19-Impact-on-CRC-Patients_Research-Brief_Komodo-Health-Fight-CRC.pdf
- Martin K, Kurowski D, Given P, Kennedy K, Clayton E. The impact of COVID-19 on the use of preventive health care. Health Care Cost Institute website. Published September 2020. Updated April 2021. Accessed May 25, 2021. https://healthcostinstitute.org/hcci-research/the-impact-of-covid-19-on-the-use-of-preventive-health-care
- Balzora S, Issaka RB, Anyane-Yeboa A, Gray DM 2nd, May FP. 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
- Jaklevic MC. Pandemic spotlights in-home colon cancer screening tests. JAMA. 2021;325(2):116–118. doi:10.1001/jama.2020.22466
- Issaka RB, Taylor P, Baxi A, Inadomi JM, Ramsey SD, Roth J. Model-based estimation of colorectal cancer screening and outcomes during the COVID-19 pandemic. JAMA Netw Open. 2021;4(4):e216454. doi:10.1001/jamanetworkopen.2021.6454
- Tinmouth J, Dong S, Stogios C, Rabeneck L, Rey M, Dubé C; ColonCancerCheck/Gastrointestinal Endoscopy COVID Working Group. Estimating the backlog of colonoscopy due to coronavirus disease 2019 and comparing strategies to recover in Ontario, Canada. Gastroenterology. 2021;160(4):1400-1402.e1. doi:10.1053/j.gastro.2020.11.048
- McBain RK, Cantor JH, Jena AB, Pera MF, Bravata DM, Whaley CM. Decline and rebound in routine cancer screening rates during the COVID-19 pandemic. Published online March 19, 2021. J Gen Intern Med. doi:10.1007/s11606-021-06660-5
- 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
- Shaukat A, Kahi CJ, Burke CA, Rabeneck L, Sauer BG, Rex DK. ACG Clinical Guidelines: Colorectal Cancer Screening 2021. Am J Gastroenterol. 2021;116(3):458-479. doi:10.14309/ajg.0000000000001122