Stool-Based Tests Mitigate Impacts of COVID-19 on Colorectal Cancer Screening

Trends in Colorectal Cancer Screening from the National Health Interview Survey: Analysis of the Impact of Different Modalities on Overall Screening Rates

Colorectal cancer is the second leading cause of cancer-related mortality in adults in the United States. Despite compelling evidence of improved outcomes in colorectal cancer, screening rates are not optimal. This study aimed to characterize colorectal cancer screening trends over the last two decades and assess the impact of various screening modalities on overall colorectal cancer screening rates. Using National Health Interview Survey data from 2005 to 2021, we examined colorectal cancer screening [colonoscopy, multitarget stool DNA (mt-sDNA), fecal occult blood test (FOBT)/fecal immunochemical test, sigmoidoscopy, CT colonography] rates among adults ages 50-75 years (n = 85,571). A pseudo-time-series cross-sectional (pseudo-TSCS) analysis was conducted including a random effects generalized least squares regression model to estimate the relative impact of each modality on changes in colorectal cancer screening rates. Among 50 to 75 year olds, the estimated colorectal cancer screening rate increased from 47.7% in 2005 to 69.9% in 2021, with the largest increase between 2005 and 2010 (47.7%-60.7%). Rates subsequently plateaued until 2015 but increased from 63.5% in 2015 to 69.9% in 2018. This was primarily driven by the increased use of mt-sDNA (2.5% in 2018 to 6.6% in 2021). Pseudo-TSCS analysis results showed that mt-sDNA contributed substantially to the increase in overall screening rates (77.3%; P < 0.0001) between 2018 and 2021. While colorectal cancer screening rates increased from 2005 to 2021, they remain below the 80% goal. The introduction of mt-sDNA, a noninvasive screening test may have improved overall rates. Sustained efforts are required to further increase screening rates to improve patient outcomes and offering a range of screening options is likely to contribute to achieving this goal.

PREVENTION RELEVANCE

This retrospective study highlights the importance of convenient stool-based colorectal cancer screening options to achieve the national goal of 80% for overall colorectal cancer screening rates. Empowering screening-eligible individuals with a choice for their colorectal cancer screening tests is imperative.

Unsatisfactory Fecal Immunochemical Tests for Colorectal Cancer Screening: Prevalence, Reasons, and Subsequent Testing

BACKGROUND

Fecal immunochemical test (FIT) is an effective colorectal cancer screening modality. Little is known about prevalence, reasons, and testing after unsatisfactory FIT, or a FIT that cannot be processed by the laboratory due to inadequate stool specimen or incomplete labeling.

METHODS

Our retrospective cohort study examined unsatisfactory FIT among average-risk individuals aged 50-74 years in a large, integrated, safety-net health system who completed an index FIT from 2010 to 2019. We determined prevalence of unsatisfactory FIT and categorized reasons hierarchically. We used multivariable logistic regression models to identify factors associated with: (i) unsatisfactory FIT; and (ii) subsequent testing within 15 months of the unsatisfactory FIT.

RESULTS

Of 56,980 individuals completing an index FIT, 10.2% had an unsatisfactory FIT. Reasons included inadequate specimen (51%), incomplete labeling (27%), old specimen (13%), and broken/leaking container (8%). Unsatisfactory FIT was associated with being male [OR, 1.10; confidence interval (CI), 1.03-1.16], Black (OR, 1.46; CI, 1.33-1.61), Spanish speaking (OR, 1.12; CI, 1.01-1.24), on Medicaid (OR, 1.42; CI, 1.28-1.58), and received FIT by mail (OR, 2.66; CI, 2.35-3.01). Among those with an unsatisfactory FIT, fewer than half (41%) completed a subsequent test within 15 months (median, 4.4 months). Adults aged 50-54 years (OR, 1.16; CI, 1.01-1.39) and those who received FIT by mail (OR, 1.92; CI, 1.49-2.09) were more likely to complete a subsequent test.

CONCLUSIONS

One in ten returned a FIT that could not be processed, mostly due to patient-related reasons. Fewer than half completed a subsequent test after unsatisfactory FIT.

IMPACT

Screening programs should address these breakdowns such as specimen collection and labeling to improve real-world effectiveness. See related In the Spotlight, p. 183.

Patterns of colorectal cancer screening and adherence rates among an average-risk population enrolled in a national health insurance provider during 2009-2018 in the United States

While colorectal cancer (CRC) is the second leading cause of cancer-related mortality in the United States (US), outcomes can be improved through timely screening. Despite the benefits and widespread availability of screening tests, adherence to recommended screening strategies is low. The study aimed to provide recent evidence regarding screening rates and adherence to screening recommendations among adults at average risk for CRC in a commercially insured and Medicare Advantage population. De-identified administrative data from a large US research database were examined to determine screening rates for the years 2009 through 2018. The study population included adults aged 50-75 years and annual study population counts ranged from 1,390,594 in 2009 to 1,654,544 in 2018. Incident screening rates were found to be relatively stable across the study years (approximately 15 %) with adherence lowest in the youngest age group (ages 50-54 years). Colonoscopies accounted for approximately 50 % of all screening tests performed, while there was a substantial increase in the use of home-based screening tests over the study timeframe. The use of the fecal immunochemical test increased from 17.2 % in 2009 to 28.9 % in 2018 and the multi-target stool DNA test increased from 0.4 % in 2015 to 9.0 % in 2018. Overall though, CRC screening and adherence rates remain relatively low among adults at average risk for CRC in the US. Improving adherence rates with CRC screening recommendations among individuals at average risk for CRC is required to improve health outcomes.

Disparities in the use of colorectal cancer screening in a universally insured population during the COVID-19 pandemic

BACKGROUND

Despite the known efficacy of colorectal cancer (CRC) screening, the rates of individuals undergoing such testing have remained lower than target thresholds, even prior to the healthcare disruptions associated with the COVID-19 pandemic. We evaluated the impact of the COVID-19 pandemic on CRC screening within a nationally representative US population and assessed disparities in screening across racial/ethnic groups and socioeconomic (SES) strata.

METHODS

We performed a retrospective cross-sectional study using all eligible TRICARE beneficiaries aged 45-64 years between FY 2018 and 2021. High-risk individuals, those with a previous or current CRC diagnosis, and/or a personal/family history of colonic polyps, were excluded. The pre-COVID-19 period (September 1, 2018-March 31, 2020) was compared to the COVID-19 period (April 1, 2020-September 30, 2021). Secondary analyses were performed, evaluating the interaction between the COVID-19 time period, race, and our proxy for socioeconomic status.

RESULTS

During the study period, we identified 1,749,688 eligible individuals. Following the onset of the COVID-19 pandemic, CRC screening overall decreased from 34% in the pre-pandemic period to 30% following the onset of the pandemic (p < 0.001). This finding persisted even after adjusting for confounders in multivariable analysis (odds ratio [OR] for the pandemic timeframe: 0.79; 95% CI: 0.27, 0.31; p < 0.001). In the setting of SES, in the pandemic period, the odds of individuals from both Senior Enlisted (OR: 0.55; 95% CI: 0.54, 0.56) and Junior Enlisted sponsor ranks (OR: 0.27; 95% CI: 0.25, 0.30) were diminished as compared to Senior Officers.

CONCLUSIONS AND RELEVANCE

We found a 21% reduction in the odds of CRC screening in the context of the COVID-19 pandemic. Reductions in colonoscopies and other types of screening tests were not offset by changes in the use of at-home tests such as Cologuard.