Impact of the COVID-19 Pandemic on Colorectal and Prostate Cancer Screening in a Large U.S. Health System

Checkup Visits in Adult Federally Qualified Health Center Patients: a Retrospective Cohort Study

BACKGROUND

Checkup visits (i.e., general health checks) can increase preventive service completion and lead to improved treatment of new chronic illnesses. After the onset of the COVID-19 pandemic, preventive service completion decreased in many groups that receive care in safety net settings.

OBJECTIVE

To examine potential benefits associated with checkups in federally qualified health center (FQHC) patients.

DESIGN

Retrospective cohort study, from March 2018 to February 2022.

PATIENTS

Adults at seven FQHCs in Illinois.

INTERVENTIONS

Checkups during a two-year Baseline (i.e., pre-COVID-19) period and two-year COVID-19 period.

MAIN MEASURES

The primary outcome was COVID-19 period checkup completion. Secondary outcomes were: mammography completion; new diagnoses of four common chronic illnesses (hypertension, diabetes, depression, or high cholesterol), and; initiation of chronic illness medications.

KEY RESULTS

Among 106,114 included patients, race/ethnicity was most commonly Latino/Hispanic (42.1%) or non-Hispanic Black (30.2%). Most patients had Medicaid coverage (40.4%) or were uninsured (33.9%). While 21.0% of patients completed a checkup during Baseline, only 15.3% did so during the COVID-19 period. In multivariable regression analysis, private insurance (versus Medicaid) was positively associated with COVID-19 period checkup completion (adjusted relative risk [aRR], 1.15; 95% confidence interval, [CI], 1.10-1.19), while non-Hispanic Black race/ethnicity (versus Latino/Hispanic) was inversely associated with checkup completion (aRR, 0.89; 95% CI, 0.85-0.93). In secondary outcome analysis, COVID-19 period checkup completion was associated with 61% greater probability of mammography (aRR, 1.61; 95% CI, 1.52-1.71), and significantly higher probability of diagnosis, and treatment initiation, for all four chronic illnesses. In exploratory interaction analysis, checkup completion was more modestly associated with diagnosis and treatment of hypertension and high cholesterol in some younger age groups (versus age ≥ 65).

CONCLUSIONS

In this large FQHC cohort, checkup completion markedly decreased during the pandemic. Checkup completion was associated with preventive service completion, chronic illness detection, and initiation of chronic illness treatment.

The impact of COVID-19 on patients diagnosed with melanoma, breast, and colorectal cancer

BACKGROUND

The COVID-19 pandemic impacted healthcare resource allocation and utilization of preventative medical services. It is unknown if there is resultant stage migration of melanoma, breast, and colorectal cancer when comparing extended time periods before and after the pandemic onset.

METHODS

A retrospective cohort study of melanoma, breast, and colorectal cancer patients was completed. Clinical and pathological staging was compared utilizing 12 and 22-month timeframes before and after the pandemic outbreak.

RESULTS

Between the 22-month pre- and post-COVID-19 groups, breast cancer clinical stage T2 significantly increased, and pathological stage 2 decreased. Colorectal cancer clinical stage T1 decreased, stage T4 increased, and stage 0 decreased in the 22-month groups. In the 12-month groups, melanoma clinical stage T1 increased, and colorectal cancer clinical stage N2 increased.

CONCLUSIONS

Evaluating extended timeframes beyond the immediate pre- and post-COVID-19 period revealed significant increases in clinical staging of breast and colorectal cancer, suggesting advanced disease is becoming more evident as time progresses.

Annual Report to the Nation on the Status of Cancer, part 2: Early assessment of the COVID-19 pandemic's impact on cancer diagnosis

BACKGROUND

With access to cancer care services limited because of coronavirus disease 2019 control measures, cancer diagnosis and treatment have been delayed. The authors explored changes in the counts of US incident cases by cancer type, age, sex, race, and disease stage in 2020.

METHODS

Data were extracted from selected US population-based cancer registries for diagnosis years 2015-2020 using first-submission data from the North American Association of Central Cancer Registries. After a quality assessment, the monthly numbers of newly diagnosed cancer cases were extracted for six cancer types: colorectal, female breast, lung, pancreas, prostate, and thyroid. The observed numbers of incident cancer cases in 2020 were compared with the estimated numbers by calculating observed-to-expected (O/E) ratios. The expected numbers of incident cases were extrapolated using Joinpoint trend models.

RESULTS

The authors report an O/E ratio <1.0 for major screening-eligible cancer sites, indicating fewer newly diagnosed cases than expected in 2020. The O/E ratios were lowest in April 2020. For every cancer site except pancreas, Asians/Pacific Islanders had the lowest O/E ratio of any race group. O/E ratios were lower for cases diagnosed at localized stages than for cases diagnosed at advanced stages.

CONCLUSIONS

The current analysis provides strong evidence for declines in cancer diagnoses, relative to the expected numbers, between March and May of 2020. The declines correlate with reductions in pathology reports and are greater for cases diagnosed at in situ and localized stage, triggering concerns about potential poor cancer outcomes in the coming years, especially in Asians/Pacific Islanders.

PLAIN LANGUAGE SUMMARY

To help control the spread of coronavirus disease 2019 (COVID-19), health care organizations suspended nonessential medical procedures, including preventive cancer screening, during early 2020. Many individuals canceled or postponed cancer screening, potentially delaying cancer diagnosis. This study examines the impact of the COVID-19 pandemic on the number of newly diagnosed cancer cases in 2020 using first-submission, population-based cancer registry database. The monthly numbers of newly diagnosed cancer cases in 2020 were compared with the expected numbers based on past trends for six cancer sites. April 2020 had the sharpest decrease in cases compared with previous years, most likely because of the COVID-19 pandemic.

Incidence trends in prostate cancer among men in the United States from 2000 to 2020 by race and ethnicity, age and tumor stage

Purpose

To explore whether prostate cancer incidence trends from 2000 to 2020 in the United States differed by race and ethnicity, age and tumor stage; to explore racial differences in prostate cancer incidence change due to the impact of COVID-19 pandemic lockdown in 2020; and to determine if there is any high-risk population that can be targeted for prevention.

Methods

We identified 1,098,349 men who were diagnosed with incident prostate cancer at age ≥20 in 2000-2020 in 17 registries of the Surveillance, Epidemiology, and End Results (SEER) program in the United States; of whom, 778,437 were non-Hispanic whites, 155,111 non-Hispanic blacks, 4,200 American Indians and Alaska Natives (AIAN), 55,267 non-Hispanic Asians/Pacific Islanders, and 105,334 Hispanics.

Results

Age-adjusted incidence rate of prostate cancer was the highest in blacks (302.6 cases per 100,000 men), followed by whites (186.6), Hispanics (153.2), AIAN (108.5), and Asians (104.9). Age-adjusted prostate cancer incidence rates dramatically decreased from 2000 to 2013 for all ethnic men. However, age-adjusted prostate cancer incidence rates increased from 2014 to 2020, in which the increasing incidence trend looked sharper in blacks and whites, flatter in Asians, and leveled in AIAN and Hispanics. Among men with local or regional stages across all years, prostate cancer incidence rate was significantly higher in blacks, but significantly lower in Hispanics, AIAN, and Asians as compared to whites. Among men in 2007-2013, the risk of distant stage prostate cancer was statistically significantly elevated in blacks (rate-ratio: 2.22, 95% CI: 2.06-2.38) and Hispanics (1.16, 1.06-1.25), not significantly different in AIAN (1.30, 0.92-1.76), but still significantly lower in Asians (0.73, 0.66-0.82) as compared to whites. There was a drop of prostate cancer incidence from 2019 to 2020 likely due to the impact of COVID-19 pandemic lockdown on the access to medical care in 2020. Overall prostate cancer incidence rate decreased by 40.4 cases per 100,000 population from 277.4 in 2019 to 237.0 in 2020 for blacks, 20.9 from 164.2 to 143.3 for whites, 16.8 from 124.8 to 108.0 for Hispanics, 14.9 from 101.7 to 86.8 for AIAN, and 12.6 from 88.4 to 75.8 for Asians.

Conclusion

The decreasing trend of prostate cancer incidence from 2000 to 2013 was statistically significant for all ethnic men. There was an increasing prostate cancer incidence from 2014 to 2020. Age-adjusted incidence rate of prostate cancer was the highest in blacks, followed by whites, Hispanics, AIAN, and Asians, regardless of age groups, tumor stages, and time periods. There will also be a need to monitor and investigate the prostate cancer incidence trend during and after COVID-19 pandemic season.

COVID-19 pandemic impact on screening and diagnosis of prostate cancer: a systematic review

INTRODUCTION

The healthcare level has been greatly affected by the COVID-19 pandemic compared with before the outbreak. This study aimed to review the impact of COVID-19 on the screening and diagnosis of prostate cancer (PCa).

METHOD

The current study was designed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020. The keywords used to perform the search strategy were COVID-19 and prostate neoplasms. The four primary electronic databases comprising PubMed/MEDLINE, Web of Science, Scopus and Embase were searched until 1 September 2022. After screening and selecting studies through the EndNote software, data were extracted from each included study by two independent authors. All studies were evaluated according to Newcastle-Ottawa Scale quality assessment tool.

RESULTS

As a result, 40 studies were included, categorised into two subjects. The majority of studies indicated a significant decrease in screening prostate-specific antibody tests during the COVID-19 pandemic compared with the pre-pandemic period, leading to delays in cancer diagnosis. The decrease in the number of diagnosed cases with low/intermediate stages to some extent was more than those with advanced stages. The PCa screening and diagnosis reduction ranged from nearly 0% to 78% and from 4.1% to 71.7%, respectively.

CONCLUSION

Our findings showed that during the COVID-19 lockdown, delays in PCa screening tests and diagnoses led to the negative health effects on patients with PCa. Thus, it is highly recommended performing regular cancer screening to reduce the impact of the COVID-19 lockdown.

PROSPERO REGISTRATION NUMBER

CRD42021291656.

The Influence of the COVID-19 Pandemic on Colorectal Cancer Secondary Preventive Healthcare Measures

This study aims to assess the impact of SARS-CoV-2 on a population enrolled in a pilot colorectal screening program started by a family doctor in Romania. This observational retrospective study was spread over 43 months, respectively, from October 2019 to April 2023, and included 169 patients. The primary objective was to compare the pre-pandemic, pandemic, and post-pandemic periods to observe significant changes. The secondary objective was to study the correlation between vaccination against SARS-CoV-2 and participation in the study, especially in the age range class of interest-50-74 years. These data are important because Romanian Healthcare policymakers can use them to estimate the participation rate in a future national colorectal cancer screening and how to adjust and facilitate their communications with the targeted population. The rise of COVID-19 significantly negatively impacted the number of patients adhering to the pilot colorectal cancer screening and the number of test results during the pandemic period. However, in the post-pandemic period, the number of patients who joined the study, and the number of fecal occult blood tests was greater than expected (128.74%). We observed that screening participation was associated with vaccination (78.11% of patients had a complete COVID-19 vaccine scheme).

The 2020 US cancer screening deficit and the timing of adults' most recent screen: a population-based cross-sectional study

OBJECTIVE

In 2020, cancer screenings declined, resulting in a cancer screening deficit. The significance of this deficit, however, has yet to be quantified from a population health perspective. Our study addresses this evidence gap by examining how the pandemic changed the timing of American adults' most recent cancer screen.

METHODOLOGY

We obtained population-based, cancer screening data from the Behavioural Risk Factor Surveillance System (BRFSS) (2010, 2012, 2014, 2016, 2018, 2020). Mammograms, pap smears and colonoscopies were each specified as a variable of mutually exclusive categories to indicate the timing since the most recent screening (never, 0-1 years, 1-2 years, 3+ years). Our cross-sectional, quasi-experimental design restricts the sample to adults surveyed in January, February or March. We then leverage a quirk in the BRFSS implementation and consider adults surveyed in the second year of the 2020 survey wave as exposed to the COVID-19 pandemic. Respondents surveyed in January 2020-March 2020 were considered unexposed. To estimate the impact of exposure to the COVID-19 pandemic on the timing of recent cancer screenings, we constructed linear and logistic regression models which control for sociodemographic characteristics associated with screening patterns, and state fixed effects and temporal trend fixed effects to control for confounding.

RESULTS

In 2020, the cancer screening deficit was largely due to a 1 year delay among adults who receive annual screening, as the proportion of adults reporting a cancer screen in the past year declined by a nearly identical proportion of adults reporting their most recent cancer screen 1-2 years ago (3%-4% points). However, the relative change was higher for mammograms and pap smears (17%) than colonoscopies (4%). We also found some evidence that the proportion of women reporting never having completed a mammogram declined in 2020, but the mechanisms for this finding should be further explored with the release of future data.

CONCLUSION

Our estimates for the pandemic's effect on cancer screening rates are smaller than prior studies. Because we account for temporal trends, we believe prior studies overestimated the effect of the pandemic and underestimated the overall downward trend in cancer screenings across the country leading up to 2020.

A Pilot Colorectal Cancer Study Using Fecal Occult Blood Tests and Colonoscopy to Identify the Weaknesses of the Romanian Public Healthcare System before Implementing National Screening

The objective of this study is to investigate the feasibility of colorectal cancer (CRC) screening in the absence of a national screening program using the resources provided by the Romanian healthcare system. Study participants were recruited from adult patients (over 18 years old) registered with a general practitioner from an urban area over a period of 3 years (October 2019 to September 2022). Patients were recruited when they came for a consult at their family physician's office. The study excluded patients with a medical history of colorectal cancer. Written consent was obtained from the patients who agreed to participate. Patients who agreed to participate were recommended to undergo a fecal occult blood test (FOBT). For those with a positive FOBT result, a colonoscopy was recommended. The study identified a need and willingness of patients to participate in CRC screening when they were informed about it, especially when it involved a noninvasive test such as FOB. We did not anticipate the refusal to perform FOBT in the public healthcare system because the recommendation was made by a GP. We identified a deficit of specialists that can perform colonoscopies in the public healthcare system, insufficient health education, and a lack of dedicated pathways for screening.

Colonoscopy Following an Abnormal Fecal Test Result from an Annual Colorectal Cancer Screening Program in a Federally Qualified Health Center

OBJECTIVE

Individuals with an abnormal fecal immunochemical test (FIT) result have an elevated risk of colorectal cancer, and the risk increases if the follow-up colonoscopy is delayed. Of note, rates of follow-up colonoscopy are alarmingly low in federally qualified health centers (FQHCs), US health care settings that serve a majority racial and ethnic minority patient population. We assessed factors associated with colonoscopy after an abnormal FIT result and used chart-abstracted data to assess reasons (including process measures) for lack of follow-up as part of an annual, mailed-FIT outreach program within a large, Latino-serving FQHC.

METHODS

As part of the National Institutes of Health-funded PROMPT study, we identified patients with an abnormal FIT result and used logistic regression to assess associations between patient demographics and receipt of follow-up colonoscopy, controlling for patients' preferred language. We report on time (days) to referral and time to colonoscopy. For charts with an abnormal FIT result but no evidence of colonoscopy, we performed a manual abstraction and obtained the reason for the absence of colonoscopy. When there was no evidence of colonoscopy in a patient's electronic health record (EHR), we performed an automated query of the administrative claims database to identify colonoscopy outcomes.

RESULTS

We identified 324 patients with abnormal FIT results from July to October 2018. These patients were mostly publicly insured (Medicaid 53.1%, Medicare 14.5%), 81.8% were aged 50 to 64 years, 55.3% were female, 80.3% were Hispanic/Latino, and 67.3% preferred to speak Spanish. We found that 108/324 (33.3%) patients completed colonoscopy within 12 months, and the median time to colonoscopy was 94 days (IQR: 68-176). Common barriers to colonoscopy completion, obtained from chart-abstracted data, were: no documentation following referral to gastrointestinal (GI) specialist or GI consultation (41.6%), no referral to GI specialist following abnormal fecal test (34.2%), and absence of a valid insurance authorization (6.5%).

CONCLUSIONS

Multi-level strategies are needed to provide optimal care across the cancer continuum for FQHC patients. In order to reduce the risk of CRC and realize the return on fecal testing investment, concerted system-level efforts are urgently needed to improve rates of follow-up colonoscopy among FQHC patients and redress racial and ethnic disparities in CRC screening outcomes.

Clinical presentation, management, screening and surveillance for colorectal cancer during the COVID-19 pandemic

Management of colorectal cancer (CRC) was severely affected by the changes implemented during the pandemic, and this resulted in delayed elective presentation, increased emergency presentation, reduced screening and delayed definitive therapy. This review was conducted to analyze the impact of the coronavirus disease 2019 (COVID-19) pandemic on management of CRC and to identify the changes made in order to adapt to the pandemic. We performed a literature search in PubMed, Medline, Index Medicus, EMBASE, SCOPUS, Reference Citation Analysis (https://www.referencecitationanalysis.com/) and Google Scholar using the following keywords in various combinations: Colorectal cancer, elective surgery, emergency surgery, stage upgrading, screening, surveillance and the COVID-19 pandemic. Only studies published in English were included. To curtail the spread of COVID-19 infection, there were modifications made in the management of CRC. Screening was limited to high risk individuals, and the screening tests of choice during the pandemic were fecal occult blood test, fecal immunochemical test and stool DNA testing. The use of capsule colonoscopy and open access colonoscopy was also encouraged. Blood-based tests like serum methylated septin 9 were also encouraged for screening of CRC during the pandemic. The presentation of CRC was also affected by the pandemic with more patients presenting with emergencies like obstruction and perforation. Stage migration was also observed during the pandemic with more patients presenting with more advanced tumors. The operative therapy of CRC was altered by the pandemic as more emergencies surgeries were done, which may require exteriorization by stoma. This was to reduce the morbidity associated with anastomosis and encourage early discharge from the hospital. There was also an initial reduction in laparoscopic surgical procedures due to the fear of aerosols and COVID-19 infection. As we gradually come out of the pandemic, we should remember the lessons learned and continue to apply them even after the pandemic passes.

The impact of COVID-19 pandemic in the diagnosis and management of colorectal cancer patients

The novel coronavirus disease 2019 (COVID-19) pandemic has posed an unprecedented challenge to healthcare systems worldwide, causing downscaling of almost all other activities, especially in its early stages. Currently, the availability of vaccines along with the spread of new viral variants has modified the epidemiology of the disease, and the previous activity is being gradually resumed in most healthcare facilities. In this review, we have summarized the influence of the COVID-19 pandemic in the diagnosis and management of colorectal cancer (CRC) patients. Population-based screening with either colonoscopy or fecal occult blood tests has proven to reduce CRC incidence and mortality, so screening programs have been implemented in most western countries. However, during the first COVID-19 wave, most of these programs had to be disrupted temporarily. In this review, we have thoroughly analyzed the consequences of these disruptions of screening programs as well as of the forced delays in diagnostic and therapeutic services on CRC prognosis, although its exact impact cannot be exactly measured yet. In any way, strategies to minimize its effect, such as catch-up strategies expanding the colonoscopy capacity or using fecal occult blood concentration and other risk factors to prioritize patients, are urgently needed. The COVID-19 pandemic has also led to a change in CRC patient presentation, with an overall temporary decreased incidence due to postponed diagnoses, but with more patients presenting in need of an emergency admission or with symptoms. Finally, changes in treatment approaches in CRC patients have been reported during the pandemic, namely a drop in the proportion of laparoscopic surgeries or a rise in short-term radiotherapy courses. We have therefore aimed to summarize the available evidence to guide the healthcare professionals treating CRC patients to choose the best treatment options in the current pandemic situation.