Colorectal Cancer Screening: Impact of COVID-19 Pandemic and Possible Consequences

The Disproportionate Impact of Primary Care Disruption and Telehealth Utilization During COVID-19

PURPOSE

The COVID-19 pandemic not only exacerbated existing disparities in health care in general but likely worsened disparities in access to primary care. Our objective was to quantify the nationwide decrease in primary care visits and increase in telehealth utilization during the pandemic and explore whether certain groups of patients were disproportionately affected.

METHODS

We used a geographically diverse primary care electronic health record data set to examine the following 3 outcomes: (1) change in total visit volume, (2) change in in-person visit volume, and (3) the telehealth conversion ratio defined as the number of pandemic telehealth visits divided by the total number of prepandemic visits. We assessed whether these outcomes were associated with patient characteristics including age, gender, race, ethnicity, comorbidities, rurality, and area-level social deprivation.

RESULTS

Our primary sample included 1,652,871 patients from 408 practices. During the pandemic we observed decreases of 7% and 17% in total and in-person visit volume and a 10% telehealth conversion ratio. The greatest decreases in visit volume were observed among pediatric patients (-24%), Asian patients (-11%), and those with more comorbidities (-9%). Telehealth usage was greatest among Hispanic or Latino patients (17%) and those living in urban areas (12%).

CONCLUSIONS

Decreases in primary care visit volume were partially offset by increasing telehealth use for all patients during the COVID-19 pandemic, but the magnitude of these changes varied significantly across all patient characteristics. These variations have implications not only for the long-term consequences of the COVID-19 pandemic, but also for planners seeking to ready the primary care delivery system for any future systematic disruptions.

Quantified trends in provider reimbursement and utilization volume in colorectal cancer screenings: analysis of Medicare claims from 2000 to 2019

AIM

Colorectal cancer (CRC) screening rates in the United States remain persistently below guideline targets, partly due to suboptimal patient utilization and provider reimbursement. To guide long-term national utilization estimates and set reasonable screening adherence targets, this study aimed to quantify trends in utilization of and reimbursement for CRC screenings using Medicare claims.

METHOD

Inflation-adjusted reimbursements and utilization volume associated with each CRC screening code were abstracted from Medicare claims between 2000 and 2019. Screenings, screenings/100 000 enrolees and reimbursement/screening were analysed with linear regression and compared with the equality of slopes tests. Average reimbursement per screening was compared using analysis of variance with Dunnett's T3 multiple comparisons test.

RESULTS

The growth rate of multitarget stool DNA tests (mt-sDNA)/100 000 was the highest at 170.4 screenings/year (R2 = 0.99, p ≤ 0.001), while that of faecal occult blood tests/100 000 was the lowest at -446.4 screenings/year (R2 = 0.90, p ≤ 0.001) (p ≤ 0.001). Provider reimbursements averaged $546.95 (95% CI $520.12-$573.78) per mt-sDNA screening, significantly higher than reimbursements for all invasive screenings. Only FOBTs significantly increased in reimbursement per screening at $0.62/year (R2 = 0.91, p ≤ 0.001).

CONCLUSION

We derived forecastable trend numbers for utilization and provider reimbursement. Faecal immunochemical tests/100 000 and mt-sDNA screenings/100 000 increased most rapidly during the entire study period. The number of nearly all invasive screenings/100 000 decreased rapidly; the number of colonoscopies/100 000 increased slightly, probably due to superior diagnostic strength. These trends indicate the that replacement of other invasive modalities with accessible noninvasive screenings will account for much of future screening behaviour and thus reductions in CRC incidence and mortality, especially given providers' reimbursement incentive to screen average-risk patients with stool-based tests.

The relationship of cancer history and chronic disease status to colorectal cancer screening: A cross-sectional analysis of 2020-2021 Behavioral Risk Factor Surveillance System

PURPOSE

We examined whether having a history of cancer and chronic diseases was associated with guideline-concordant colorectal cancer (CRC) screening utilization.

METHODS

Self-reported data from the 2020 and 2021 Behavioral Risk Factor Surveillance System in Oregon and West Virginia were used. Guideline-concordant CRC screening was the outcome of interest. The exposure was having a personal history of cancer, chronic diseases, or both. Multivariable logistic regressions were applied to assess the abovementioned association.

RESULTS

Among 10,373 respondents aged 45-75 years, 75.5% of those with a history of cancer and chronic diseases had guideline-concordant CRC screening use versus 52.8% of those without any history (p-value < 0.05). In multivariable analysis, having a history of cancer (OR 1.74; 95% CI 1.11-2.71), chronic diseases (OR 1.35; 95% CI 1.14-1.59), and both cancer and chronic diseases (OR 2.14; 95% CI 1.62-2.82) were positively associated with screening uptake compared to respondents without any history. Regardless of disease history, older age was associated with greater CRC screening uptake (p-value < 0.05). Among respondents with chronic diseases only or without any condition, those with a health care provider had 1.7-fold and 2.7-fold increased odds of receiving CRC screening, respectively. However, current smokers were 28% and 34% less likely to be screened for CRC among those with chronic diseases only and without any conditions, respectively.

CONCLUSION

Having a personal history of cancer and chronic diseases appears to be positively associated with guideline-concordant CRC screening use. Effective implementation of patient-centered communication through primary care initiatives may increase adherence to CRC screening recommendations.

Management of colorectal cancer screening backlog due to the COVID-19 pandemic: A retrospective analysis of the use of a colorectal cancer screening clinical-decision support tool in Argentina

BACKGROUND

The COVID-19 pandemic created a backlog in colorectal cancer (CRC) screening and surveillance colonoscopies. The real impact in Argentina is not fully known.

GOAL

To estimate the impact of the COVID-19 pandemic on CRC prevention by comparing the number of CRC screening and surveillance consults in a clinical decision support-tool used in Argentina before, during and after pandemic lockdown.

METHODS

We analyzed data from May 2019 to December 2021 from CaPtyVa, a clinical decision support tool for CRC screening and surveillance. Queries were divided in pre-pandemic (May 2019 to March 2020), lockdown (April 2020 to December 2020), and post-lockdown (January 2021 to December 2021). The number of CRC monthly screening and surveillance visits were compared among the three periods and stratified according to CRC risk.

RESULTS

Overall, 27,563 consults were analyzed of which 9035 were screening and 18,528 were surveillance. Pre-pandemic, the median number of screening consults was 346 per month (IQR25-75 280-410). There was a decrease to 156 (80-210)/month (p<0.005) during lockdown that partially recovered during post-lockdown to 230 (170-290)/month (p=0.05). Pre-pandemic, the median number of surveillance consults was 716 (560-880)/month. They decreased to 354 (190-470)/month during lockdown (p<.05) and unlike screening, completely recovered during post-lockdown to 581 (450-790)/month.

CONCLUSIONS

There was a >50% decrease in the number of CRC screening and surveillance consults registered in CaPtyVa during lockdown in Argentina. Post-lockdown, surveillance consults recovered to pre-pandemic levels, but screening consults remained at 66% of pre-pandemic levels. This has implications for delays in CRC diagnoses and patient outcomes.

Inequality in uptake of bowel cancer screening by deprivation, ethnicity and smoking status: cross-sectional study in 86 850 citizens

BACKGROUND

Survival from colorectal cancer depends on stage at detection. In England, bowel cancer mortality has historically been highest in deprived areas. During the initial stages of the COVID-19 pandemic, it was necessary to temporarily halt many screening programmes, which may have led to inequalities in uptake since screening restarted.

METHODS

Cross-sectional data from the Bristol, North Somerset and South Gloucestershire Systemwide Dataset were analyzed. Associations of baseline characteristics with uptake of bowel screening were examined using logistic regression.

RESULTS

Amongst 86 850 eligible adults aged 60-74 years, 5261 had no screening record. There was little evidence of association between no screening and sex (adjusted odds ratio 0.95 (95% confidence interval 0.90, 1.02)). Absence of screening record was associated with deprivation (1.26 (1.14, 1.40) for the most compared with the least deprived groups), smoking (1.11 (1.04, 1.18)) compared with no smoking record and black (1.36 (1.09, 1.70)) and mixed (1.08 (1.01, 1.15)) ethnicity compared with white ethnicity.

CONCLUSIONS

In a data set covering a whole NHS Integrated Care Board, there was evidence of lower uptake of bowel cancer screening in adults living in more deprived areas, of minority ethnic groups and who smoked. These findings may help focus community engagement work and inform research aimed at reducing inequalities.

Comprehensive Insight into Colorectal Cancer Metabolites and Lipids for Human Serum: A Proof-of-Concept Study

Colorectal cancer (CRC) ranks as the third most frequently diagnosed cancer and the second leading cause of cancer-related deaths. The current endoscopic-based or stool-based diagnostic techniques are either highly invasive or lack sufficient sensitivity. Thus, there is a need for less invasive and more sensitive screening approaches. We, therefore, conducted a study on 64 human serum samples representing three different groups (adenocarcinoma, adenoma, and control) using cutting-edge GC×GC-LR/HR-TOFMS (comprehensive two-dimensional gas chromatography coupled with low/high-resolution time-of-flight mass spectrometry). We analyzed samples with two different specifically tailored sample preparation approaches for lipidomics (fatty acids) (25 μL serum) and metabolomics (50 μL serum). In-depth chemometric screening with supervised and unsupervised approaches and metabolic pathway analysis were applied to both datasets. A lipidomics study revealed that specific PUFA (ω-3) molecules are inversely associated with increased odds of CRC, while some PUFA (ω-6) analytes show a positive correlation. The metabolomics approach revealed downregulation of amino acids (alanine, glutamate, methionine, threonine, tyrosine, and valine) and myo-inositol in CRC, while 3-hydroxybutyrate levels were increased. This unique study provides comprehensive insight into molecular-level changes associated with CRC and allows for a comparison of the efficiency of two different analytical approaches for CRC screening using same serum samples and single instrumentation.

Why Does Obesity as an Inflammatory Condition Predispose to Colorectal Cancer?

Obesity is a complex and multifactorial problem of global importance. Additionally, obesity causes chronic inflammation, upregulates cell growth, disturbs the immune system, and causes genomic instability, increasing the risk of carcinogenesis. Colorectal cancer is one of the most common cancers, and it has become a global problem. In 2018, there were around 1.8 million new cases and around 881,000 deaths worldwide. Another risk factor of colorectal cancer associated with obesity is poor diet. A Western diet, including a high intake of red and processed meat and a low consumption of whole grains, fruits, vegetables, and fiber, may increase the risk of both colorectal cancer and obesity. Moreover, the Western diet is associated with a proinflammatory profile diet, which may also affect chronic low-grade inflammation. In fact, people with obesity often present gut dysbiosis, increased inflammation, and risk of colorectal cancer. In this article, the association between obesity and colorectal cancer is discussed, including the most important mechanisms, such as low-grade chronic inflammation, gut dysbiosis, and poor diet.

Using cognitive interviews to improve a measure of organizational readiness for implementation

BACKGROUND

Organizational readiness is a key factor for successful implementation of evidence-based interventions (EBIs), but a valid and reliable measure to assess readiness across contexts and settings is needed. The R = MC² heuristic posits that organizational readiness stems from an organization's motivation, capacity to implement a specific innovation, and its general capacity. This paper describes a process used to examine the face and content validity of items in a readiness survey developed to assess organizational readiness (based on R = MC²) among federally qualified health centers (FQHC) implementing colorectal cancer screening (CRCS) EBIs.

METHODS

We conducted 20 cognitive interviews with FQHC staff (clinical and non-clinical) in South Carolina and Texas. Participants were provided a subset of items from the readiness survey to review. A semi-structured interview guide was developed to elicit feedback from participants using "think aloud" and probing techniques. Participants were recruited using a purposive sampling approach and interviews were conducted virtually using Zoom and WebEx. Participants were asked 1) about the relevancy of items, 2) how they interpreted the meaning of items or specific terms, 3) to identify items that were difficult to understand, and 4) how items could be improved. Interviews were transcribed verbatim and coded in ATLAS.ti. Findings were used to revise the readiness survey.

RESULTS

Key recommendations included reducing the survey length and removing redundant or difficult to understand items. Additionally, participants recommended using consistent terms throughout (e.g., other units/teams vs. departments) the survey and changing pronouns (e.g., people, we) to be more specific (e.g., leadership, staff). Moreover, participants recommended specifying ambiguous terms (e.g., define what "better" means).

CONCLUSION

Use of cognitive interviews allowed for an engaged process to refine an existing measure of readiness. The improved and finalized readiness survey can be used to support and improve implementation of CRCS EBIs in the clinic setting and thus reduce the cancer burden and cancer-related health disparities.

Cancer Patients during COVID-19 Pandemic: A Mini-Review

Since its emergence, coronavirus disease 2019 (COVID-19) has affected the entire world and all commerce and industries, including healthcare systems. COVID-19 adversely affects cancer patients because they are immunocompromised. Increased COVID-19 infection and shortage of medical supplies, beds and healthcare workers in hospitals affect cancer care. This paper includes a description of the existing research that shows the impact of COVID-19 on the management of cancer patients. Aged people with various chronic conditions such as cancer and comorbidities face more challenges as they have a greater risk of disease severity. COVID-19 has affected care delivery, including patient management, and has been responsible for increased mortality among cancer patients. Cancer patients with severe symptoms require regular therapies and treatment; therefore, they have a higher risk of exposure. Due to the risk of transmission, various steps were taken to combat this disease; however, they have affected the existing operational efficiency. Herein, we present the changing priorities during COVID-19, which also affected cancer care, including delayed diagnosis, treatment, and surgeries.

Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic

COVID-19 caused significant declines in colorectal cancer (CRC) screening. Health systems and clinics, faced with a new rapidly spreading infectious disease, adapted to maintain patient safety and address the effects of the pandemic on healthcare delivery. This study aimed to understand how CDC-funded Colorectal Cancer Control Program recipients and their partner health systems and clinics may have modified evidence-based intervention (EBI) implementation to promote CRC screening during the COVID-19 pandemic; to identify barriers and facilitators to implementing modifications; and to extract lessons that can be applied to support CRC screening, chronic disease management, and clinic resilience in the face of future public health crises. Nine recipients were selected to reflect the diversity inherent among all CRCCP recipients. Recipient and clinic partner staff answered unique sets of pre-interview questions to inform tailoring of interview guides that were developed using constructs from the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) and Consolidated Framework for Implementation Research (CFIR). The study team then interviewed recipient, health system, and clinic partner staff incorporating pre-interview responses to focus each conversation. We employed a rapid qualitative analysis approach then conducted virtual focus groups with recipient representatives to validate emergent themes. Three modifications that emerged from thematic analysis include: (1) offering mailed fecal immunochemical test (FIT) kits for CRC screening with mail or drop off return; (2) increasing the use of patient education and engagement strategies; and (3) increasing the use of or improving automated patient messaging systems. With improved tracking and automated reminder systems, mailed FIT kits paired with tailored patient education and clear instructions for completing the test could help primary care clinics catch up on the backlog of missed screenings during COVID-19. Future research can assess the effectiveness and cost-effectiveness of offering mailed FIT kits on maintaining or improving CRC screening, especially among people who are medically underserved.

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.

COVID-19 Pandemic Effects on Cervical Cancer Diagnosis and Management: A Population-Based Study in Romania

The Pap test plays a significant role worldwide in the early diagnosis of and high curability rates for cervical cancer. However, the coronavirus disease 2019 (COVID-19) pandemic necessitated the use of multiple drastic measures to stop the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, limiting women’s access to essential invasive and non-invasive investigations for cervical cancer diagnosis. Therefore, we aimed to determine the impact the COVID-19 pandemic had on cancer diagnosis and management in western Romania. A retrospective study design allowed us to compare the last 24 months of the pre-pandemic period with the first 24 months of the COVID-19 pandemic to determine the change in volume of cervical screening tests, the number of newly diagnosed cases and their severity, and the access to cancer care. A drastic 75.5% decrease in the volume of tests was observed in April 2020 during the first lockdown, after which the volume of cases decreased by up to 36.1% in December 2021. The total volume loss of tests during the first 24 months of the pandemic was 49.9%. The percentage of late-stage cervical cancers (III–IV) rose by 17%, while the number of newly diagnosed cancers in our outpatient clinic was significantly lower than the baseline, with a 45% drop. The access to cancer care was negatively influenced, with 9.2% more patients waiting longer to receive test results over four weeks, while taking longer to seek cancer care after diagnosis (6.4 months vs. 4.1 months pre-pandemic) and missing significantly more appointments. The COVID-19 pandemic had a significantly negative impact on cervical cancer diagnosis and management during the first 24 months compared with the same period before the pandemic. Although the numbers are now recovering, there is still a big gap, meaning that many cervical cancer cases were potentially missed. We recommend further interventions to reduce the gap between the pre-pandemic and pandemic period.

State-of-the-Art Review on Immersive Virtual Reality Interventions for Colonoscopy-Induced Anxiety and Pain

BACKGROUND

Colonoscopy related fear impairs the current gold standard screening of colorectal cancer. Compared to other minimally invasive procedures for cancer screening, colonoscopy-induced anxiety exceeds the procedure through bowel preparation. Immersive virtual reality's (iVR) role in alleviating the complex stress-pain relationship encountered during medical procedures is directly proportional to the rising affordability of state-of-the-art Head-Mounted-Displays (HMDs).

OBJECTIVE

to assess the effect of iVR on patients' colonoscopy-induced anxiety and pain.

MATERIALS AND METHODS

A systematic search was conducted in PubMed, Cochrane Central Register of Controlled Trials, Web of Science, Embase and Scopus databases up to January 2022. Clinical trials evaluating anxiety as an outcome were included without language restriction.

RESULTS

Four clinical trials were included: three on the patients' intraprocedural anxiety and one on patient education. Intraprocedural iVR interventions for colonoscopy-induced anxiety and pain revealed a similar effect as conventional sedation, while a statistically significant reduction was reported for non-sedated patients. iVR patient education improved the quality of bowel preparation and reduced patient anxiety before colonoscopy.

CONCLUSIONS

The current research highlights the need to use high-end HMDs and appropriate interactive iVR software content for colonoscopy-induced anxiety. Methodological frameworks regarding the eligibility of participants, double-blinding and randomization of iVR studies can facilitate the development of iVR implementation for anxiety and pain management.

Colorectal Surgery in the COVID-19 Era: A Systematic Review and Meta-Analysis

(1) Background: To determine the impact of the COVID-19 pandemic in the management of colorectal cancer patients requiring surgery and to examine whether the restructuring of healthcare systems led to cancer stage upshifting or adverse treatment outcomes; (2) Methods: A systematic literature search of the MedLine, Scopus, Web of Science, and CNKI databases was performed (PROSPERO ID: CRD42021288432). Data were summarized as odds ratios (OR) or weighted mean differences (WMDs) with 95% confidence intervals (95% CIs); (3) Results: Ten studies were examined, including 26,808 patients. The number of patients presenting with metastases during the pandemic was significantly increased (OR 1.65, 95% CI 1.02−2.67, p = 0.04), with no differences regarding the extent of the primary tumor (T) and nodal (N) status. Patients were more likely to have undergone neoadjuvant therapy (OR 1.22, 95% CI 1.09−1.37, p < 0.001), while emergency presentations (OR 1.74, 95% CI 1.07−2.84, p = 0.03) and palliative surgeries (OR 1.95, 95% CI 1.13−3.36, p = 0.02) were more frequent during the pandemic. There was no significant difference recorded in terms of postoperative morbidity; (4) Conclusions: Patients during the pandemic were more likely to undergo palliative interventions or receive neoadjuvant treatment.

Effect of COVID-19 Pandemic on Hepatocellular Carcinoma Diagnosis: Results from a Tertiary Care Center in North-West Italy

The COVID-19 pandemic has forced us to direct most of the available resources towards its management. This has led to the neglect of all other pathologies, including cancer. The aim of this study was to verify whether the difficulty in accessing the health system has led to a reduction in new diagnoses of hepatocellular carcinoma (HCC) and whether this has already been reflected in a more advanced stage of the cancer. A single-center, retrospective study including adult patients with a new diagnosis of HCC was performed. Patients were divided into three groups: the prelockdown phase (May 2019–February 2020), the lockdown phase (March 2020–December 2020), and the postlockdown phase (January 2021–October 2021); 247 patients were included. The number of patients diagnosed with HCC distinctly diminished in the periods March 2020–December 2020 (n = 69; −35%) and January 2021–October 2021 (n = 72; −32%) as compared to the period May 2019–February 2020 (n = 106). Noteworthy was the reduced surveillance in the period January 2021–October 2021 as compared to May 2019–February 2020 (22.9% vs. 36.6%, p = 0.056). No significant changes have yet been observed in tumor characteristics (BCLC staging distribution remained unvaried, p = 0.665). In conclusion, the number of new HCC diagnoses decreased sharply in the first 2 years of the pandemic, with no worsening of the stage. A more advanced stage of the disease could be expected in the next few years in patients who have escaped diagnosis.

Healthcare Professional and Patient Perceptions of Changes in Colorectal Cancer Care Delivery During the COVID-19 Pandemic and Impact on Health Inequalities

BACKGROUND

The COVID-19 pandemic changed the way in which people were diagnosed and treated for cancer. We explored healthcare professional and patient perceptions of the main changes to colorectal cancer delivery during the COVID-19 pandemic and how they impacted on socioeconomic inequalities in care.

METHODS

In 2020, using a qualitative approach, we interviewed patients (n = 15) who accessed primary care with colorectal cancer symptoms and were referred for further investigations. In 2021, we interviewed a wide range of healthcare professionals (n = 30) across the cancer care pathway and gathered national and local documents/guidelines regarding changes in colorectal cancer care.

RESULTS

Changes with the potential to exacerbate inequalities in care, included: the move to remote consultations; changes in symptomatic triage, new COVID testing procedures/ways to access healthcare, changes in visitor policies and treatment (e.g., shorter course radiotherapy). Changes that improved patient access/convenience or the diagnostic process have the potential to reduce inequalities in care.

DISCUSSION

Changes in healthcare delivery during the COVID-19 pandemic have the ongoing potential to exacerbate existing health inequalities due to changes in how patients are triaged, changes to diagnostic and disease management processes, reduced social support available to patients and potential over-reliance on digital first approaches. We provide several recommendations to help mitigate these harms, whilst harnessing the gains.