Re-FIT-ting Colorectal Cancer Screening During and Beyond COVID.

See “Noninvasive colorectal cancer screening tests help close screening gaps during coronavirus disease 2019 pandemic,” by Myint A, Roh L, Yang L, et al, on page 712.

Behind the tragic global crisis caused by the response to COVID-19, there lies another, silent, health crisis: that of the undiagnosed cancers and unattended chronic diseases. Around the world, routine ambulatory care and screening have been put on the back burner, or into ever-expanding backlogs which are expected to linger for several years to come.

While it is impossible to fully measure the impact of the pandemic response on cancer burden at this time, several modeling studies indicate that even short-term interruptions of screening may have significant consequences. In the United Kingdom, a national population-based modeling study estimated that the delay in colorectal cancer (CRC) diagnosis induced by a 12-month disruption in screening and usual care could give rise to up to 16.6% more CRC-related deaths at 5 years. Another modeling study of organized fecal immunochemical test (FIT)–based screening predicted that much of the excess mortality they found could be avoided if interventions to “catch up” on missed screening are undertaken in the near future, which would require additional FIT and colonoscopy resources.

With every day of this pandemic, every wave, and every return to lockdown, the tension between this overt COVID crisis and the growing, silent, pandemic of unattended care and unaddressed diagnoses grows. Confronted with these pressures, the need to find efficiencies within the system is imperative. Solutions are required imminently, but it is predicable that the effects of the COVID-19 response will remain with us for a long time and that we may not ever return to the pre-COVID status quo. In other words, the delivery of GI care will have to adapt to a new normal.

In the United States, the National Cancer Institute’s Population-Based Research to Optimize the Screening Process (PROSPR) consortium estimated that CRC screening rates dropped by 82% in 2020. How have health organizations reacted to the abrupt and drastic disruption, and are there examples of adaptability and innovation that we can learn from?

In the United States Veterans Affairs (VA) hospitals, multilevel interventions were performed to help alleviate the consequences of the March 2020 directive to cease all elective and nonurgent procedures. Guidances to primary care and endoscopy services were promptly released to encourage the use of FIT instead of colonoscopy for CRC screening and on the prioritization of endoscopic procedures. Preexisting IT tools were also adapted to default to FIT instead of colonoscopy as first-line CRC screening test and to assign a priority level to each postponed or incoming request for procedure; the system was also able to measure the backlog and categorize it by indication and priority level.

This month’s issue of Gastroenterology features another example of prompt service adaptation. Myint et al demonstrate how purposefully encouraging the use of stool-based CRC screening modalities among patients and providers of the University of California Los Angeles (UCLA) health system allowed screening to continue despite the temporary cessation of elective endoscopies. In the months following resumption of elective endoscopy, the authors also observed a dramatic increase in overall screening test utilization, with a predominant rise in utilization of noninvasive screening modalities (ie, FIT and stool DNA) whereas the use of colonoscopy approached but did not match pre-pandemic volumes.

These examples highlight that, in this new reality imposed by the COVID pandemic, the ideal CRC screening test is one that does not require a procedure or a visit to a health facility, that is easy to use, and that is accessible and yet effective, such as FIT. In fact, in response to the COVID pandemic, the PROSPR consortium recommended increasing the use of established methods of remote testing, such as mailed FIT kits, to improve outcomes of screening and decrease disparities.

Not only could FIT allow screening to continue during the pandemic, it also represents an effective strategy to debulk the endoscopy backlog. Tinmouth et al have shown that redirecting requests for either average-risk colonoscopy or surveillance in people with low-risk adenoma to FIT can substantially reduce the colonoscopy backlog and its recovery time. To achieve a similar effect, colonoscopy capacity would need to exceed mean historical volumes by as much as 45%. This approach effectively “converts” procedures with a low yield for advanced colorectal neoplasia (such as average-risk colonoscopy) into “high-yield” ones, as about one-third of colonoscopies performed in FIT-positive individuals will reveal advanced colorectal neoplasia, including CRC in about 1 in every 19 such colonoscopies.

In many parts of the world, the pandemic has strained health care systems which were already saturated, pushing innovation and rapid changes. It has also exposed blatant flaws and inefficiencies that may have been tolerated in the past and which may no longer be considered acceptable. It behooves us to critically appraise the effectiveness of the millions of procedures performed each year. The realization that CRC screening through a FIT-based model is a safer, more accessible, more equitable evidence-based model than a colonoscopy-based model, as made obvious during the pandemic, is likely to drive permanent changes in the delivery of GI care. One can expect that the nature of colonoscopy will evolve to become primarily a diagnostic and interventional procedure, rather than a screening modality. ,

The ease and rapidity by which this change occurs within a health care system will likely depend on its level of organization, integration, and the adequacy of its IT infrastructure, as illustrated by the examples from the VA hospitals and UCLA health system, which were both able to swiftly and effectively implement changes to reduce the impact of endoscopy closures. ,

Opportunities abound to create centralized processes for evidence-based triage, prioritization, and procedure booking with the use of a single queue. In such models, the conversion of referrals for screening colonoscopy may easily be redirected to an FIT test, and referring physicians may be educated about the benefits of this new strategy. This promotes equity and reduces the use of scarce endoscopy resources for procedures of questionable benefit, or procedures that could safely be avoided and substituted for noninvasive tests, such as FIT for CRC screening.