Impairment of colorectal cancer screening during the COVID-19 pandemic.

We read with great interest the Article by Lucie de Jonge and colleagues. The authors acknowledge a substantial concern regarding colorectal cancer screening: the short-term and long-term negative effects of disruptions in screening due to the COVID-19 pandemic. By applying microsimulation models to three countries with established screening programmes—Australia, Canada, and the Netherlands—the authors predict a worrying increase in colorectal cancer incidence (0·4–1·2%) and related deaths (0·8–2·0%) within 30 years, assuming a 12-month screening disruption. They conclude that providing immediate catch-up screening can restrict colorectal cancer incidence and deaths (2020–50) to less than 0·1% in all three countries.

Considering that catch-up screening could temporarily increase colonoscopy demand to nearly twice that of normal levels, we feel this solution might not be feasible in some health-care systems. Highlighting alternative solutions is imperative for a colonoscopy service that is already under strain.

In a 2020 guideline update by Spada and colleagues, CT colonography (CTC) is recommended when faecal immunohistochemical test (FIT)-based screening is unavailable, because of reported higher participation and acceptability with CTC versus colonoscopy, and a similar frequency of adverse events (0·2% vs 0·3%).

Furthermore, Vuik and colleagues reported in their systematic review that colon capsule endoscopy (CCE), compared with CTC, had a higher polyp detection rate (60·0–100·0% vs 28·6–81·0%) and sensitivity (84·0–97·3% vs 32·0–90·0%), with similar specificity (87·8–97·0% vs 84·8–99·0%). Our local Irish data, published by the Trinity Academic Gastroenterology Group research centre at Tallaght University Hospital (Dublin, Ireland) confirms that CCE is effective at detecting neoplastic polyps in a FIT-positive screening cohort and would reduce the number of colonoscopies by 71%.

In Ireland, colorectal cancer screening is only done in units certified by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG), by endoscopists accredited by the National Cancer Screening Service. Owing to excess waiting lists in most Irish endoscopy units, a minority are JAG-certified. The training time to become an accredited endoscopist is around 5–8 years. Applicants are required to meet quality indicators for colonoscopies and to have done more than 300 colonoscopies within a year. By contrast, much less time is required to train competent screening CCE readers. In an unpublished survey at our CCE centre at Tallaght University Hospital, we found that CCE readers can achieve competence at 30–50 procedures, and similar reading times to colonoscopy (30–45 min). Artificial intelligence in capsule endoscopy will improve CCE training and further shorten reading time, allowing CCE to be used as a viable alternative in catch-up colorectal cancer screening.

To conclude, colorectal cancer screening has required new solutions in the current climate and alternative modalities should be a serious consideration.

We declare no competing interests. SS and MSI contributed equally to this Correspondence.