The Domino effect: COVID-19 and the implication on CRC screening

Leading colorectal cancer (CRC) experts discuss the significant health impacts from the pandemic related to CRC screening delays and look towards a possible pathway forward to handle future health crises

Colorectal cancer (CRC) is the second most common cause of cancer death among both men and women in Europe.1 CRC accounts for 13% of all cancers and is the most common digestive cancer, with over 375,000 newly diagnosed cases annually.2 Colorectal cancer is easier to treat when detected at early stages; when diagnosed at stage I, the overall 5-year survival rate is around 90%.3

Since the rollout of screening programmes across Europe, a steady decline in CRC mortality rates has been observed.4 However, this success has been halted since the start of the pandemic due to screening delays.

A primary tool in FIT-positives used for the screening, early diagnosis, and treatment of digestive cancers is endoscopy. Following the pandemic and multiple lockdowns, endoscopy has been one of the most heavily affected procedures, leading to a dramatic decrease of screening and surveillance procedures.5 A new analysis of NHS England data led by UCL researchers concluded an estimated endoscopy screening backlog of 476,000 recorded in January 2021.6 This delay is particularly problematic as bar an expected increase in overall survival, early detection also allows for minimally invasive surgery. This type of surgery results in a faster recovery for the patient, and is consequently cheaper for the healthcare system, which is essential in times of crisis to help relieve economic burdens.6

The experts

Prof Luigi Riccardiello, Research Committee Chair, United European Gastroenterology
Impact of screening delays

“The majority of diagnostic and treatment pathways utilised in the management of CRC have been severely affected by COVID, most notably demonstrated by the delays for CRC screening tests. Delays in screening are particularly problematic for CRC as the best outcomes are attained in those whose tumours are diagnosed at an early stage.7 Screening delays beyond 4-6 months have been shown to significantly increase advanced CRC cases and impact mortality if lasting beyond 12 months.8

We need to focus on implementing an unbroken prevention pathway and reorganising our efforts against high-impact disease, such as CRC, to prepare for future waves of COVID-19 or other pandemics.8 Moving forward we need to make sure to address the backlog of screenings that has accumulated, to avoid the risk of significant increases in deaths from colorectal cancer over the next few years.”

Prof Thomas Seufferlein, Editor in Chief of the German Journal of Gastroenterology
Varying CRC screening rates across Europe

“The health impacts of the pandemic relating to CRC seem to be inconsistent across Europe, mostly dependent on the healthcare systems in place for each country. In Germany, where colonoscopy screening is largely done within private practice, there were fewer screening delays reported during the second and third COVID-19 waves once all protective measures were established.9,10

It has been reported that only 14% of EU citizens aged between 50-74 years old have the opportunity to participate in formal population-based screening programme for CRC.4 Therefore, having a screening programme alone is not sufficient, it must also meet quality criteria in terms of invitations for every inhabitant and equal opportunities for all, awareness creation, repeat messages, and sensitivity to tone and style that will enhance citizen participation.4,8 EU member governments should look to urgently address both the implementation and reorganisation of screening programmes available, in a bid to improve both the coverage and overall quality of screenings.2”

Prof Evelien Dekker, Gastrointestinal Oncology
The role of pre-existing barriers

“Pre-existing barriers to screenings were still present throughout the pandemic and if anything were exacerbated.11 This includes patient barriers such as fear, where individuals who may have already been apprehensive to participate in for a screening were even more conscious throughout the pandemic, and thus the fear of getting COVID only compounded the issue of people not going for their screening. Therefore, moving forward we must focus on reassuring a patient with a positive FIT result that colonoscopy centers are safe and COVID-free areas. This will help foster individual compliance for screenings and prevent later stage diagnosis of CRC.

Additionally, there are health care provider and health system barriers, such as a lack of follow-up and screening costs, which would have been a larger cause for concern throughout the pandemic.11 Due to the overload on resources, its likely many providers were late in following up with individuals to get them in for screenings, which would have added to screening delays. Systems were also stretched in terms of budgets to keep up with the demands of COVID-19, and thus the screening costs may have acted as a barrier to ensuring prompt and speedy screenings for patients.

Lastly, but possibly most importantly, the significance of screening by FIT cannot be understated. According to the European guideline, this is the preferred screening test, triaging those that need colonoscopy and thus sparing the limited capacity for those who need it.

FIT-programmes are not only beneficial in reducing morbidity but also cost-effective and making best use of colonoscopy capacity, which is always essential, but especially during pandemic. It results in performing colonoscopy in those who need it most, and saving money needed for treating advanced stage cancers which can be reallocated for necessary COVID-care.”

References

1. World Health Organization. Colorectal Cancer. 2021/2. www.euro.who.int/en/health-topics/noncommunicable diseases/cancer/news/news/2012/2/early-detection-of-common-cancers/colorectal-cancer (accessed December 2021).
2. Open Access Government. Reducing the burden of colorectal cancer across Europe. 2020. [online] www.openaccessgovernment.org/reducing-the-burden-of-colorectal-cancer-across-europe/83896/ (accessed December 2021).
3. Iarc.who.int. 2021. Colorectal Cancer Awareness Month 2021 – IARC. [online] www.iarc.who.int/news-events/colorectal-cancer-awareness-month-2021/> (accessed December 2021).
4. Maringe C et al. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study. Lancet Oncol 2020;21(8):1023–34.
5. Peck‐Radosavljevic M et al. COVID‐19 and digestive health: Implications for prevention, care and the use of COVID‐19 vaccines in vulnerable patients. United Eur Gastroenterol J 2021;9(9):1091–5.
6. UCL. COVID-19: Backlog of half a million endoscopies and rising. 2021. [online] www.ucl.ac.uk/news/2021/mar/covid-19-backlog-half-million-endoscopies-and-rising (accessed December 2021).
7. Ricciardiello L et al. 2021. Impact of SARS-CoV-2 Pandemic on Colorectal Cancer Screening Delay: Effect on Stage Shift and Increased Mortality. Clin Gastroenterol Hepatol 2021;9(7):1410–17.e9.
8. Iarc.who.int. 2021. Launch of online learning programme on “Improving the Quality of Cancer Screening” – IARC. [online] www.iarc.who.int/news-events/launch-of-online-learning-programme-on-improving-the-quality-of-cancer-screening/> (accessed December 2021).
9. Mangiapane S et al. Veränderung der vertragsärztlichen Leistungsinanspruchnahme während der COVID-Krise. Hrsg.: Zentralinstitut für die kassenärztliche Versorgung in der Bundesrepublik Deutschland (2020).
10. Schmidt C. Auswirkungen der COVID-19-Pandemie. Z Gastroenterol 2020;58:1–4.
11. Unger-Saldaña K et al. Barriers and facilitators for colorectal cancer screening in a low-income urban community in Mexico City. Implement Sci Commun 2020;1:64.