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20th October 2023
The potential for detection of colorectal cancer based on an analysis of the variability in a patient‘s gut microbiome has been highlighted in a study presented at United European Gastroenterology (UEG) Week.
The findings come from the Dutch microbiome project, which is a large-scale studying involving 8,208 participants. Researchers analysed the gut microbiome of those who developed pre-cancerous colorectal lesions before faecal sampling between 2000 and 2015, in addition to those who developed such lesions following sampling between 2015 and 2022.
They then compared the results with samples taken from individuals with a normal colonoscopy, as well as exploring the range of bacterial species present and their function within the gut by reconstructing their genomes from metagenomic data.
The team identified that when compared to those who had a normal colonoscopy, individuals who developed colonic lesions after faecal sampling displayed a greater diversity in their gut microbiome. In addition, the composition and function of the microbes differed in those with pre-existing or future lesions based on the type of lesion.
In terms of the specific organisms, researchers identified that those from the family of Lachnospiraceae and the genera Roseburia and Eubacterium were linked with the future development of lesions.
Significant variation in the gut microbiome of individuals who developed pre-cancerous colorectal lesions offers another potential avenue to explore to enhance the detection and prevention of colorectal cancer.
Commenting on the findings, study lead, Dr Ranko Gacesa, postdoctoral researcher at the University Medical Center Groningen in the Netherlands, said: ‘While we didn’t investigate mechanisms in this study, it is known from previous research that some of the bacterial species identified may have properties that could contribute to the development of colorectal lesions.
‘A bacterium called Bacteroides fragilis, for example, is known to produce a toxin that can lead to chronic low-grade inflammation in the gut. Prolonged inflammation is believed to be potentially genotoxic and carcinogenic, meaning it may cause genetic damage and promote cancer.’
In a discussion of the potential implications of the study findings, Dr Gacesa added: ‘The connection between the gut microbiome and pre-cancerous lesions has been underexplored, leaving uncertainty about whether gut bacteria can predict the future onset of colorectal cancer.
‘Our findings suggest that the microbiome could act as a valuable tool to improve existing tests, advancing early detection methods for pre-cancerous lesions and colorectal cancer.’
According to the World Health Organization, colorectal cancer is the third most common cancer and there were nearly two million cases and almost one million deaths in 2020, with a spike in diagnoses of the cancer at an advanced stage during the pandemic.
In addition, an increasing number of studies reveal how the progression of colorectal cancer is related to gut microbiome composition. In fact, the published literature related to the development of colorectal cancer has demonstrated that many bacteria affect tumour development and growth. It is also clear that gut microbiome can modulate the efficacy of conventional chemotherapy, through regulating cytotoxicity by participating in the metabolic process of anti-cancer drugs.
20th December 2022
Widespread state medical marijuana legalisation in the US is associated with a lower rate of opioid dispensing and pain-related hospital events among some adults receiving treatment for newly diagnosed cancer according to an analysis by US researchers.
Pain is an extremely common cancer symptom with a 2022 meta-analysis of 12 studies (10 with breast cancer and 2 lung cancer) patients, finding a pooled pain prevalence rate of 40%. Although paracetamol and non-steroidal anti-inflammatory drugs are universally accepted as part of the treatment of cancer pain at any stage of the WHO analgesic ladder, strong opioids are the mainstay of analgesic therapy in treating moderate to severe cancer-related pain. Nevertheless, with tightened regulations leading to a decrease in opioid prescribing across the United States, evidence points to a decline in opioid use among end-of-life care in those with cancer although there has been a rise in pain-related emergency department visits, suggesting that end of life cancer pain management may be worsening. Although medical marijuana has been studied and found to be efficacious for relief of pain in patients with advanced cancer pain not fully relieved by strong opioids, a 2016 review suggested that while marijuana may have the potential for refractory cancer pain, much of the data are based on animal data, small trials, or are outdated.
With the potential to help patients with cancer pain, in the current study, US researchers set out to assess the associations between medical marijuana legalisation and opioid-related and pain-related outcomes for adult patients receiving cancer treatment. The team used data from national commercial claims between 2012 to 2017. The researchers assessed several measures including the proportion of patients having 1 or more days of opioids and 1 or more pain-related emergency department visits or hospital events, during the 6 months after a new cancer diagnosis.
Medical marijuana and opiate use
A total of 38,189 patients with newly diagnosed breast cancer, 12,816 with colorectal cancer (55.4% male) and 7,190 (51.1% female) with lung cancer were included in the analysis.
Medical marijuana legalisation was associated with a reduction in the rate of 1 or more opioid days from 90.1% to 84.4% (difference = 5.6, 95% CI 2.2 – 9.0, p = 0.01) among breast cancer patients. For colorectal cancer patients, there was also a reduction, this time from 89.4% to 84.4% (difference = 4.9, 95% CI 0.5 – 9.4, p = 0.03). Finally, opioid use reduced from 31.5% to 22.1% (difference = 9.4, 95% CI 0.8 – 17.9, p = 0.03) among patients with lung cancer with recent opioids.
Medical marijuana legalisation was also associated with a reduction in the rate of 1 or more pain-related hospital events from 19.3% to 13.0% (difference = 6.3, 95% CI 0.70 – 12.0, p = 0.03) among patients with lung cancer with recent opioids. However, the difference for the other two forms of cancer was not significant.
The authors concluded that medical marijuana legalisation was associated with a lower rate of opioid dispensing and pain-related hospital events among some adults receiving treatment for newly diagnosed cancer.
Citation
Bao Y et al. Medical Marijuana Legalization and Opioid- and Pain-Related Outcomes Among Patients Newly Diagnosed With Cancer Receiving Anticancer Treatment. JAMA Oncol 2022
19th December 2022
The COVID-19 pandemic period was associated with a higher level of advanced colorectal cancer diagnoses compared to pre-pandemic levels.
Italian researchers have found that the COVID-19 pandemic was associated with the diagnosis of more advanced stage colorectal cancer in comparison to pre-pandemic levels.
The World Health Organization describes how globally, colorectal cancer is the third most common cancer with nearly two million cases and almost one million deaths in 2020.
Nevertheless, despite screening programs being widely available, emerging data from, for example, the US, clearly shows how after the national lockdowns imposed because of COVID-19, while stool testing increased by 7%, there was a 16% decrease in colonoscopy between 2018 and 2020.
Consequently, there have been concerns that the pandemic together with a reluctance of patients to seek medical attention, could be associated with a risk of more advanced colorectal cancer at diagnosis.
Moreover, one modelling study estimated 1,176,942 to 2,014,164 fewer colorectal cancer screenings, 8,346 to 12,894 fewer colorectal cancer diagnoses and 6,113 to 9,301 fewer early-stage colorectal cancer diagnoses between 2020 and 2023.
Nevertheless, there has been a lack of real-world evidence on the actual level of advanced colorectal diagnoses because of COVID-19.
In the present study, the Italian team set out to determine if the pandemic was associated with more advanced oncologic stage and change in clinical presentation for patients with colorectal cancer.
The team undertook a retrospective, multicentre cohort study of all adult patients who underwent surgery for colorectal cancer from 1 March 2020, to 31 December 2021 (pandemic period) in comparison to 1 January 2018, to 29 February 2020 (the pre-pandemic period).
They considered any type of surgical procedure for colorectal cancer, including explorative surgery, palliative procedures, and atypical or segmental resections.
The primary outcome was advanced stage of colorectal cancer at diagnosis whereas secondary outcomes included distant metastasis and T4 stage.
A total of 17,938 patients with a mean age of 70.6 years (55.8% male) underwent surgery for colorectal cancer, 43.5% of whom had surgery during the pandemic period.
The proportion of patients with stage 1 disease was significantly lower during the pandemic period compared to the pre-pandemic phase (20.7% vs 23.3%, p < 0.001). In addition, there was a significantly higher proportion of stage 4 disease during the pandemic (15% vs 13.9%, p = 0.03).
Using regression analysis, the pandemic period was found to be significantly associated with an increased rate of advanced-stage colorectal cancer (odds ratio, OR = 1.07, 95% CI 1.01 – 1.13, p = 0.03), an aggressive biology (OR = 1.32, p < 0.01) and stenotic lesions (OR = 1.15, p = 0.03).
The authors concluded that the COVID-19 pandemic was significantly associated with a risk of a more advanced oncologic stage at diagnosis among patients undergoing surgery for colorectal cancer. They added that these results may indicate a potential reduced survival for these patients.
Citation
Rottoli M et al. Colorectal Cancer Stage at Diagnosis Before vs During the COVID-19 Pandemic in Italy. JAMA Netw Open 2022.
8th August 2022
Resistant starch does not reduce colorectal cancer (CRC) among patients with Lynch syndrome (LS) but does significantly lower the risk of developing non-colorectal LS cancers, according to the findings of a randomised, placebo-controlled trial by an international research team.
Lynch syndrome is characterised by an increased risk for the development of colorectal cancer, endometrial cancer and various other cancers because of a mutation in one of several mismatch repair genes. In effect, LS can be described as a hereditary cancer syndrome and is estimated that 1 in every 300 people may be carriers of an alteration in a gene associated with it.
Another option to help reduce the risk of CRC is through greater intake of dietary fibre. In 1972, Burkitt suggested that dietary fibre has a role in the prevention of certain large-bowel and other diseases which have become prevalent in Western countries.
Despite this belief which has subsequently popularised the importance of fibre for the prevention of colorectal cancer, a 2005 meta-analysis concluded that while dietary fibre intake is inversely associated with risk of colorectal cancer in age-adjusted analyses, after adjusting for other dietary risk factors, the association became non-significant.
In the present study, researchers recruited patients with LS as part of the CAPP2 study in which participants were randomised to receive aspirin and/or resistant starch and followed for several years with the primary hypothesis being that both interventions might prevent colorectal cancer.
The researchers focused on CAPP2 participants randomly assigned to resistant starch, which was given as a 30g daily supplement or matching placebo. The primary outcome was the development of colorectal cancers after 2 years whereas secondary outcomes focused on non-colorectal LS cancers which included those affecting the stomach/duodenum, urinary, ovarian and bile duct pancreas. In addition, non-LS cancer incidence, such as bladder, bone, breast, lung and many others, were also examined.
Resistant starch and cancer outcomes
A total of 918 participants with a mean age of 45 years (56.3% female) were included in the analysis, 463 of whom were randomised to resistant starch and followed for a mean of 25 months.
A total of 52 and 53 participants developed colorectal cancer in the resistant starch and placebo groups, which was not significantly different (incidence rate ratio, IRR = 0.85, 95% CI 0.58 – 1.25, p = 0.41). However, more patients in the placebo group developed non-colorectal LS cancers (27 vs 53) and this difference was significant (IRR = 0.52, 95% CI 0.32 – 0.84, p = 0.0075). Despite this reduction, there was no difference between the two groups for non-LS cancers (IRR = 0.88, 95% CI 0.56 – 1.40, p = 0.60).
The authors discussed that while resistant starch did not reduce colorectal cancer, there was a significant effect against non-colorectal LS cancers and concluded that this should be investigated further.
Citation
Mathers JC et al. Cancer Prevention with Resistant Starch in Lynch Syndrome Patients in the CAPP2-Randomized Placebo Controlled Trial: Planned 10-Year Follow-up Cancer Prev Res (Phila) 2022
11th July 2022
Cancer screening for breast, colorectal and cervical cancers was significantly reduced during the period of the pandemic compared to pre-pandemic levels according to the results of a systematic review by a group of Italian and US researchers.
According to GLOBOCAN in 2020 there were an estimated 19.3 million new cancer cases and almost 10.0 million cancer deaths and that cancer screening has contributed to a decrease in both cancer morbidity and mortality. As a result, any reduction in screening could potentially lead to a surge in cases. In fact, modelling studies have already indicated a possibly large increase in cases due to the pandemic.
Moreover, in a UK-based modelling study, the authors estimated that as a consequence of the pandemic, there would be a 7·9-9·6% increase in the number of deaths due to breast cancer up to year 5 after diagnosis and for colorectal cancer a 15·3 – 16·6% increase in additional deaths.
However, because of differences in the start date and duration of lockdown measures across the world, for the present study, the researchers wanted to examine how this variation impacted on screening. They focused on breast, colorectal and cervical cancer screening since the beginning of the pandemic and made a comparison with pre-pandemic levels.
The team searched all the major databases for observational studies and articles that reported data from cancer registries and which compared the level of screening tests performed before and during the pandemic and in different areas of the world.
Cancer screening reductions during the pandemic
A total of 39 articles were identified and included in the analysis with 21 related to breast, 22 colorectal and 11 for cervical cancers.
For the period between January and October 2020, there was an overall 46.7% (95% CI -55.5% to -37.8%) decrease in breast cancer screening in comparison the pre-pandemic level.
For colorectal cancer, the overall reduction was 44.9% (95% CI -53.8% to -36.1%) and this included a 52.5% reduction in colonoscopy, a 37.8% decrease in faecal occult blood testing and a 37.8% decrease in immuno-chemical testing.
With cervical cancer, the overall reduction was -51.8% (95% CI -64.7% to -38.9%).
Commenting on their findings, the authors noted that these reductions in screening occurred across the world but that there were some obvious differences. For example, Europe saw the largest reduction in mammography compared to North America. although the decrease for both colorectal and cervical cancer screening was similar in both areas.
The authors suggested that the most likely explanation for the reduced screening was the ‘stay at home’ order introduced during the early stages of the pandemic.
They concluded that there was a large reduction in cancer screening as a consequence of the COVID-19 pandemic and which could be associated with an increased number of deaths and called for further work to investigate the relationship between cancer diagnosis and treatment during the pandemic.
Citation
Teglia F et al. Global Association of COVID-19 Pandemic Measures With Cancer Screening: A Systematic Review and Meta-analysis JAMA Oncol 2022
9th June 2022
The use of screening endoscopy in women before the age of 50 is associated with a 55% lower risk of being diagnosed with colorectal cancer (CRC) at age 55. This was the conclusion of a prospective cohort study of US women.
Although incidence rates among those of screening age have decreased, data from the US shows that among individuals under 50 years of age, the incidence rate has increased by approximately 2% between 2011 and 2016.
According to the American Cancer Society, screening for CRC is associated with a significant reduction in CRC incidence and CRC-related mortality and have recommended that adults aged 45 years and older with an average risk of CRC should undergo regular screening.
Furthermore, long-term follow studies suggest that screening endoscopy is associated with a reduced colorectal-cancer mortality. Nevertheless, there are limited data on the value of screening endoscopy in younger patients.
For the present study, the US researchers used data in the Nurses’ Health Study II, primarily because participants in this prospective registry were aged 26 to 45 at enrolment and this therefore provided an opportunity to examine any potential associations between the age of screening endoscopy and the development of CRC.
Using 1991 as the baseline because this was the first year when questions about screening endoscopy were included, participants were asked in subsequent questionnaires if they had undergone sigmoidoscopy or colonoscopy in the past two years and the reason for this screening.
The primary endpoint was overall CRC incidence although the researchers included the incidence of younger-onset CRC (diagnosed before age 55) and CRC mortality as secondary outcomes.
Screening endoscopy and development of colorectal cancer
A total of 111,801 women with a median of 36 years at enrolment were included in the analysis and followed for 26 years, during which time 519 incident cases of CRC were documented. Compared to women who underwent screening endoscopy age 50 or later, those who underwent a screen before 45 years of age were more likely to have a family history of CRC.
When compared to women who did not undergo screening endoscopy, the adjusted hazard ratios (HRs) for any CRC were 0.37 (95% CI 0.26 – 0.53) for women aged under 45 years, 0.43 (95% CI 0.29 – 0.62) for those 45 to 49 years of age and 0.46 (95% CI 0.30 – 0.69) for those 55 years and older. Hence there was a significantly lower risk of incident CRC when screening was started before the age of 45.
The authors calculated that the absolute reduction in the estimated cumulative incidence of CRC up to age 60 was 72 per 100,00 people if screening endoscopy was started between the ages of 45 to 49 compared to being performed between the ages of 50 to 54.
The risk of being diagnosed with CRC at age 55 was 55% lower if screening was started before the age of 45 (HR = 0.45, 95% CI 0.29 – 0.70) and equally lower (HR = 0.43) when started between the ages of 45 and 49.
The authors concluded that earlier screening endoscopy (before 50 years of age) was associated with a significantly lower risk of both CRC and a diagnosis before age 55.
Citation
Ma W et al. Age at Initiation of Lower Gastrointestinal Endoscopy and Colorectal Cancer Risk Among US Women JAMA Oncol 2022
6th May 2022
Globally, cancer of the colon and rectum (colorectal cancer) was diagnosed in 1.93 million people in 2020 and responsible for 916,000 deaths. Moreover, screening colonoscopy has been shown to be associated with a substantial decreased mortality risk.
CT colonography (CTC) is a minimally invasive test that uses CT scans to check the colon and rectum. In a 2008 study, the authors concluded that CTC screening identified 90% of subjects with adenomas or cancers measuring 10 mm or more in diameter and that the results augmented published data on the role of CTC in screening patients with an average risk of colorectal cancer. However, to date, there is limited information on the sociodemographic factors that might influence uptake of CTC.
For the present investigation, the researchers turned to the National Health Interview Survey (NHIS), which is a nationally representative cross-sectional survey and used data collected in 2019.
Included participants were aged 50 to 75 years of age and with no recorded history of colorectal cancer. In the NHIS survey, individuals were asked about whether or not they ever had a CTC and if they responded positively, when the scan had been performed.
The researchers collected additional information on age, gender, ethnicity and employment status. They employed multiple variable logistic regression to evaluate predictors of CTC use.
Predictors of CTC utilisation
A total of 13,709 individuals with a mean age of 61.4 years (52.7% female) were included in the analysis, of whom, 70.3% were White, 10.4% Black and 12.1% Hispanic.
In total, only 1.4% of participants reported having previously undergone CTC and, of these, 39.9% had the procedure within the last 12 months.
When analysing the association between CTC use and ethnicity, Hispanic individuals were more than twice as likely to undergo CTC compared with White participants (OR = 2.67, 95% CI 1.66 – 4.29, p < 0.001). There was also a similarly higher use among Black individuals (OR = 2.47, 95% CI 1.60 – 3.82, p < 0.001) than White participants.
Among the other sociodemographic factors examined, only participants who reported that they worked in the last week were significantly less likely to have a CTC (OR = 0.61, 95% CI 0.40 – 0.94, p = 0.024).
One limitation recognised by the authors was how the study data were collected in 2019 prior to the COVID-19 pandemic and therefore they were unable to assess any potential impact on CTC uptake. They concluded that strategies improving access to CTC services could mitigate the observed racial disparities.
Citation
O’Connor B et al. Predictors of CT Colonography Use: Results From the 2019 National Health Interview Cross-Sectional Survey J Am Coll Radiol 2022
19th January 2022
The presence of neoplasia or precancerous lesions, have been identified after colorectal screening in patients aged 45 to 49 years of age, highlighting the need for lowering the age of such screening for average risk individuals. This was the finding from an examination of real-world outpatient colonoscopy data by a team from the Dr. Henry D. Janowitz Division of Gastroenterology, New York, US.
Colorectal cancer is a malignant tumour that forms in the tissues of the colon and is often grouped together with rectal cancer, due to the fact that these cancers share common features. During 2020 in Europe, colorectal cancer became the second most common cancer and the second highest cause of cancer death, accounting for 12.7% of all new cancer diagnoses and 12.4% of cancer deaths.
Moreover, the importance of screening has been highlighted in a study which observed that the largest decreases in colorectal cancer mortality were seen in countries with long-standing screening programmes.
The incidence of early-onset colorectal cancer (i.e., cases in those aged under 50 years of age) has seen a world-wide increase, especially in high-income countries although the reasons behind this increase are uncertain.
In addition, data suggests that the incidence of deaths due to early-onset colorectal cancer are also rising, had that these had increased by 1.3% annually between 2008 and 2017, in those aged younger than 50 years. Despite this, most screening programmes in Europe begin at 50 years of age.
But could there be an advantage from earlier screening and could this help identify those with neoplasia? This was the aim of the present study and the US team analysed data from a large and nationally representative set of outpatient colonoscopies to identify colorectal neoplasia among patients aged 18 to 54 years of age.
They undertook a retrospective analysis of colonoscopy data and compared a ‘young onset group (defined as aged 18 to 49) with those aged 50 to 54 years.
Findings
A total of 562,559 colonoscopy procedures were included in the analysis, 145,998 of which were undertaken in those aged 18 to 44 years and 79,934 in those aged 45 to49 years.
Among individuals aged 45 to 49, approximately 32% had any form of neoplasia, 7.5% had advanced premalignant lesions and 0.58% had colorectal cancer with a neoplasia present in 26.6% of those aged 40 to 44 years.
Discussing their findings, the authors stated that in a representative sample of patients under 50 years of age, the prevalence of any neoplasia among those aged 45 to 49 were almost as high as in those in the 50 to 54 year olds. They concluded that lowering the screening age to 45 will likely enable the detection of important pathology more frequently.
Citation
Trivedi PD et al. Prevalence and Predictors of Young-Onset Colorectal Neoplasia: Insights from a Nationally Representative Colonoscopy Registry Gastroenterology 2022.
4th January 2022
Dietary supplements (DS) are used by 40% of adult patients diagnosed with either breast, prostate or colorectal cancer according to research by a team from the Department of Behavioural Science and Health, University College London, UK.
Survival from cancer appears to be increasing, with a 2018 global surveillance study finding that survival trends are generally increasing, even for some of the more lethal cancers.
While evidence supporting various strategies aimed at reducing cancer risk in those living with and beyond cancer is rather limited, a 2018 report by the World Cancer Research fund and the American Institute for Cancer research, is clear in its view that ‘high-dose dietary supplements are not recommended for cancer prevention’, encouraging individuals to meet their nutritional needs through diet alone.
Nevertheless, some data shows that cancer survivors tend to report a higher usage of DS than those with the disease.
For the current study, the authors sought to gain a better understanding the range of and reasons for, use of DS among survivors of breast, prostate and colorectal cancer. They undertook a cross-sectional survey using data from the Advancing Survival Cancer Outcomes Trial (ASCOT) and asked respondents with each of the three cancers their thoughts about lifestyle and cancer, use of specific foods, e.g. fruits, vegetables, meat and high calorie foods together with information on the use of DS and any other non-prescribed treatments such as herbal extracts.
Respondents were asked to express their views (using a Likert scale) on the perceived importance of supplements as an approach to prevent cancer reoccurrence.
Findings
A total of 1049 participants with mean age of 64.4 years (62.1% female) provided usable data for analysis. Breast cancer was the most common (54.4%) among respondents, followed by prostate (25.2%) and colorectal (20.4%). In addition, the majority were of white ethnicity (94%) and 68% had either no (34.9%) or at least one co-morbidity.
In total, 40% of respondents reported DS use, of whom, 32% believed that these supplements were important for a reduction in cancer recurrence. The most commonly used form of supplements were fish oils (13.1%), followed by calcium and vitamin D (9.1%) and multivitamin and minerals (8.2%).
Using regression analysis, the only factors significantly associated with DS use were meeting the requirements for fruit and vegetable intake (odds ratio, OR = 1.36, 95% CI 1.02 – 1.82, p = 0.039), a belief in the importance of supplements to prevent cancer recurrence (OR = 3.13, 95% CI 2.35 – 4.18, p < 0.001) and the absence of obesity (OR = 0.58, 95% CI 0.38 – 0.87, p = 0.010).
The authors concluded that DS use among cancer survivors was common and influenced by patient’s beliefs about recurrence. They added that further work was required to better understand the reasons for such beliefs and how best to provide appropriate supplement advice to those living with a cancer diagnosis.
Citation
Conway RE et al. Dietary supplement use by individuals living with and beyond breast, prostate, and colorectal cancer: A cross‐sectional survey Cancer 2021.
10th December 2021
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
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
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