Two studies explore impact of pandemic on colorectal cancer screening and diagnosis

(Press-News.org) INDIANAPOLIS – Two recent studies by researchers from Regenstrief Institute and the Indiana University School of Medicine explore the effect of the pandemic on colorectal cancer screening tests and diagnostic colonoscopies in Central Indiana. The findings of temporary disruption to the former and minimal impact on the latter are similar to findings across the U.S., contributing to the compendium of knowledge on preventive health uptake and subsequent treatment in various populations during the pandemic.

One study, published in PLoS One, examines both non-invasive and colonoscopy screening trends during the pandemic. The other study, published in Preventive Medicine Reports, evaluates the interval between a positive non-invasive screening test and subsequent diagnostic colonoscopy.

The findings of both studies are based on deidentified electronic health record (EHR) data from both a public and a private healthcare system and are germane to discussions of the pandemic’s influence on future incidence of this potentially deadly disease.

Colorectal cancer develops in the colon or rectum, which are parts of the large intestine. It is the second most common cancer in the U.S. in men and women combined and the second-leading cause of cancer deaths. The American Cancer Society estimates the disease will cause about 52,900 deaths in the U.S. in 2025. Regular colorectal screening is a significant way of preventing or catching colorectal cancer at an early, more curable stage.

Colorectal cancer screening trends over 30 months showed sharp decline and rapid rebound

“The effect of the pandemic on colorectal cancer screening, especially colonoscopies, was profound at two multi-facility healthcare systems in Central Indiana over a 30-month period prior to and during the first 18 months of COVID-19. There were literally no screening colonoscopies performed during April of 2020, reflecting the illiquid nature of screening and the acuity of the pandemic which dictated the need for the apportioning of resources to other healthcare needs but this rebounded within a few months,” said Regenstrief Institute and the IU School of Medicine researcher-clinician Thomas F.  Imperiale, M.D., the senior author of both studies. “Noninvasive testing done at home declined as well but rebounded faster – both FIT (fecal immunochemical tests) and FIT/DNA tests.”

FIT detects hidden blood in stool. FIT/DNA examines stool for both occult blood and biomarkers for DNA mutations associated with colorectal cancer.

Examining data from January 2019 to June 2021 (a longer period than evaluated in most other studies of pandemic-era colorectal cancer screening around the world), the researchers highlighted that overall colonoscopy volume declined by about 19 percent in 2020 compared to 2019 but returned to baseline in 2021, with no difference in early versus late-stage cancers detected. These findings were based on 16,939 FIT tests, 2,942 FIT/DNA tests and 38,332 screening colonoscopies.

“As we found, health services don't necessarily have to come to a stop during events that tax the healthcare system. When it comes to colorectal cancer screening, the alternatives to colonoscopy came more into the public eye during the pandemic, especially the early months when people were concerned about leaving their homes,” said Dr. Imperiale. “Future studies should focus on evaluating the effectiveness of remote monitoring technologies and telehealth interventions to facilitate colorectal cancer screening because this is unlikely to be the last pandemic.

“To be able to offer preventive services to people who do not want or are unable to physically see the doctor, we can rely on telehealth as we did during the pandemic. We need to further develop or at least maintain this technology so that telehealth options are available for the next pandemic or the next time it becomes necessary to modify our healthcare practices.”

In addition to highlighting the need for strategies to mitigate the impact of future disruptions -- pandemics or other -- on healthcare services, the authors call for public health campaigns and initiatives that promote the use of non-invasive testing while maintaining adequate access to diagnostic colonoscopy for individuals with positive screening results.

“Effect of the COVID-19 pandemic on colorectal cancer screening in two university-affiliated health care systems” is published in PLoS One. The study was supported by the Advanced Scholars Program for Internists in Research and Education (ASPIRE) within the Department of Medicine at the IU School of Medicine and by Regenstrief Institute.

Authors and affiliations as listed in the paper:

Vinod Kumar1, Lilian Golzarri-Arroyo2, Sarah Roth3, Thomas F Imperiale3,4

1Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, IN, United States of America. 2Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN, United States of America. 3Center for Health Services Research, Regenstrief Institute Inc, Indianapolis, IN, United States of America. 4Division of Gastroenterology & Hepatology, Department of Medicine Indiana University School of Medicine, Indianapolis, IN, United States of America. Interval between positive non-invasive screening result and diagnostic colonoscopy did not increase during pandemic

“Although there was a mild delay in follow-up diagnostic colonoscopy after a positive non-invasive screening in 2020 compared with 2019 and 2021, it wasn't concerning. We found that the proportion of people completing colonoscopy did not differ numerically. It was still over 70 percent over the two-and-a-half-year period, which is quite good,” said Dr. Imperiale. “Follow-up diagnostic colonoscopies were a priority during the pandemic for both patients and healthcare systems in Central Indiana as other studies have shown nationally.”

While timeliness of completion of a diagnostic colonoscopy was similar for users of both FIT and FIT/DNA screening who tested positive, those who had used a FIT/DNA screening test were more likely to follow-up with a diagnostic colonoscopy than FIT users.

“We did this study because we wanted to know what was happening in our part of the country and because we had not seen studies from other geographic areas on this specific, most important aspect of colorectal cancer screening, which is follow up on a positive, noninvasive test,” said Dr. Imperiale. “And the few studies we did find reported similar delays, but hadn't looked, as we did, much beyond the peak of the pandemic period.”

Diagnostic colonoscopy is a test performed because of a symptom such as rectal bleeding or abdominal pain, a sign such as anemia or unintentional weight loss, or following a positive screening test. A short interval between screening procedure and a diagnostic colonoscopy is preferable in order to find a lesion early, before it advances in stage and while it is most curable.

“Impact of the COVID-19 pandemic on adherence to diagnostic colonoscopy after a positive non-invasive screening test for colorectal cancer in two Indiana healthcare systems” is published in Preventive Medicine Reports. The study was supported by the Advanced Scholars Program for Internists in Research and Education (ASPIRE) within the Department of Medicine at the IU School of Medicine and by Regenstrief Institute.

Authors and affiliations as listed in the paper:

Benjamin Richter1, Sarah M Roth2, Lilian Golzarri-Arroyo3, Vinod Kumar4, Rick Tuason5, Thomas F Imperiale1,2

1Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States. 2Center for Health Services Research, Regenstrief Institute, Indianapolis, IN, United States. 3Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, IN, United States. 4Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN, United States. 5Clinical Research Systems, Indiana University Health, Indianapolis, IN, United States.  Thomas F. Imperiale, M.D. 

In addition to his role as a research scientist at Regenstrief Institute, Thomas F. Imperiale, M.D., is a core investigator for the U.S. Department of Veterans Affairs Health Systems Research, Richard L. Roudebush VA Medical Center. He is the Lawrence Lumeng Professor of Gastroenterology and Hepatology at the Indiana University School of Medicine as well.

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