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Colorectal Cancer Screening in the Novel Coronavirus Disease-2019 Era

2020; Elsevier BV; Volume: 159; Issue: 6 Linguagem: Inglês

10.1053/j.gastro.2020.09.018

1528-0012

Evelien Dekker, Han‐Mo Chiu, Iris Lansdorp‐Vogelaar, Luís Ernesto, Jason A. Dominitz, Stephen P Halloran, Cesare Hassan, Julia Ismael, Rodrigo Jover, Michał F. Kamiński, Tim Kortlever, Ernst J. Kuipers, Theodore R. Levin, Takahisa Matsuda, Dominika Novak Mlakar, Lix Alfredo Reis de Oliveira, Susan Parry, Linda Rabeneck, Matthew D. Rutter, Roque Sáenz, Carlo Senore, Graeme P. Young, Ning Zhang,

COVID-19 diagnosis using AI

"All major population-based screening programs will shortly grind to an unseemly halt." If this had been the title of a WEO Screening Committee meeting presentation in October 2019, it would have been described as sensationalist, an exaggeration, perhaps even fiction. However, in the context of the impact that the novel coronavirus disease-2019 (COVID-19) pandemic has had on endoscopic services over the last months, it can no longer be dismissed. But will we be prepared for the next pandemic? Will lessons have been learned? The COVID-19 pandemic is an unprecedented global health crisis that has so far led to the deaths of more than half a million people. It has severely challenged the provision of routine health care, including screening for colorectal cancer (CRC).1COVID-19 Dashboard by the Center of Systems Science and Engineering at John Hopkins University.https://coronavirus.jhu.edu/map.htmlGoogle Scholar Many countries curtailed CRC screening, in the face of staff relocation, diminishing health care resources, government-imposed isolation measures, and the fear of spreading the virus during endoscopic procedures. Although an effective response to the COVID-19 pandemic is of utmost importance, failing to screen will in itself increase mortality. In regions where the spread of the virus is under control, the focus needs to extend to responsibly restoring screening. This article explores the impact that the pandemic has currently had on CRC screening, it identifies issues that need to be addressed to successfully resume screening, and it describes how to transform CRC screening to mitigate the adverse clinical impact of future outbreaks of COVID-19 and other infectious agents. The COVID-19 pandemic has challenged the provision of routine health care, resulting in a temporary curtailment of many CRC screening programs. The WEO Colorectal Cancer Screening Committee focuses on the science and practice of CRC screening and has a large membership from all parts of the world. A survey of selected members of this committee showed that most national and regional screening programs paused or markedly curtailed their provision of screening during the pandemic. This was influenced by national and regional policies, differences in healthcare systems and the structure and methodology adopted by the different screening programs. Although many programs were forced to pause all screening-related activities, including the provision of colonoscopy for fecal immunochemical test (FIT)-positive individuals, others maintained a colonoscopy service with markedly reduced capacity. Some centers in the United States used FIT positivity to prioritize colonoscopies for symptomatic patients. Some countries that successfully contained the spread of severe acute respiratory syndrome novel coronavirus-2 (SARS-CoV-2), such as Taiwan and Australia, continued CRC screening. Others with stringent and effective lockdowns, such as New Zealand, were able to pause for a short period. As screening programs around the world were forced to constrain their routine services, many people found themselves unable to participate in screening or subject to long delays for colonoscopy after a positive FIT or guaiac fecal occult blood test and therefore the possibility of later stage cancer diagnosis. Previous studies have shown that delaying colonoscopy by >9 months after a positive FIT can lead to increased risk of CRC and advanced stage CRC.2Corley D.A. Jensen C.D. Quinn V.P. et al.Association between time to colonoscopy after a positive fecal test result and risk of colorectal cancer and cancer stage at diagnosis.JAMA. 2017; 317: 1631-1641Crossref PubMed Scopus (194) Google Scholar,3Lee Y.C. Fann J.C. Chiang T.H. et al.Time to colonoscopy and risk of colorectal cancer in patients with positive results from fecal immunochemical tests.Clin Gastroenterol Hepatol. 2019; 17: 1332-13340 e3Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar Performing a colonoscopy during the pandemic has been associated with SARS-CoV-2 infection, albeit in only a few cases. Endoscopists in Northern Italy reported a 1% rate of SARS-CoV-2 infection among endoscopy patients, and a lower rate of infection among endoscopy personnel (4.3%) than among all health care workers (10%).4Repici A. Aragona G. Cengia G. et al.Low risk of covid-19 transmission in GI endoscopy.Gut. 2020; 69: 1925-1927Crossref PubMed Scopus (102) Google Scholar In the United States, colonoscopy is considered a potential aerosol generating procedure and the presence of SARS-CoV-2 RNA in fecal samples has been reported in a marked proportion of infected patients.5The ACG Endoscopy Resumption Task Forceguidance on safely reopening your endoscopy center.https://webfiles.gi.org/docs/policy/2020resuming-endoscopy-fin-05122020.pdfGoogle Scholar, 6Sultan S. Lim J.K. Altayar O. et al.AGA rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic.Gastroenterology. 2020; 159: 739-758Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar, 7Guda N.M. Emura F. Reddy D.N. et al.Recommendations for the operation of endoscopy centers in the setting of the COVID19 pandemic - a WEO guidance document.Dig Endosc. 2020 Jun 22; ([Epub ahead of print])Crossref Scopus (22) Google Scholar, 8Cheung K.S. Hung I.F.N. Chan P.P.Y. et al.Gastrointestinal manifestations of SARS-CoV-2 infection and virus load in fecal samples from a Hong Kong cohort: systematic review and meta-analysis.Gastroenterology. 2020; 159: 81-95Abstract Full Text Full Text PDF PubMed Scopus (1145) Google Scholar To decrease the risk of infection, preprocedure testing of patients or regular testing of staff for SARS-CoV-2 can be considered, after factoring in the availability of testing material, the local case rates of COVID-19, and the limited yield of testing in asymptomatic individuals. Also, personal protective equipment (eg, gloves, gowns, glasses, and face masks) should be worn during a screening colonoscopy or sigmoidoscopy.9Gralnek I.M. Hassan C. Beilenhoff U. et al.ESGE and ESGENA Position Statement on gastrointestinal endoscopy and the COVID-19 pandemic.Endoscopy. 2020; 52: 483-490Crossref PubMed Scopus (258) Google Scholar Standard surgical face masks can be used during the endoscopy of a patient with a negative SARS-CoV-2 test or a patient without COVID-19 symptoms, not having been in close unprotected contact with an infected individual, and not having recently ( 40 years old and iron deficiency anemia in nonmenstruating persons). Finally, efforts made to minimize a decrease in endoscopic capacity will mean that doctors have to work more hours and will inevitably also compete with time consuming academic, teaching and research activities. An important concern when resuming screening is the potential disruptive impact that the COVID-19 pandemic might have on participation. Fear of contracting SARS-CoV-2 from health care settings has been widely reported and has resulted in delayed presentations of patients with a cardiovascular emergency.19Pessoa-Amorim G. Camm C.F. Gajendragadkar P. et al.Admission of patients with STEMI since the outbreak of the COVID-19 pandemic: a survey by the European Society of Cardiology.Eur Heart J Qual Care Clin Outcomes. 2020; 6: 210-216Crossref PubMed Scopus (169) Google Scholar This fear may affect screening, especially with primary endoscopic screening or after FIT-positive colonoscopy. In addition, loss of employment-linked insurance due to a pandemic-induced economic crisis may lead to a decrease in screening participation, especially among minority groups. Many studies have demonstrated that public awareness and the way screening services are provided significantly influences screening uptake.20Senore C. Inadomi J. Segnan N. Bellisario C. Hassan C. Optimising colorectal cancer screening acceptance: a review.Gut. 2015; 64: 1158-1177Crossref PubMed Scopus (97) Google Scholar When resuming CRC screening after an outbreak of SARS-COV-2, various approaches might encourage CRC screening participation. In regions where participants collect their kits from family practitioners, pharmacists, or hospitals, direct mailing of the FIT screening kit could be considered and might even increase uptake in both organized and opportunistic screening programs. Leading screening physicians, but also (well-known) patients, could consider promoting public awareness of CRC screening and its importance in local and national media during the pandemic.21Back A. Tulsky J.A. Arnold R.M. Communication skills in the age of COVID-19.Ann Intern Med. 2020; 172: 759-760Crossref PubMed Scopus (98) Google Scholar A centralized communication team could exploit telemedicine or telephone communication instead of physical appointments to invite and encourage screening participation and colonoscopy attendance. It might also be worthwhile offering multiple screening choices to facilitate screening compliance.22Inadomi J.M. Vijan S. Janz N.K. et al.Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies.Arch Intern Med. 2012; 172: 575-582Crossref PubMed Scopus (471) Google Scholar Last, public confidence in safety of attending colonoscopy units could be restored by promoting regular testing of staff as well as patients.23Larremore D.B. Wilder B. Lester E. et al.Test sensitivity is secondary to frequency and turnaround time for COVID-19 surveillance.medRxiv. 2020; (2020.06.22.20136309)PubMed Google Scholar To measure the impact of the pandemic and the effect of measures taken to restart CRC screening, various indicators seem relevant (Table 1). Established measures of the early impact of screening, such as the detection rate of neoplastic lesions, stage distribution of screen detected cancers and interval cancer rate, allow us to assess the impact of the delay on these outcomes. We should consider the rate of COVID-19 infections associated with colonoscopies performed in screening programs and its impact on diagnostic follow-up for CRC. This will provide information about the actual risk associated with these procedures, as well as about the effectiveness of protective measures.Table 1Proposed Indicators to Assess the Impact of the COVID-19 Pandemic on Screening and Outcomes for Colorectal CancerProcess IndicatorsOutcome IndicatorsPercentage of delayed screening invitations (3–6, 6–12 months and ≥12 months)Response rate to screening invitationPositivity rate of FIT/gFOBTDetection rate of CRC and advanced adenomasInterval between positive FIT/gFOBT result and colonoscopyStage distribution of detected cancersProportion of refused/rescheduled appointments related to COVID-19Interval cancer rateRate of SARS-CoV-2 infections associated with CRC screening and diagnostic follow-upCRC-related mortalityCOVID-19, coronavirus disease-2019; CRC, colorectal cancer; FIT, fecal immunochemical test; gFOBT, guaiac fecal occult blood test. Open table in a new tab COVID-19, coronavirus disease-2019; CRC, colorectal cancer; FIT, fecal immunochemical test; gFOBT, guaiac fecal occult blood test. To ensure successful operation of the program during the transition to routine screening, indicators of short-term screening activity are useful. The response rate of people invited for primary screening or to colonoscopy following a positive FIT test, should be monitored so that organizational barriers and subjects' fears and concerns about the potential risk of infection can be addressed in a timely fashion. This could also include the possibility to stratify the data based on postal code or ethnicity to detect general disparities in health access between social groups. Consideration should be given to introducing a new indicator designed to measure the proportion of refusals or rescheduled appointments for colonoscopy after a positive screening test related to COVID-19 (mainly fear of being infected when attending an examination in an endoscopy center24Rex D.K. Vemulapalli K.C. Lahr R.E. et al.Endoscopy staff are concerned about acquiring COVID-19 infection when resuming elective endoscopy.Gastroenterology. 2020; 159: 1167-1169Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar,25Podboy A. Cholankeril G. Cianfichi L. et al.Implementation and Impact of Universal Pre-procedure Testing of Patients for COVID-19 prior to Endoscopy.Gastroenterology. 2020; 159: 1586-1588Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar). In addition to existing indicators of screening activity (eg, invitation coverage and wait time for diagnostic colonoscopy), new indicators based on the observed trends are needed to support decisions on recovery plans. Strict and continuous real-time monitoring of the number of procedures performed in each program/ or , as well as of the backlog, provides the necessary information to estimate the expected time to a complete recovery, to assess the ability of the program to achieve the expected targets and to make quick adjustments as problems became apparent. Ideally, continuous rather than categorical data should be collected to assess the association between the delay and the outcome. Because the COVID-19 pandemic is unprecedented, there are no clinical studies to inform decision making for our screening programs. That is where well-established and validated decision models using closely monitored outcomes from existing and new indicators come into play. Modelers from all around the world have joined forces in the COVID-19 and Cancer Global Modelling Consortium (ccgmc.org) to simulate different scenarios of disruption and recovery strategies and predict both long-term outcomes of CRC cases and deaths as well as short-term and long-term costs and savings. Comparing the benefits, harms, and costs of the different scenarios, policymakers can decide on the best recovery strategy for their programs. Will we be prepared for the next pandemic? Will lessons have been learned? We, as an expert working group, describe the following observations from which lessons are to be learned (Table 2).Table 2Observations of the Impact of the COVID-19 Pandemic on Colorectal Cancer ScreeningHealth care resources can be rapidly overwhelmed during a pandemic.If screening is not considered to be of high priority, it may be ignored by policymakers responding to a pandemic, especially if prior planning is lacking or delegation ineffective.Available screening staff will quickly be diminished, be redeployed to acute services, or be indisposed due to personal or family illness or enforced isolation.Without a plan, FIT-kit distribution, laboratory analysis and endoscopic activity can be uncoordinated and disrupted.Without previously prepared media releases or personal communications, the public will not be adequately informed about screening arrangements.Public anxiety can grow about missed tests, positive FIT results without a colonoscopy appointment, cancelled appointments and fear of contracting COVID-19 in an endoscopy unit.Personal Protective Equipment may not be available for (screening) endoscopy.Screening IT and communication systems may not be supported owing to staff shortages or modified priorities.Without prior planning, it will not be clear how to prioritize a backlog of FIT-kits awaiting distribution or testing and many months of delayed endoscopy and associated surgery.New or existing endoscopy units may be unsuited to social distancing and may compromise the safety of patients and staff not wearing protective gear.COVID-19, coronavirus disease-2019; FIT, fecal immunochemical test; gFOBT, guaiac fecal occult blood test. Open table in a new tab COVID-19, coronavirus disease-2019; FIT, fecal immunochemical test; gFOBT, guaiac fecal occult blood test. The multiple steps in the CRC screening process make it a complex enterprise that can be easily affected if one component fails. The observations described in Table 2 could inform plans to strengthen screening programs and decrease the risk of major service disruption in future pandemic waves. Policymakers must recognize that cancer screening is an important component of modern health care. The COVID-19 pandemic provides an opportunity for screening programs to reflect on their current arrangements and decide whether, if reorganized, they could increase coverage, uptake, and clinical effectiveness, as well as being more robust to a future disruption. Considerations should include what proportion of endoscopy capacity is allocated to screening, and how to maximize its yield with limited capacity (eg, by moving from colonoscopy to a noninvasive screening test or adjusting the positivity cut-off for FIT-screening). Finally, we should reflect on how well we communicate with the public, ensure safety for patients and staff during endoscopic procedures, and strengthen communication and collaboration between screening, surgery, and oncology. These plans can be made and implemented with the help of sound evidence from the current crisis. Extensive monitoring and review of the current restart and upscaling efforts of CRC screening is therefore of vital importance. Already in the pre-COVID era, health care systems worldwide were forced to deal with increasing demands, shortage in workforce, and budget constraints. These factors all strengthened the need for prevention, such as with relevant cancer screening programs. These programs reduce the need for intense treatments of patients with advanced disease. The COVID-19 pandemic has markedly increased the constraints as discussed elsewhere in this Commentary and thus makes CRC screening far more instead of less relevant. We are presented with an opportunity to strengthen CRC screening programs as we resume services blighted by the pandemic. By learning from this crisis, we can have a robust plan for the next! The contents of this work do not represent the views of the Department of Veterans Affairs or the United States Government. Luis Ernesto Caro4, Jason A. Dominitz5,6, Stephen Halloran7,8, Cesare Hassan9, Julia Ismael10, Rodrigo Jover11, Michal F. Kaminski12, Tim Kortlever1, Ernst J. Kuipers13, Theodore R. Levin14,15, Takahisa Matsuda16, Dominika Novak Mlakar17, Lix A.R. Oliveira18, Susan Parry19,20, Linda Rabeneck21,22, Matthew Rutter23,24, Roque Sáenz25, Carlo Senore26, Graeme P. Young27, Ning Zhang28. 4LATAM Chairman Scr CCR WEO, President of the Gedyt Foundation. General Director of the Gedyt, Director of the Digestive Endoscopy Specialist Career, Permanent Secretary of SIED; 5Gastroenterology Section, VA Puget Sound Health Care System, Seattle, Washington; 6University of Washington School of Medicine, Seattle, Washington; 7Faculty of Health and Medical Science, University of Surrey, Guildford, UK; 8Public Health England; 9Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy; 10Clinical Oncologist, Policy Researcher - Global Health, Former Director NCI, Director of the Gedyt Foundation; 11Servicio de Medicina Digestiva. Hospital General Universitario de Alicante. Instituto de Investigación Biomédica ISABIAL. Alicante, Spain; 12Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland; 13Erasmus MC University Medical Center, Rotterdam, The Netherlands; 14Kaiser Permanente Division of Research, Oakland, California; 15Kaiser Permanente Medical Center, Walnut Creek, California; 16Cancer Screening Center, Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan; 17National Institute of Public Health, Cancer Screening, Ljubljana, Slovenia; 18Pontifical Catholic University, Campinas, Brazil. Member of Brazilian Society and Interamerican Society of Prevention of Colorectal Cancer (SOBED)(SIED); 19National Bowel Screening Programme, National Screening Unit, Ministry of Health, Wellington, New Zealand; 20New Zealand Familial Gastrointestinal Cancer Service, Auckland Hospital, Auckland, New Zealand; 21Department of Medicine, University of Toronto; 22Prevention and Cancer Control, Ontario Health (Cancer Care Ontario), Toronto, Canada; 23Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK; 24Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, UK; 25Universidad del Desarrollo, Clinica Alemana Santiago, Santiago, Chile; 26Epidemiology and screening unit – CPO, University hospital Città della Salute e della Scienza, Turin, Italy; 27Cancer Research, Flinders Health and Medical Research Institute, Flinders University. Adelaide, SA, Australia; 28Department of Gastroenterology, The first affiliated hospital of Sun Yat-sen University, Guangzhou, P.R. China.