- A survey of adults eligible for colorectal cancer screening patterns found a preference for at-home fecal occult blood testing (FOBT) versus colonoscopy during the COVID-19 pandemic.
- Survey respondents reported less use of colonoscopy during the pandemic compared to pre-pandemic levels, with factors related to both COVID-19 infection concerns and the financial strain of having copays.
- FOBT shows potential as an alternative to screening colonoscopy to improve access to colorectal cancer screening in the context of COVID-19 safety and economic concerns.
CHICAGO: The impact of the COVID-19 pandemic on patients’ willingness to keep appointments for non-COVID-19 illnesses has been well documented, but a team of researchers at Virginia Commonwealth University report that for people hesitant to come into the hospital or an outpatient center to get a colonoscopy, home-administered fecal occult blood tests (FOBT) may provide a useful workaround tool. About 30 percent more survey respondents completed home-based test during the pandemic than before.
Kristine Kenning, MD, MS, presented findings from a survey of adults age-eligible for screening at the virtual American College of Surgeons (ACS) Clinical Congress 2021. “The key message from our findings is that barriers to screening have increased during the pandemic, and we have to find a way to work with the community to increase those rates,” said Dr. Kenning, chief general surgery resident at Virginia Commonwealth University (VCU) School of Medicine, Richmond. “Our study found that people are compliant with, and willing to do, home-based fecal occult blood testing. This test provides a very important way for us to increase screening for colorectal cancer.”
The American College of Gastroenterology clinical guidelines recommend colonoscopy for colorectal cancer evaluation and following a positive FOBT with a colonoscopy.1 About 148,000 cases of colorectal cancers are newly diagnosed in the United States each year, the American Cancer Society reports, and they account for 53,000 deaths.2
About the survey
The cross-sectional survey involved 765 people age 50 years and older. Dr. Kenning and colleagues found that their respondents reported a higher completion of stool tests pre-COVID than the American Cancer Society reported,2 32 percent vs. 11 percent. During the pandemic, 50 percent of respondents said they completed the FOBT. By contrast, 44 percent of survey respondents who said they had colon screening during the pandemic underwent a colonoscopy. This practice appears to demonstrate substitution of stool-based testing for colonoscopy, Dr. Kenning noted.
“Our study looked at attitudes toward colorectal cancer screening and how they were impacted during the pandemic, both related to concerns about the pandemic as well as to economic impacts,” senior author Emily B. Rivet, MD, MBA, FACS, said. “What we learned is that fecal occult blood testing was seen by patients as a viable alternative to conventional screening colonoscopy.” Dr. Rivet is an associate professor in the department of surgery, division of colorectal surgery, and an affiliated professor of internal medicine at VCU School of Medicine.
Patient concerns about copays
Notably, a greater percentage of respondents indicated being unemployed during the pandemic than the year prior: 7.4 vs. 2.6 percent. In addition, 41 percent of respondents expressed concerns about copays; 57.6 percent of those respondents said this was a factor for delaying screening. Dr. Kenning noted that she is working with Carrie Miller, PhD, MPH, the principal investigator of the larger survey, on a follow-up assessment of the pandemic-related impact on attitudes toward colorectal cancer screening. Dr. Miller is post-doctoral fellow with VCU’s department of health behavior and policy.
Other screening delays
Copays were not the only deterrent to getting scheduled colorectal screenings during the pandemic, the study found. Almost two-thirds of respondents—65.9 percent—confirmed concerns about COVID-19 exposure when scheduling colonoscopies; and 59 percent of them said this caused them to delay their screening.
To address those concerns, respondents endorsed that being offered protective equipment (gloves and masks), visits to smaller offices, or weekend screening appointments would increase their likelihood of following through with the colonoscopy; respectively, 30.7 percent for each of the two former factors and 19.7 percent for weekend screening. However, 48.1 percent of respondents said they were willing to do an at-home FOBT as an alternative to colonoscopy, among whom 93 percent indicated they would be willing to undergo a follow-up colonoscopy if the FOBT was positive.
Lessons learned from the pandemic
“Even pre-pandemic, the rates for colorectal screening in the United States were very far from 100 percent, so I think the lessons that we are learning from this pandemic and working with patients to find alternatives to what the conventional approaches have been in the past are going to be applicable to care moving forward. This approach applies even if we do eventually enter a post-pandemic state, which is, of course, what we are all hoping for,” Dr. Rivet said.
Dr. Kenning said the survey results show that there is still much work to do to improve colorectal screening. “Colorectal cancer screening has decreased significantly during the pandemic and still hasn’t improved to the rate that it was before,” Dr. Kenning said. “Making sure that we’re offering all of the options to patients is very important so that, whatever form of screening they’re comfortable with, they’ll start down that pathway in order to get the screening they need.”
The survey results also underscore the need to tailor colorectal cancer screening to each patient’s concerns and needs, Dr. Rivet said. “It’s important to have a conversation about all of these different alternatives and what the different positives and negatives are,” she said.
Study coauthors are Dr. Miller and Bernard F. Fuemmeler, PhD, MPH, also with the department of health behavior and policy at VCU; and Jaime L. Bohl, MD, FACS, with the department of surgery at VCU.
“FACS” designates that a surgeon is a Fellow of the American College of Surgeons.
The study authors have no relevant financial relationships to disclose. The survey was funded as part of a larger survey led by Dr. Miller on colorectal cancer and funded, in part, through support of an institutional training grant awarded by the National Cancer Institute (T32CA093423).
Citation: Kenning K. et al, COVID-19 Pandemic Impact on Colorectal Cancer Screening. Scientific Forum Presentation. American College of Surgeons Clinical Congress 2021.
- Shaukat A, Kahi C, Burke CA, Rabeneck L, Sauer BG, Rex DK. ACG Clinical Guidelines: Colorectal Cancer Screening 2021. Amerc J Gastroenterol. 2021;116(3):458-479. doi: 10.14309/ajg.0000000000001122
- American Cancer Society. Colorectal Cancer Facts & Figures 2020-2022. Atlanta: American Cancer Society; 2020:22. Available at: https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/colorectal-cancer-facts-and-figures/colorectal-cancer-facts-and-figures-2020-2022.pdf
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About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org.