Colon cancer screening has been witnessing a change in the midst of this pandemic. COVID-19 has resulted in a drop in screening rates for colorectal cancer. Not just in the US but in other countries across the globe. An opinion piece in JAMA elaborated on the use of fecal immunochemical testing or FIT kits to screen for colon cancer in the United States.
Fecal immunochemical testing or FIT is being promoted and employed on a large basis in the US. These kits have been approved and are promoted by insurance companies in the States. The FIT test helps to detect blood in human stool and this has been found to be very useful during the pandemic to screen individuals for colorectal cancer in the comfort of their home.
This has reduced hospital visits and potential risk of close interaction with healthcare workers. In the US, screening is recommended for individuals at the age of 50 although the draft recommendation of the US Preventive Services Task Force suggests screening to begin at the age of 45. In a similar way, another stool test, called Cologuard, has been found to be effective in screening for colorectal cancer. Cologuard is a DNA test where, in addition to blood, the test identifies cancer biomarkers (gene variations that indicate change from the normal) in the stool.
The pandemic has imposed restrictions on movement. Screening tests that are not urgent have been delayed. Most individuals in the age group that require screening, have to undergo colonoscopy once every 10 years. In the event of cancer detection, the individual is subjected to follow-up procedures of biopsy and related treatment. When we consider regular screening procedures, screening tests using human stool are becoming popular as it avoids the trip to the hospital, social contact with high-risk individuals (e.g. health workers, other patients in the hospital), and reduces the potential risk of acquiring a coronavirus infection. When you consider the effort required from the individual to screen with FIT or Cologuard, it is negligible. Individuals just send in their stool for analysis.
In the case of Cologuard, individuals have to be screened once every three years, while FIT screening is recommended once every year. The other recommended screening tests for colorectal cancer are colonoscopy, sigmoidoscopy and CT colonography. Colonoscopy and sigmoidoscopy are invasive techniques. Sigmoidoscopy involves the use of a tube that is flexible and thin enough to pass into the rectum. The lighted tube provides information on the presence of polyps or tumor growths within the rectum or the lower end of the colon. In colonoscopy, the tube is used to scan the entire colon for polyps or tumors. When tests like FIT or Cologuard give suspicious results, they can be verified with either a sigmoidoscopy or a colonoscopy.
As screening procedures, sigmoidoscopy is recommended every 5 or 10 years while colonoscopy is performed every 10 years. A study in Norway, published in November 2020 with 139 291 participants, showed that FIT could detect more colorectal cancer cases and advanced adenomas when compared with standardized sigmoidoscopy. This enhanced detection was obtained after three rounds of FIT. However, the number of detected cases with just one round of FIT were comparable with sigmoidoscopy. The participants were screened once every two years between the period of 2012 and 2019. The interesting fact was that it obtained more participants for the FIT study due to the ease of the procedure. Doctors are now observing that most individuals who have to undergo routine colonoscopy prefer to opt for home-based stool kits that can be used for screening. Hospital visits are avoided and there is no pain involved in sending a sample for FIT or Cologuard. Besides, individuals do not have to follow any diet restrictions to provide the sample.
However, FIT has not been a poster boy for colorectal cancer screening. A study, published in 2017, noted that rural populations were far more likely to get screened with a stool test especially those who did not have a negative perception of their body weight and those with annual incomes lower than $15 000. In other words, stool tests have not been popular with many people for various reasons, such as lack of information, reluctance to collect and send in a stool sample, discouraging advice from family and friends, or just forgetting to send in a sample.
Although stool tests have been recommended along with colonoscopy, most doctors suggest a colonoscopy since it is a test that can detect, confirm and remove any precancerous polyps. Most individuals who go in for their routine screening are unaware of the various options for colorectal cancer screening. Physicians avoid discussing the different options since they do not have sufficient time to explain them. The pandemic has ushered in a new way of thinking and living. Insurance companies in the US are now taking an active interest to promote stool screening options. They have begun identifying those who have not had a screening test and based on their age, they are sent FIT kits in the mail.
A study on the use of FIT noted that despite the ease of using the kit, many people are still reluctant to use and send in the results. Reminders through email or personal calls from the physician’s office, boosted screening adherence. Personalized messages in the form of experiences of those who have used the kit are another means of coaxing reluctant individuals to get themselves screened. The US has already seen a drop in screening rates (64% between the period of March and June 2020) during the pandemic. The National Cancer Institute estimates an increase of 4500 deaths in the next 10 years due to reduced screening. Other countries, such as Canada, Australia, and the Netherlands are projected to see an increase in colorectal cancer-related deaths over the next 3 decades due to a disruption in screening as a result of the pandemic. For every 3-, 6-, and 12-month delay in diagnosis, the percentage of increase in the number of deaths doubles in Australia and the Netherlands. The Journal of Medical Screening has noted through modelling simulations that 6-month disruptions in screening for colorectal cancer in Canada will result in an increase of 450 deaths if screening is resumed without delay after 6 months or an increase of 1150 deaths if there is a delay in screening over a period of 2 years. As countries resume cancer screening procedures due to increased confidence in the vaccination drive of COVID-19, different strategies need to be implemented to convince individuals to get their routine colorectal cancer screening test done. However, it is not a simple process. Individuals will need to be educated on the benefits to screen themselves with FIT regularly.
To boost the confidence of the individual on the healthcare system, doctors, nurses, and technicians should be tested prior to any interaction with those who go for screening. Online or personalized telephone communication can replace actual visits to the physician’s office. The FIT kit could be mailed to individuals at risk so they can avoid visiting the hospital or clinic. Talking and educating people about the different screening options through media will also help ease the burden on the healthcare system. Similarly, the selection process for colorectal cancer screening should first include those who have suspicious indications or risk of colorectal cancer (e.g. blood in the stools) and those who have a previous positive FIT result.
Screening history is a good way to select those who need the screening process more than certain others, especially in cases where screening is long overdue, there has been no screening, or there has been indication of fecal hemoglobin content previously. When a strategy is followed to resume screening, this could reduce the projected increase in diagnosed cases and the number of deaths. With increased screening, the chances of detecting potential colorectal cancer cases also increases. Treatment can begin early and mortality can be reduced. This increases life expectancy.
The goal of all countries is to reduce the burden on the health system that has been reeling under the onslaught of the pandemic. Taiwan, New Zealand and Australia were able to continue screening for colorectal cancer due to the negligible spread of COVID-19 in those countries. Taiwan has increased their plans to mail out FIT kits, as a result of the pandemic.
In the context of the pandemic and what lies ahead in the future, at-home screening tests for colorectal cancer will be more acceptable among physicians, insurance companies, and individuals who need to be screened. Individuals can avoid the discomfort of a colonoscopy if the FIT results are negative. Healthcare systems will be spared the time and trained manpower to screen every eligible individual with colonoscopy but, at the same time, they can monitor the health of the individual with the help of FIT data.
It is now clear to healthcare systems that a uniques strategy is needed to educate the public on the importance of screening regularly and to provide options that may not require a visit to the clinic or hospital. While FIT is gaining popularity as a ubiquitous screening test for colorectal cancer, some studies have shown that warm temperatures could compromise the sensitivity of FIT results. Places like Nigeria in West Africa have observed issues with compliance and low accuracy in FIT results. Compliance issues have been noted when people with positive FIT results are reluctant to undergo invasive procedures, such as colonoscopy to confirm the diagnosis.
Low accuracy has been reported in one study in Nigeria, which studied the population belonging to the Yoruba tribe and found low sensitivity of FIT results. A similar variability in results was observed in California when samples for FIT were obtained in the warmer months. Hence, a screening strategy for colorectal cancer needs to be developed in the context of the characteristics of the population, the climatic conditions, and the culture of the community. A sustainable screening strategy in the face of hurdles like the current pandemic will help to manage the life expectancy of the population. Colorectal cancer screening tests.
Centers for Disease Control. Updated Feb 8, 2021. Accessed Feb 19, 2021; Cited Feb 20, 2021. https://www.cdc.gov/cancer/colorectal/basic_info/screening/tests.htm
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