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COVID-19 and the impact of delayed colorectal cancer screening

By: Amanda M. Papp, MSN, RN

Educate patients about the importance of this procedure.

Takeaways:

  • As healthcare systems adapt to a new post-pandemic normal, we must evaluate the impact of COVID-19 on patient completion of elective procedures.
  • We’re still learning about the lasting effects (including increases colorectal cancer incidence) of mandated endoscopy center closures.

When the COVID-19 pandemic began, healthcare systems adapted to meet the surge of expected patients. Procedural areas faced closures and experienced significant disruptions to the care they typically provide. Because endoscopic procedures, including colonoscopies, are elective, outpatient endoscopy centers closed to preserve supplies and deploy healthcare workers to areas of highest need. We’re now beginning to see the impact of mandated endoscopy department closures on patients forced to delay colorectal cancer screenings. The drastic drop in screenings requires that we explore its effects on healthcare systems and early colorectal cancer detection. (See More about colorectal cancer.)

More about colorectal cancer

The detection rate of adenoma (abnormal tissue that can lead to cancer if not removed) is considered a national benchmark for the quality of screening colonoscopies and serves as the primary indicator for decreasing colorectal cancer. The survival rate for colon cancer, the third most diagnosed cancer in both men and women, is generally high. According to reports by the American Society of Clinical Oncology, colorectal cancer diagnosed at a localized stage has a 91% 5-year survival.

Screening recommendations

Based on evidence of disease risk as well as benefits and harms of screening, the American Cancer Society decreased the recommended age to begin screening colonoscopies for those with an average risk for colorectal cancer from 50 to 45. The rising incidence of colorectal cancer in younger generations prompted this guideline change. Ahmed reported that screening colonoscopies are associated with a 75% risk reduction in death for left-sided colorectal cancer and a 65% risk reduction for right-sided colon cancer.

Individual risk factors

As individuals reach the age for a colorectal cancer screening, they should consider personal risk factors that might increase the likelihood of developing cancer. Modifiable risk factors include being overweight, physical inactivity, consuming a diet high in red meat, smoking, and alcohol use. Lifestyle changes can help address these risks. Nonmodifiable risk factors include increasing age, a personal or family history of polyps or colorectal cancer, inflammatory bowel disease, and having an inherited syndrome (such as Lynch syndrome or familial adenomatous polyposis). Individuals with these risk factors may require encouragement to remain diligent about colorectal screenings to identify abnormal tissue growth. According to Cancer.org, Black Americans have the highest colorectal cancer incidence and mortality rates of all racial groups in the United States. This high rate may be related to various factors, including comorbidities and access to care.

Effects of screening delays

Delays in colorectal cancer screenings present increases in late-stage diagnoses and colorectal attributable deaths. Approximately 95% of colorectal cancers arise from preexisting adenomas. Missed screening colonoscopies and significant delays influence the rate of detecting abnormal tissue growth. Sundaram and colleagues found that as a direct result of screening colonoscopy cancellations prompted by the COVID-19 pandemic, the rate of early detection of malignant colorectal cancer decreased by 39.9%. Reductions in early detection and increases in late-stage diagnoses can increase patient and healthcare system burden as a result of fewer and more costly treatment options.

Colonoscopy challenges

Even before the pandemic, a need existed to improve patient education and enhance community efforts to raise overall screening rates. Screening colonoscopy, the gold-standard for early colorectal cancer detection, provides the only option for examining the entire colon and removing polyps (abnormal tissue growth) simultaneously. However, according to Issaka and colleagues, only 67% of adults between ages 50 and 75 are current with colorectal cancer screenings. Adherence to screening colonoscopies has consistently been difficult to achieve. Much of the target population considers the bowel preparation, required time off from work, and associated costs cumbersome.

Cancellation of elective procedures (as recommended by the American College of Surgeons in an effort to reduce COVID-19 transmission rates and spare healthcare resources) resulted in colonoscopy screenings declining by over 90%. Patients who missed these screenings have been faced with delays in rescheduling them. The high caseload volume for rescheduling has placed a burden on patients and the healthcare system. Securing appointments occurs months in advance, and many patients may not understand the importance of rescheduling. In addition, some patients find scheduling difficult to navigate, are frustrated with care delays, or still have concerns about the pandemic and hesitate to even enter a medical facility.

Addressing patient needs

Lack of access to routine primary care and limited healthcare literacy significantly hinder an individual’s likelihood of seeking a screening procedure. Patients unfamiliar with medical procedure processes and colonoscopies may struggle to adequately complete bowel preparation and follow all pre-procedure instructions, simply because they didn’t receive proper information and education. In the United States, according to the Literacy Project, 50% of adults can’t read at the 8th grade level. To have the greatest impact on patients we must create procedure information materials at or below this reading level to ensure adequate comprehension.

Patient instructions must include an easy-to-follow, step-by-step guide for completing bowel prep, descriptions of what patients can eat or drink before the procedure (including when to stop), and information for reaching a medical professional with questions. Clear and concise directions can help ensure patient success and reduce the likelihood of needing a repeat colonoscopy, which some patients may be reluctant to do.

Nurses also can help address a patient’s educational needs by first reviewing how to perform the bowel preparation regimen and the timeline for completion, based on the provider’s preference. Confusion around dietary restrictions frequently results in inadequate or poor preparation, which can require procedure cancellation. By reinforcing a clear liquid diet the day before the procedure and nothing by mouth restrictions the day of, nurses can help ensure patients know what to expect before and during their endoscopic experience. Taking the time to implement individualized patient education and care can significantly improve the overall efficiency and effectiveness of the procedure.

Impact on endoscopy departments

In addition to the personal health risks endoscopy personnel face due to the nature of the procedures they perform (wearing proper personal protective equipment helps to mitigate these risks), they’re also encountering increased workloads as patients reschedule cancelled appointments and new cases enter the queue. Factors influencing demand for screening colonoscopies include the number of referrals that require initial office visits, procedural appointments, and availability of endoscopy centers, as well as departmental staffing to support cases.

Healthcare organizations are calling for increased case volume with lower staffing levels than before the pandemic. Staffing shortages, a common concern for nurses, create a significant challenge to adequately caring for this patient population. Healthcare organizations must address remaining staffing deficits before they can start to rebuild and meet the growing demand and volume of endoscopic procedures. The increased use of travel nurses has helped to ease this burden and allowed for outpatient centers to slowly increase procedural capacity, but this is a temporary fix. Efficiently providing procedures for more patients requires permanent staff.

The true impact of missed colorectal cancer diagnoses due to mandated closures may not be felt until most of the patients with delayed procedures have been rescheduled and completed. Martin and colleagues identified a substantial drop in healthcare use at the start of the pandemic. This deficit may prove difficult to overcome in the short-term. Healthcare systems and endoscopy departments must develop an action plan and take intentional steps to combat the long-term effects backlogged cases will have on providing preventive care.

Solutions to the challenge

Healthcare organizations can overcome the barriers to colonoscopy screening presented by the pandemic by providing alternatives, including fecal immunochemical tests (FIT), multiplatform patient education, and increased hospital colonoscopy capacity.

Primary care providers can order FIT, an easy-to-use at-home alternative to colonoscopy. Any patient with a positive result is referred for a screening colonoscopy. FIT helps to reduce the burden on patients and healthcare systems, allowing low-risk patients to avoid struggling with appointment delays and permitting high-risk patients to schedule procedures more efficiently.

A multiplatform approach of encouragement from primary care providers as well as coverage by national media, digital marketing, and social media has helped increase the rate of patients completing their screening colonos­copies. Improving public knowledge about the importance of colorectal cancer screenings will ultimately lead to better patient outcomes.

As staffing levels continue to increase or surpass pre-pandemic levels, organizations will be able to offer more colonoscopy appointments. This will allow for quicker scheduling and completion of procedures for patients experiencing symptoms as well as those seeking screening colonoscopies.

Recovering for the future

We’re still learning what long-term effects the pandemic will have on colorectal cancer rates. As we settle into our new normal, we must make concentrated efforts to ensure healthcare systems recover from caseload burdens created by mandatory department shutdowns and procedure cancellations with a priority on avoiding further screening delays. Screening colonoscopies, although considered elective, provide the opportunity for life-saving early detection of colorectal cancers. Mistaking all elective procedures as optional can delay care and significantly increase health risks.

Although many healthcare systems have experienced negative effects from shutdowns and procedure cancellations, patients have experienced the greatest impact. Peri­yanayagam and colleagues found that during the pandemic, 78% of patients with colorectal cancer reported feeling nervous, anxious, or on edge about navigating their care moving forward. We must strive to offer efficient, compassionate care. We can’t allow the challenges of rebuilding departments overshadow our commitment to our patients and communities. Offering empathy, kindness, and reassurance that we’re ready to care for and support patients will go a long way as our healthcare systems continue recovering from COVID-19.

Amanda M. Papp is a nurse at Summa Health System in Akron, Ohio. When writing this article, she was an MSN student at Kent State University in Kent, Ohio.

American Nurse Journal. 2023; 18(1). Doi: 10.51256/ANJ012340

Key words: delayed colonoscopies, colorectal cancer screenings, COVID-19, elective procedures, endoscopy

References

Ahmed M. Colon cancer: A clinician’s perspective in 2019. Gastroenterology Res. 2020;13(1):1-10. doi:10.14740/gr1239

American Cancer Society. Colorectal cancer risk factors. cancer.org/cancer/colon-rectal-cancer/causes-risks-prevention/risk-factors.html

Cancer.Net. Colorectal cancer: Statistics. May 2022. cancer.net/cancer-types/colorectal-cancer/statistics

Doubeni CA, Corley DA, Quinn VP, et al. Effectiveness of screening colonoscopy in reducing the risk of death from right and left colon cancer: A large community-based study. Gut. 2018;67(2):291-8. doi:10.1136/gutjnl-2016-312712

Ganesh Kumar N, Drolet BC. COVID-19—Implications on and of surgical practices: Where do we draw the line? Ann Surg. 2020;272(2):45-6. doi:10.1097/SLA.0000000000004009

Hancock J, Palmer GA. Detection rate of colorectal cancer or precancer adenoma by colonoscopy after 1, 2, or 3 positive results via fecal immunochemical testing. Lab Med. 2019;50(3):263-7. doi:10.1093/labmed/lmy075

Issaka RB, Taylor P, Baxi A, Inadomi JM, Ramsey SD, Roth J. Model-based estimation of colorectal cancer screening and outcomes during the COVID-19 pandemic. JAMA Netw Open. 2021;4(4):e216454. doi:10.1001/jamanetworkopen.2021.6454

Literacy Project. Illiteracy by the numbers. literacyproj.org

Martin K, Kurowski D, Given P, Kennedy K, Clayton E. The impact of COVID-19 on the use of preventive health care. Health Care Cost Institute. April 16, 2021. healthcostinstitute.org/hcci-research/the-impact-of-covid-19-on-the-use-of-preventive-health-care

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Periyanayagam U, Dwyer A, Kim J, Garcia R, Worrall S, Davis A. New colorectal cancer diagnoses fall by one-third as colonoscopy screenings and biopsies grind to a halt during height of COVID-19. komodohealth. May 2020. knowledge.komodohealth.com/hubfs/_RESEARCH_BRIEFS/COVID19_Impact_on_CRC_Patients_Research_Brief_Komodo_Health_Fight_CRC.pdf

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Siegel RL, Jakubowski CD, Fedewa SA, Davis A, Azad NS. Colorectal cancer in the young: Epidemiology, prevention, management. Am Soc Clin Oncol Educ Book. 2020;40:1-4. doi:
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