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 (VCU) report that for people hesitant to come into the hospital or an outpatient center to get a colonoscopy, a home-administered fecal occult blood test (FOBT) may provide a useful workaround tool. About 30 percent more survey respondents completed the home-based test during the pandemic than before.

Kristine Kenning, MD, MS, chief general surgery resident at VCU School of Medicine, Richmond. 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,” Kenning says. “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 also 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

Survey Findings

The cross-sectional survey involved 765 people age 50 years and older. Kenning and colleagues found that their respondents reported a higher completion of stool tests pre-COVID than the American Cancer Society reported2—32% vs. 11%. During the pandemic, 50% of respondents said they completed the FOBT. By contrast, 44% 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, Kenning notes. 

“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,” says senior author Emily B. Rivet, MD, MBA, FACS, associate professor in the department of surgery, division of colorectal surgery, and an affiliated professor of internal medicine at VCU School of Medicine. “What we learned is that fecal occult blood testing was seen by patients as a viable alternative to conventional screening colonoscopy.”

Screening Delays 

Notably, a greater percentage of respondents indicated being unemployed during the pandemic than the year prior: 7.4% vs. 2.6%. In addition, 41% of respondents expressed concerns about copays, with 57.6% of those respondents noting that this was a factor for delaying screening. Kenning says 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. Miller is a post-doctoral fellow with VCU’s department of health behavior and policy.

Copays were not the only deterrent to getting scheduled colorectal screenings during the pandemic, the study found. Almost two-thirds of respondents—65.9%—confirmed concerns about COVID-19 exposure when scheduling colonoscopies, and 59% of these said this caused them to delay their screening.

To address those concerns, participants responded that being offered protective equipment such as gloves and masks (30.7% of respondents), visits to smaller offices (30.7%), or weekend screening appointments (19.7%) would increase their likelihood of following through with the colonoscopy. However, 48.1% of respondents said they were willing to do an at-home FOBT as an alternative to colonoscopy, with 93% of these indicating they would be willing to undergo a follow-up colonoscopy if the FOBT was positive. 

Learning From the Pandemic

As patient compliance has dropped even further during the pandemic, improving screening rates for colorectal cancer continues to be a priority for physicians.

“Even prepandemic, the rates for colorectal screening in the United States were very far from 100%,” Rivet says. “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 postpandemic state, which is, of course, what we are all hoping for.” 

According to Kenning, 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,” Kenning says. “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, Rivet says. “It’s important to have a conversation about all of these different alternatives and what the different positives and negatives are,” she says.

Study coauthors include 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.

The study authors have no relevant financial relationships to disclose. The survey was funded as part of a larger survey led by Miller on colorectal cancer and funded, in part, through support of an institutional training grant awarded by the National Cancer Institute (T32CA093423).

Featured Image: The COVID-19 pandemic impacted patient attitudes about colorectal cancer screening. Illustration: American College of Surgeons

References

 1. 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

2. 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