Colorectal Cancer Screening Rates at Federally Qualified Health Centers in California During the COVID-19 Pandemic: Insights From National Health Resources and Services Administration Data

Introduction: Federally Qualified Health Centers (FQHCs) provide preventive health services such as colorectal cancer (CRC) screening to low-income and underinsured individuals. Federally Qualified Health Center (FQHC) characteristics (2020 data) and the colorectal cancer (CRC) screening rate change (SRC) in California FQHCs from 2019 to 2020 by quartiles Frequency or Percent Overall (n=168) SRC Q1 (n=42) SRC Q2+Q3+Q4 (n=126) P Value Total Patients Eligible for CRC Screening (Age 50-74)Y 1,207,401 346,591 860,810 -- CRC Screening Rate in 2019 (median %) 44.5 53.7 41.6 < 0.0001 CRC Screening Rate in 2020 (median %) 36.8 31.2 37.7 0.030 Change in CRC Screening Uptake between 2020 and 2019  Median -5.7 -18.6 -3.1 < 0.0001  Interquartile Range -13.1,-0.6 -28.4,-15.1 -7.5,1.0 Sex Male (median %) 42.5 41.3 42.9 0.010 Race & Ethnicity (median %)  White Non-Hispanic 17.5 11.5 18.9 0.002  Black Non-Hispanic 3.0 2.8 3.0 0.890  Hispanic/Latina/Latino/Latinx 55.8 68.2 51.1 0.002  Other Non-Hispanic 3.2 2.9 3.4 0.180 Preference for Non-English Language (median %) 33.1 38.7 30.6 0.009 Urban FQHCs, n (%) 133 (79.2%) 38 (90.5%) 95 (75.4%) 0.040 Experiencing Homelessness (median %) 3.2 3.3 3.2 0.890 Income Level >200% Federal Poverty Line (median %) 3.3 2.7 3.8 0.480 Uninsured (median %) 18.6 18.8 18.5 0.120 Medicaid (median %) 39.3 35.9 40.3 0.240 Medicare/Medicaid Dually Eligible (median %) 4.2 3.0 4.7 0.002 Private Insurance (median %) 8.6 10.2 8.3 0.610 Agricultural Workers (median %) 0.9 1.0 0.7 0.790 *SRC Q1 represents FQHCs with the largest decline in CRC screening rates from 2019 to 2020, and SRC Q2+Q3+Q4 represents all other FQHCs. *p-values represent comparisons (Wilcoxon rank-sum and chi-square tests) between the first quartile and second through fourth quartiles combined for FQHCs’ median percentage of White, Black, Hispanic/Latino, and other races, median percentage patient population with preference for non-English language, homelessness, income level above 200% of the Federal Poverty Line, uninsured status, and FQHC urbanicity. YThese calculated values do not account for practice-changing 2021 United States Preventative Services Task Force guideline updates dictating that average-risk patients begin CRC screening at age 45.

Colorectal Cancer: In the Pursuit of Health Equity.

Colorectal cancer mortality has decreased considerably following the adoption of national screening programs, yet, within at-risk subgroups, there continue to be measurable differences in clinical outcomes from variations in screening, receipt of chemotherapy, radiation or surgery, access to clinical trials, research participation, and survivorship. These disparities are well-described and some have worsened over time. Disparities identified have included race and ethnicity, age (specifically young adults), socioeconomic status, insurance access, geography, and environmental exposures. In the context of the COVID-19 pandemic, colorectal cancer care has necessarily shifted dramatically, with broad, immediate uptake of telemedicine, transition to oral medications when feasible, and considerations for sequence of treatment. However, it has additionally marginalized patients with colorectal cancer with historically disparate cancer-specific outcomes; among them, uninsured, low-income, immigrant, and ethnic-minority patients-all of whom are more likely to become infected, be hospitalized, and die of either COVID-19 or colorectal cancer. Herein, we outline measurable disparities, review implemented solutions, and define strategies toward ensuring that all have a fair and just opportunity to be as healthy as possible.

Impact of COVID-19 on colorectal cancer disparities and the way forward.

In response to the coronavirus disease 2019 (COVID-19) pandemic, the U.S. Surgeon General advised all hospitals and ambulatory care centers to delay nonurgent medical procedures and surgeries. This recommendation, echoed by a multigastroenterology society guideline, led to the suspension of colonoscopies for colorectal cancer (CRC) screening and surveillance. Although this temporary suspension was necessary to contain COVID-19 infections, we as gastroenterologists, patient advocates, and CRC researchers have witnessed the downstream impact of COVID-19 and this recommendation on CRC screening, research, and advocacy. These effects are particularly noticeable in medically underserved communities where CRC morbidity and mortality are highest. COVID-19-related pauses in medical care, as well as shifts in resource allocation and workforce deployment, threaten decades worth of work to improve CRC disparities in medically underserved populations. In this perspective, we present the unique challenges COVID-19 poses to health equity in CRC prevention and provide potential solutions as we navigate these uncharted waters.