ABSTRACT
Background: Ontario Health (Cancer Care Ontario) oversees ColonCancerCheck (CCC), Ontario's population-based organized colorectal cancer (CRC) screening program. CCC recommends average risk screening with the fecal immunochemical test (FIT), but colonoscopy is available opportunistically. A central lab mails FIT kits directly to people upon request from care providers. CCC's recommendations are promoted centrally with Regional Cancer Programs and regional clinical leaders. At the start of the COVID-19 pandemic, FIT kit mailing and mailed letters to invite/remind people to screen were paused. Colonoscopy capacity varied with the waves of the pandemic depending on local factors. Subsequently, CCC gradually implemented recovery activities, such as resuming FIT kit and letter mailing, and provided guidance on screening prioritization, which included conversion of low yield colonoscopy to FIT. Aim: To understand the impact of COVID-19 on CRC screening in Ontario across four periods: pre-, early-, mid- and late-COVID-19. Methods: We compared key performance indicators over time: percent overdue for CRC screening, FIT requisition volumes, FIT requisition rejection rates, FIT kit return rates, colonoscopy volumes and colonoscopy wait times. Results: Comparing pre- to late-COVID-19 periods, the percent of people overdue for CRC screening increased (39.5% vs. 43.1%). An increase in FIT participation was observed, with greater volumes of FIT kits being requested (101,925 vs. 119,113 per month) and improved FIT kit return rates (54.7% vs. 60.8%). However, FIT requisition rejection rates also increased (5.7% vs. 15.0%). Overall colonoscopy volumes declined (24,432 vs. 21,317 per month), with decreases in average risk screening colonoscopy (15.5% vs. 9.9%). The proportion of people getting a colonoscopy within 8 weeks of an abnormal FIT result improved (81.2% vs. 83.5%). Interpretation: While screening performance declined at the start of the pandemic, as screening activities resumed, it has improved in key areas, even exceeding pre-COVID metrics: greater FIT participation, a reduction in average risk screening colonoscopies, and improved colonoscopy wait times for abnormal FIT. Fewer patient-provider interactions and participant reluctance to seek healthcare may have led to an increase in the number of people overdue for CRC screening. CCC's centralized approach to FIT distribution and its pandemic response, including consistent messaging and a regional infrastructure, facilitated the uptake of pandemic guidance and may have led to improved performance. Conclusions: These results suggest that there are opportunities for organized screening programs to improve performance during times of crisis. Sustaining these program performance improvements post-pandemic is essential if CRC screening participation is to return to pre-pandemic levels. (Table Presented)
ABSTRACT
OBJECTIVE: To describe the immediate impact of the COVID-19 pandemic on cervical screening, colposcopy and treatment volumes in Ontario, Canada. DESIGN: Population-based retrospective observational study. SETTING: Ontario, Canada. POPULATION: People with a cervix age of 21-69 years who completed at least one cervical screening cytology test, colposcopy or treatment procedure for cervical dysplasia between January 2019 and August 2020. METHODS: Administrative databases were used to compare cervical screening cytology, colposcopy and treatment procedure volumes before (historical comparator) and during the first 6 months of the COVID-19 pandemic (March-August 2020). MAIN OUTCOME MEASURES: Changes in cervical screening cytology, colposcopy and treatment volumes; individuals with high-grade cytology awaiting colposcopy. RESULTS: During the first 6 months of the COVID-19 pandemic, the monthly average number of cervical screening cytology tests, colposcopies and treatments decreased by 63.8% (range: -92.3 to -41.0%), 39.7% (range: -75.1 to -14.3%) and 31.1% (range: -43.5 to -23.6%), respectively, when compared with the corresponding months in 2019. Between March and August 2020, on average 292 (-51.0%) fewer high-grade cytological abnormalities were detected through screening each month. As of August 2020, 1159 (29.2%) individuals with high-grade screening cytology were awaiting follow-up colposcopy. CONCLUSIONS: The COVID-19 pandemic has had a substantial impact on key cervical screening and follow-up services in Ontario. As the pandemic continues, ongoing monitoring of service utilisation to inform system response and recovery is required. Future efforts to understand the impact of COVID-19-related disruptions on cervical cancer outcomes will be needed. TWEETABLE ABSTRACT: COVID-19 has had a substantial impact on cervical screening and follow-up services in Ontario, Canada.