ABSTRACT
Background Because of limited access to gastrointestinal (GI) endoscopy during the COVID-19 pandemic, there is a need to prioritize procedures to avoid negative health impacts from delays. Ontario Health (OH) has provided guidance to facilities to prioritize colonoscopies in people with an abnormal fecal immunochemical test (FIT) result, based on the high likelihood to detect invasive colorectal cancer (CRC) and recommends FIT for screening people at average risk of CRC and those with prior low-risk adenoma. Purpose To measure the invasive CRC detection rate (CDR) of colonoscopies performed in Ontario by indication, setting, age, and sex over a 31-month period before and during the COVID-19 pandemic. Method We calculated the CDRs among outpatients ages 18 and over who had colonoscopies performed in a hospital or private clinic setting from June 2019 to December 2021. We identified hospital colonoscopies from OH's GI Endoscopy Data Submission Portal and clinic colonoscopies from Ontario Health Insurance Plan (OHIP) data (OHIP code E749A). Invasive CRC was identified from the Ontario Cancer Registry (OCR) as: ICD-O-3 codes C18.0, C18.2-C18.9, C19.9, C20.9, a morphology indicative of CRC, microscopically confirmed and with a pathology report. CRCs were included if diagnosed 7 days before and up to 183 days after colonoscopy. Colonoscopy volumes and CDRs were stratified by age and sex (all volumes), and, for hospital colonoscopies, by indication. Result(s) During the study period, 984,109 colonoscopies were performed (638,900 in hospitals;345,209 in clinics). Patients who had their colonoscopies in clinics were younger than those who had them in hospitals (Table 1). In both settings, colonoscopies were evenly distributed by sex. Overall, 12,021 CRCs were detected (CDR: 1.22%);9,451 CRCs in hospitals (CDR: 1.48%), and 2,570 CRCs in clinics (CDR: 0.74%). CDRs at any age were lower in clinics as compared to hospitals. In hospitals, CDRs by colonoscopy indication were: 5.16% for FIT+, 1.93% in symptomatic patients, 0.52% in surveillance, 0.70% in average-risk screening, and 0.35% in screening due to family history. FIT+ colonoscopies accounted for the smallest proportion of colonoscopies (6.2%) but the 2nd largest proportion of CRCs detected (Figure 1). Hospital-based CDR increased during the period of observation from 1.23% pre-pandemic (June-December 2019) to 1.55% during the pandemic (January-December 2021). Clinic CDR was 0.71% pre-pandemic and 0.75% during the pandemic. Image Conclusion(s) In Ontario, colonoscopy yield (CDR) is highest in FIT+ patients;just over one in 20 colonoscopies will yield a diagnosis of CRC. In contrast, primary screening and surveillance indications have very low CRC yields. The overall yield of colonoscopies in clinics, for all age groups, is lower than in hospital setting. There was a slight increase in CDR during the pandemic compared to before the pandemic, in both settings. Please acknowledge all funding agencies by checking the applicable boxes below Other Please indicate your source of funding;Ontario Health - Cancer Care Ontario Disclosure of Interest None Declared
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)