Colorectal Cancer Referrals during CoVID-19: The Use of CT and qFIT in Triaging Patients in NHS Grampian

Introduction: The CoVID-19 outbreak resulted in fundamental changes to clinical practice for patients referred to secondary care with lower Gastrointestinal symptoms. The use of colonoscopy services was reduced due to a perceived risk of viral transmission. Resultantly, computed tomography abdomen pelvis (CTAp) scans were utilised to triage patients. This study aimed to assess The accuracy of CTAp and qFIT in triaging patients at risk of colorectal cancer. Method(s): This study retrospectively gathered data On patients referred via The urgent suspected Cancer (USC) pathway from The start of lockdown over a 6-month period in a single Scottish Health Board. Data were collected On presenting symptoms, qFIT levels, vetting decision, investigations, and subsequent diagnosis. Patients were vetted into one of five pathways: CTAp, direct to colonoscopy, downgraded from assessment, flexible sigmoidoscopy, or CT colonography. Result(s): The overall Cancer detection rate was 6.4%. Of The patients with Cancer On The CTAp pathway, 22.9% had Cancer undetected On CTAp which was later identified On colonoscopy. In The cohort of patients with colorectal malignancy, 7.5% had a negative qFIT value (<10 ug/g). Conclusion(s): CTAp alone may not be accurate in detecting colorectal cancers. One should consider The whole clinical picture and decide whether further imaging is warranted following a negative CTAp scan. Additionally, qFIT remains The leading laboratory investigation within screening programmes, however, it should not be used in isolation to rule out colorectal malignancy.

EVALUATION OF THE AT-HOME CAPSULE ENDOSCOPY (ACE) SERVICE AT UCLH: PRELIMINARY FINDINGS

Introduction UCLH has developed a modified 'At Home' Capsule endoscopy (ACE) service for patients undergoing capsule endoscopy where the entire procedure is completed at home through remote (telemedicine) assistance. This aimed to improve access to endoscopy services during the covid-19 pandemic. This a preliminary review of the ACE focusing on procedure safety, success rates and patient satisfaction. Methods Data on all ACE procedures at UCLH was looked at prospectively. Demographics, completion rates, and complication rates were recorded. All patients were asked to complete patient satisfaction questionnaires relating to the at home process (experience of the process, support from staff, expectations, tolerance of procedure, satisfaction, and preference for future investigations). Results 34 ACE procedures were looked at for this study. 13 were colon capsule endoscopies (CCE) and 21 small bowel capsule endoscopies (SBCE). Mean age of participants was 38 years and 17 (50%) were males. Indications were FIT positive (2.9%), iron-deficiency anaemia (14.7%), inflammatory bowel disease (61.7%) or investigation of other symptoms (20.6%). 31 (91.1%) procedures were successful- defined as a complete procedure with adequate bowel preparation. There were 3 failed ACEs (2= poor prep, 1= capsule not excreted). There were no complications and no need to convert the remote test to 'in-hospital'. 16 (47%) patient satisfaction questionnaires were returned. No patients found the procedure painful or embarrassing and 12 (75%) patients were not anxious prior to their procedure. On a satisfaction scale of 1-10, 12 patients (75%) scored ACE as ≥8. 13 (81.3%) patients would choose to have ACE vs inhospital CE. 12 (75%) patients would choose ACE as their preferred colonic investigation over CE in-hospital, colonoscopy, and CT colonography. Importantly, 87.5% of those patients had previously undergone a colonoscopy. Conclusions This is preliminary data on ACE, which shows a similar safety and success rate to standard practice in-hospital capsule endoscopy. 75% of patients preferred ACE over any other colonic investigation, suggesting potential increased acceptance by the public as a colorectal cancer screening test.

SUCCESSFUL INTERVENTIONS TO INCREASE COLON CANCER SCREENING RATES IN A SINGLE URBAN-BASED ENDOSCOPY UNIVERSITY CENTER;A QUALITY IMPROVEMENT PROJECT

Background: Colorectal cancer (CRC) screening is essential in preventive care (1, 2, 3). Societies, such as the American College of Gastroenterology (ACG) and the National Colorectal Cancer Roundtable (NCCRT), have a goal of reaching colorectal cancer screening rates of 80 % per community (4, 5). The screening rate in our clinic was 42.8 % in 2019;however, the majority of the residents were only offering invasive measures;such as colonoscopy. We aimed to improve the CRC screening rate by multiple modalities including;reeducating residents, implementing changes to the electronic medical record, and scheduling patients for wellness/preventative care visits to increase the colon cancer screening rate. Methods: Multiple methods were used as follows;An initial questionnaire to inquire about the CRC screening options given by the residents to the patient, then a didactic lecture to further explain different options, and a follow-up lecture in the clinic. Also, The Electronic medical record was adjusted to have a particular notification tab and preventive care options if the patient qualifies for CRC screening. The percent change, percent difference and the absolute difference were used to analyze the results. The Institutional Review Board approved this study. Results: CRC screening rates increased from 42.8% in 2019 to 67.4% in July 2020 with an absolute difference of 24.6, a percent difference of 44.65 %, and a percent change of 57.48 % (Figure 1). Discussion: Colonoscopy remains the gold standard for CRC screening;however other modalities are also approved including;stool testing and virtual colonoscopies (1, 2, 3, 6). Multiple societies in the United States have set a goal to reach 80% screening per community (4, 5). In 2019, the screening rate at our institution was 42.8 %. After noticing this, we decided to conduct this QI project to improve our screening rates. Our experience focused on a survey-based approach, mainly on assessing what residents offer for colon cancer screening, especially when the patients refuse colonoscopy as a form of screening (3). Residents were educated in their regular didactic sessions and with small seminars during their continuity clinic. Patient visits were also changed and focused on scheduling patients during regular wellness/preventative health care visits. Screening rates showed an absolute difference increase of 24.6 despite being affected by the COVID pandemic. We anticipate further increase in the following years and hopefully, we will reach the 80% screening goal of ACG and NCCRT (4, 5). Conclusions: Interventions that address root cause analysis and education continue to be the answer to most of our questions.(Figure Presented)

'One stop colorectal cancer and radiological staging' (OSCARS) pathway reduces time from referral to diagnosis

Purpose/Background: To investigate the effectiveness of a one-stop colorectal cancer (CRC) staging pathway using faecal immunochemical test (FIT) as stratification tool. Methods/Interventions: The OSCARS pathway, which uses FIT as a triage tool to identify 'high risk' patients, was formally introduced in March 2020 in our Hospital Trust. A major driving force for this was to deal with the increased pressures on diagnostic services resulting from the COVID-19 pandemic. 2 week wait colorectal cancer referrals deemed appropriate to proceed to diagnostic testing prior to a clinic review ('straight to test') who had a FIT > 100 μg Hb/g faeces were allocated to the OSCARS pathway. This involved a single hospital visit during which they would have an endoscopy, a staging CT or completion CT colonography if needed, and be assessed and counseled by a colorectal cancer surgeon. Notes of all patents referred with suspected colorectal cancer between 01/01/2020 and 16/03/2021 (prior to the introduction of the pathway) and 16/03/2021 and 31/07/2021 (post introduction of the pathway) were reviewed to evaluate outcomes of the pathway. Time from referral to investigations, histological diagnosis and discussion at multidisciplinary team (MDT) meeting was compared before and after the introduction of the OSCARS pathway. Results/Outcomes: There were a total of 748 patients referred with suspected colorectal cancer in the pre-OSCARS group and 1194 in the OSCARS group. of those who were referred with an increased FIT, 43 (8.0%) and 86 (7.9%) were diagnosed with colorectal cancer (CRC) respectively. CRC diagnoses established on a 'straight to test' pathway increased from 69.8% in pre-OSCARS to 86.0% in the OSCARS groups, likely due to better stratification to a 'straight to test' pathway through the use of FIT. Despite the COVID-19 pandemic coinciding with the introduction of the OSCARS pathway, time for 'referral to first investigation' and 'referral to endoscopy' were similar between the groups (13 vs 12 days, p = 0.511 and 13 vs 13, p = 0.988). All patients diagnosed with cancer in the OSCARS group had staging CT scan on the same day (as opposed to 4 days pre-OSCARS, p = 0.002) but the difference in time for 'endoscopy to MRI' (8 vs 5 days, p0.271) or 'endoscopy to histopathology (4 vs 5 days, p = 0.236) did not change significantly. Time for 'endoscopy to MDT' was significantly reduced from 14.5 to 9 days (p = 0.019). Conclusion/Discussion: Time from referral to diagnostic test on 'straight to test' pathway remained unchanged in our Trust despite COVID-19 pandemic as a result of stringent stratification using FIT. Time from 'endoscopy to MDT' was significantly reduced with introduction of the OSCARS pathway due to same day access to CT scanner. It is likely that this section of the 2ww pathway would further be reduced with improved access to MRI and histopathology reporting services. Although OSCARS pathway reduces the number of hospital visits, its effect on patients' experience needs to be formally assessed.

The utility of Computerized Axial Tomography (CT) investigation in two week waits colorectal referral pathway: Should it be done more often during the pandemic?

Aim: Colorectal two week wait pathway investigations have been majorly affected due to Covid 19 especially with regards to endoscopy as well as virtual colonoscopy procedures in comparison to CT scan. We aimed to analyze the CT scan findings of colorectal rapid access patients. Method: A total of 1900 patients was referred via the straight to test pathway in the year 2020.A retrospective analysis of CT scan investigation performed in these patients was analyzed. Results: A total of 90 (4.74%) patients had a CT Scan as part of the work.20 patients (22%) of the CT scan revealed malignancy. 10 patients (50%) had metastatic disease on the scan. Among them, 6 (60%) were due to colorectal primary and another 2 (20%) was due to thoracic cancers. The remaining were diagnosed with widespread metastatic disease of unknown origin. Among the remaining 10 patients, Curative surgery was offered to 5 patients with colorectal primary and one patient with hepatocellular carcinoma. The remaining patients were diagnosed with High grade B cell lymphoma, Neuroendocrine tumor, pancreatic mass and primary renal cell carcinoma. One patient had high grade small bowel obstruction due to a band adhesion resulting in emergency surgery and 5% of the patient needed a vascular referral for Abdominal aneurysm. Conclusion: CT scan in two week colorectal referral patients play a significant role in diagnosis of advanced disease. The ease of the procedure makes it more attractive during the pandemic in contrast to endoscopy and virtual-colonoscopy which has been significantly impacted by COVID 19.

Role of CT scan as initial investigation in colorectal rapid access patients

Background: We looked into CT colonoscopies and CT abdomen and pelvis which were booked as initial investigation in patients referred via the colorectal rapid access pathway. These tests were directly booked following the referral after a nurse led triage. As per our colorectal straight to test protocol (STT) any patients over the age of 75 or unfit individuals will have a CT colonoscopy (virtual colonoscopy) instead of colonoscopy. CT trunk was used during COVID pandemic as the initial investigation when the aerosol generating procedures were stopped. CT trunks are also the initial investigation as per the STT protocol when patients are referred with suspected abdominal mass, weight loss or abdominal pain. Methods: Retrospective analysis of prospective electronic data base of colorectal STT referrals from Feb 2020 to end of October 2020. Results: • Total no colorectal STT referrals -1524 • CT colonoscopies and CT trunks booked as initial investigation 420(27.55%) • Patients who refused to have the scans due to COVID 93/420 (22.14%) • Colorectal cancer diagnosis 25/327 (7.64%) • Non-colorectal cancer diagnosis 20/327(6.11%) Incidental AAA 15/ 327(4.58%) • Normal examination 91/327(27.82%) • Colonic polyps 27/327(8.25%) • Diverticular disease 92/327(28.13%) Conclusion: CT colonoscopies and CT trunks form part of initial diagnostic tool in the colorectal rapid access patients. They are particularly useful in high risk patients who cannot tolerate colonoscopy. These investigations complement the lower GI endoscopy. These scans also identify non-colorectal malignancies and retroperitoneal pathology such as AAA.CT trunks were useful tools during COVID 19 Pandemic.

Colon capsule endoscopy versus computed tomographic colonography for identifying colorectal cancer and polyps: A systemic review and meta-analysis

Aim: Early diagnosis and treatment of Colorectal Cancer can improve outcomes. Polypectomy with colonoscopy has failure and incompletion rates with risk of aerosol-generation. Computed Tomographic Colonography, second investigation, is limited by radiation exposure and aerosol generation. Colon Capsule endoscopy is a novel technique without gas insufflation, therefore avoiding the discomfort and aerosol- generation. Our aim is to compare the yield of the CCE with CTC in CRC and polyps in patients with positive stool tests or diagnosed colorectal lesions. Methods: Review followed PRISMA standards. Electronic database (EMBASE, MEDLINE, PubMed, CINAHL) searched for RCTs and Observational studies. MedCalc Statistical Software used for the synthesis of results. Primary (Per-Lesion and Per-Patient sensitivity analysis) and secondary (Other lesion and completion rate sensitivity analysis) outcomes measured using a random-effect model. Results: We found one RCT and three observational studies. Per-Lesion Sensitivity Analysis of CCE versus CTC showed overall effect of 1.903 (0.990- 1.937), p-value-0.057. Per-Patient Sensitivity Analysis of showed overall effect of 1.928 (0.995-1.892), p-value-0.054. Other lesions Sensitivity Analysis showed overall effect of 0.810 (0.121-161.995), pvalue- 0.418. Completion Rate Sensitivity Analysis showed overall effect of -0.419 (0.526-1.516), p-value-0.676. Conclusion: CCE had a better detection rate for colorectal cancer and polyp than the CTC, but this was not statistically significant. Therefore, this study failed to prove CCE's superiority over CTC. A careful decision can be made in current COVID-19 pandemic since its advantage of zero aerosolisation. Researchers should focus on innovation in techniques and simultaneous high-quality studies to evaluate them.

Impact of the COVID-19 pandemic on endoscopic cancer detection at a single-centre in the UK

Introduction Endoscopy services were paused during the first wave of the COVID-19 pandemic between March - April 2020. Endoscopy resumed in May 2020 at a reduced productivity alongside early clinical triage in an effort to use resources responsibly. We assessed whether our reduced service led to reductions in gastrointestinal (GI) cancer detection. We assessed differences in the choice of initial investigation, clinical triage and referral to endoscopy time among GI cancers diagnosed via the suspected GI cancer referral pathway. Methods GI cancer diagnoses were reviewed retrospectively over a seven month period (Mar-Oct 2020). Inclusion criteria were patients coded with a new diagnosis of GI cancer. The volume of endoscopic procedures performed was assessed using our endoscopy reporting software. Results were compared to the equivalent time period in 2019. Differences in time to endoscopy (days) were evaluated with a two-sample unpaired t-test. Results There was a 28.5% reduction in GI cancer diagnoses in 2020 (Mar-Oct) compared to 2019 (191 vs 267), with a 27.1% reduction in GI cancers diagnosed via endoscopic procedures (132 vs 181). There was a 42.7% reduction in endoscopic procedures in 2020 (Mar-Oct) compared to 2019 (6977 vs 12186). In terms of referrals for suspected GI cancers from GPs, there was a 30% reduction (3188 vs 4579). In 2020 (Mar-Oct), among cancers diagnosed via endoscopic procedures on the suspected GI cancer pathway, 40 of 68 (58.8%) patients had imaging as their first investigation (n=5 Barium swallow, n=13 CT abdomen, n=22 CT colonography) compared to 21 of 81 (25.9%) patients in 2019 (n=11 CT abdomen, n=9 CT colonography). Following the start of clinical triage (May-Oct 2020), 36 of 54 (67%) patients were triaged as 'very urgent'. 17 of 54 (31%) patients were triaged as 'urgent'. 1 patient was not prioritised as their barium swallow suggested a diagnosis of achalasia which was later found to be an oesophageal malignancy (referral to endoscopy 95 days). There was no significant difference in referral to endoscopy time in 2020 (Mar-Oct) [mean 45 days, SD 40.2] compared to 2019 [mean 41.6 days, SD 26.7] (mean difference 3.4 days p=0.55). Conclusions The COVID-19 pandemic has led to a 28.5% reduction in GI cancer diagnoses. This worrying reduction in cancer detection will need to be ameliorated by an increase in endoscopy capacity. Radiological investigations were utilised more during this period to assess suspected GI cancer referrals. 98% of cancer patients were appropriately prioritised as very urgent or urgent based on clinical triage, and radiological investigations aided in triage. There was no significant difference in referral to endoscopy time. We highlight that achalasia diagnosed on barium swallow should always visualised directly, even with curtailed endoscopy capacity.

Colorectal cancer diagnosed at sigmoidoscopy, is colonoscopy necessary to assess for synchronous cancer?

Introduction The Association of Coloproctology of Great Britain & Ireland (ACGBI) 2017 colorectal cancer (CRC) guidelines reaffirmed the longstanding practice of assessing for synchronous cancer in patients diagnosed with CRC at sigmoidoscopy (f-sig). Ideally by colonoscopy in addition to CT staging of chest, abdomen & pelvis (CT CAP), or alternatively CT colonography (CTC) and CT thorax if complete colonoscopy not possible. In the literature, approximately 3.5% of patients had synchronous CRC. Scheduling colonoscopy may delay treatment and be onerous for patients. Access to prompt colonoscopy can be challenging due to capacity issues, especially in the COVID-19 pandemic era. Methods Data were retrospectively analysed from electronic endoscopy, radiology and pathology records from patients diagnosed with CRC at f-sig and colonoscopy over 11 years (2010-2020 inclusive). Results Analysis 1: 680 patients who had CRC diagnosed at fsig: 230 underwent pre-treatment colonoscopy (33.8%). Interval between f-sig and colonoscopy;mean 17.5 days/ median 15.0 days. Two synchronous cancers identified at colonoscopy;0.9% 1. 57 years old man with primary rectal cancer and synchronous transverse colon cancer - both lesions reported on staging imaging scans. • 69 years old woman with a primary rectal cancer and synchronous sigmoid colon cancer (not seen at f-sig due to poor preparation) - both lesions reported on staging imaging scans. Analysis 2: 796 patients who had CRC diagnosed at colonoscopy: 48/796 have a significant 2nd finding (6.0%) • 24 had synchronous CRC (3.0%)/24 had a significant polyp >20 mm (3.0%) In these 48 cases, if F-sig was performed instead of colon, what would have been the outcome? • Only in one case would a significant lesion be missed. 72 years old man with a primary rectal cancer and a 30 mm ascending colon polyp (not seen on staging CT scan). • In the other 47 cases;staging CT scans pick up lesions or metastases, or lesions are all left sided and would be seen at F-sig, or lesions are all right sided and would not be seen at f-sig, or missed lesion was a benign polyp. Conclusions This is a large analysis of 1476 patients diagnosed with CRC. Of the 796 diagnosed at colonoscopy, 6.0% had a synchronous lesion (48 patients), 3.0% had a synchronous CRC, only 1 patient would have had a missed lesion if they'd had a f-sig alone. Of the 680 patients diagnosed with CRC at f-sig, 230 had a colonoscopy (33.5%), the rest were precluded due to advanced disease/obstruction or weren't fit due to advanced age/co-morbidity. Colonoscopy was undertaken at a median of 15.0 days. The yield of identifying a synchronous cancer at colonoscopy in this cohort is < 1%, in both cases these lesions were reported on staging imaging scans. British Society of Gastroenterology and ACPGBI guidelines from 2019 suggest that in patients who are fit/suitable they should undergo a surveillance colonoscopy at 12 months post CRC diagnosis. Given the capacity issues affecting colonoscopy services in the pandemic era, a proposed pathway for patients diagnosed with CRC at sigmoidoscopy;if staging imaging scans shows resectable CRC without synchronous lesion, is to consider undergoing surgery and to utilise 12-month colonoscopy to clear any adenomas. Alternatively CTC and CT thorax could be utilised though capacity issues may limit this approach. This data supports the consideration of alternative approaches as the likelihood of a synchronous cancer not seen at sigmoidoscopy and staging imaging scan appears to be very low.