Delivery of Cervical and Colorectal Cancer Screenings During the Pandemic in Community Health Centers: Practice Changes and Recovery Strategies.

BACKGROUND: The coronavirus disease 2019 pandemic led to clinical practice changes, which affected cancer preventive care delivery. OBJECTIVES: To investigate the impact of the coronavirus disease 2019 pandemic on the delivery of colorectal cancer (CRC) and cervical cancer (CVC) screenings. RESEARCH DESIGN: Parallel mixed methods design using electronic health record data (extracted between January 2019 and July 2021). Study results focused on 3 pandemic-related periods: March-May 2020, June-October 2020, and November 2020-September 2021. SUBJECTS: Two hundred seventeen community health centers located in 13 states and 29 semistructured interviews from 13 community health centers. MEASURES: Monthly up-to-date CRC and CVC screening rates and monthly rates of completed colonoscopies, fecal immunochemical test (FIT)/fecal occult blood test (FOBT) procedures, Papanicolaou tests among age and sex-eligible patients. Analysis used generalized estimating equations Poisson modeling. Qualitative analysts developed case summaries and created a cross-case data display for comparison. RESULTS: The results showed a reduction of 75% for colonoscopy [rate ratio (RR) = 0.250, 95% CI: 0.224-0.279], 78% for FIT/FOBT (RR = 0.218, 95% CI: 0.208-0.230), and 87% for Papanicolaou (RR = 0.130, 95% CI: 0.125-0.136) rates after the start of the pandemic. During this early pandemic period, CRC screening was impacted by hospitals halting services. Clinic staff moved toward FIT/FOBT screenings. CVC screening was impacted by guidelines encouraging pausing CVC screening, patient reluctance, and concerns about exposure. During the recovery period, leadership-driven preventive care prioritization and quality improvement capacity influenced CRC and CVC screening maintenance and recovery. CONCLUSIONS: Efforts supporting quality improvement capacity could be key actionable elements for these health centers to endure major disruptions to their care delivery system and to drive rapid recovery.

Impact of delayed screening invitations on screen-detected and interval cancers in the Dutch colorectal cancer screening programme: individual-level data analysis.

OBJECTIVE: To assess the impact of delayed invitation on screen-detected and interval colorectal cancers (CRC) within a faecal immunochemical testing (FIT)-based CRC screening programme. DESIGN: All individuals that participated in 2017 and 2018 with a negative FIT and were eligible for CRC screening in 2019 and 2020 were included using individual-level data. Multivariable logistic regression analyses were used to assess the association between either the different time periods (ie, 'before', 'during' and 'after' the first COVID-19 wave) or the invitation interval on screen-detected and interval CRCs. RESULTS: Positive predictive value for advanced neoplasia (AN) was slightly lower during (OR=0.91) and after (OR=0.95) the first COVID-19 wave, but no significant difference was observed for the different invitation intervals. Out of all individuals that previously tested negative, 84 (0.004%) had an interval CRC beyond the 24 months since their last invitation. The time period of invitation as well as the extended invitation interval was not associated with detection rates for AN and interval CRC rate. CONCLUSION: The impact of the first COVID-19 wave on screening yield was modest. A very small proportion of the FIT negatives had an interval CRC possibly due to an extended interval, which potentially could have been prevented if they had received the invitation earlier. Nonetheless, no increase in interval CRC rate was observed, indicating that an extended invitation interval up to 30 months had no negative impact on the performance of the CRC screening programme and a modest extension of the invitation interval seems an appropriate intervention.

Defensive information processing and nonadherence to health-protective behaviors.

PLAIN LANGUAGE SUMMARY: In this issue of Cancer, Clarke et al. measure defensive information processing (DIP) to avoid fecal immunochemical testing for colorectal cancer. DIP is a way of reducing the negative psychological effects of threats such as cancer and may influence health-protective behaviors such as the completion of recommended cancer screening. This editorial complements Clarke et al.'s study with a discussion of interventions for decreasing DIP around cancer screening and other health-protective recommendations.

Supply and quality of colonoscopy according to the characteristics of gastroenterologists in the French population-based colorectal-cancer screening program.

BACKGROUND: Since its complete roll-out in 2009, the French colorectal cancer screening program (CRCSP) experienced 3 major constraints [use of a less efficient Guaiac-test (gFOBT), stopping the supply of Fecal-Immunochemical-Test kits (FIT), and suspension of the program due to the coronavirus disease 2019 (COVID-19)] affecting its effectiveness. AIM: To describe the impact of the constraints in terms of changes in the quality of screening-colonoscopy (Quali-Colo). METHODS: This retrospective cohort study included screening-colonoscopies performed by gastroenterologists between Jan-2010 and Dec-2020 in people aged 50-74 living in Ile-de-France (France). The changes in Quali-colo (Proportion of colonoscopies performed beyond 7 mo (Colo_7 mo), Frequency of serious adverse events (SAE) and Colonoscopy detection rate) were described in a cohort of Gastroenterologists who performed at least one colonoscopy over each of the four periods defined according to the chronology of the constraints [gFOBT: Normal progress of the CRCSP using gFOBT (2010-2014); FIT: Normal progress of the CRCSP using FIT (2015-2018); STOP-FIT: Year (2019) during which the CRCSP experienced the cessation of the supply of test kits; COVID: Program suspension due to the COVID-19 health crisis (2020)]. The link between each dependent variable (Colo_7 mo; SAE occurrence, neoplasm detection rate) and the predictive factors was analyzed in a two-level multivariate hierarchical model. RESULTS: The 533 gastroenterologists (cohort) achieved 21509 screening colonoscopies over gFOBT period, 38352 over FIT, 7342 over STOP-FIT and 7995 over COVID period. The frequency of SAE did not change between periods (gFOBT: 0.3%; FIT: 0.3%; STOP-FIT: 0.3%; and COVID: 0.2%; P = 0.10). The risk of Colo_7 mo doubled between FIT [adjusted odds ratio (aOR): 1.2 (1.1; 1.2)] and STOP-FIT [aOR: 2.4 (2.1; 2.6)]; then, decreased by 40% between STOP-FIT and COVID [aOR: 2.0 (1.8; 2.2)]. Regardless of the period, this Colo_7 mo's risk was twice as high for screening colonoscopy performed in a public hospital [aOR: 2.1 (1.3; 3.6)] compared to screening-colonoscopy performed in a private clinic. The neoplasm detection, which increased by 60% between gFOBT and FIT [aOR: 1.6 (1.5; 1.7)], decreased by 40% between FIT and COVID [aOR: 1.1 (1.0; 1.3)]. CONCLUSION: The constraints likely affected the time-to-colonoscopy as well as the colonoscopy detection rate without impacting the SAE's occurrence, highlighting the need for a respectable reference time-to-colonoscopy in CRCSP.

Colorectal Cancer Screening During the COVID-19 Pandemic.

Shared decision-making (SDM) can help patients make good decisions about preventive health interventions such as cancer screening. We illustrate the use of SDM in the case of a 53-year-old man who had a new patient visit with a primary care physician and had never been screened for colorectal cancer (CRC). The patient had recently recovered from a serious COVID-19 infection requiring weeks of mechanical ventilation. When the primary care physician initially offered a screening colonoscopy, the man expressed great reluctance to return to the hospital for the exam. The PCP then offered a stool test, which could be completed at home, but emphasized that if it were positive, a colonoscopy would be required. He agreed to complete the stool test, and unfortunately, it was positive. He then agreed to undergo colonoscopy, which uncovered a large rectal cancer. The carcinoma had invaded the mesorectal fat but there were no metastases. After undergoing neoadjuvant chemotherapy followed by a low anterior resection of the tumor, he has no evidence of recurrence so far. Many clinicians favor colonoscopy for CRC screening, but evidence suggests that patients who are offered more than one reasonable option are more likely to undergo screening. If screening had been delayed in this patient until he was willing to accept a screening colonoscopy, there was the potential the cancer may have been more advanced when diagnosed, with a worse outcome. Shared decision-making was a key approach to understanding the patient's feelings related to this screening decision and making a decision consistent with his preferences.

Impact of the COVID-19 Pandemic on Fecal Immunochemical Testing, Colonoscopy Services, and Colorectal Neoplasia Detection in a Large United States Community-based Population.

BACKGROUND & AIMS: The COVID-19 pandemic has affected clinical services globally, including colorectal cancer (CRC) screening and diagnostic testing. We investigated the pandemic's impact on fecal immunochemical test (FIT) screening, colonoscopy utilization, and colorectal neoplasia detection across 21 medical centers in a large integrated health care organization. METHODS: We performed a retrospective cohort study in Kaiser Permanente Northern California patients ages 18 to 89 years in 2019 and 2020 and measured changes in the numbers of mailed, completed, and positive FITs; colonoscopies; and cases of colorectal neoplasia detected by colonoscopy in 2020 vs 2019. RESULTS: FIT kit mailings ceased in mid-March through April 2020 but then rebounded and there was an 8.7% increase in kits mailed compared with 2019. With the later mailing of FIT kits, there were 9.0% fewer FITs completed and 10.1% fewer positive tests in 2020 vs 2019. Colonoscopy volumes declined 79.4% in April 2020 compared with April 2019 but recovered to near pre-pandemic volumes in September through December, resulting in a 26.9% decline in total colonoscopies performed in 2020. The number of patients diagnosed by colonoscopy with CRC and advanced adenoma declined by 8.7% and 26.9%, respectively, in 2020 vs 2019. CONCLUSIONS: The pandemic led to fewer FIT screenings and colonoscopies in 2020 vs 2019; however, after the lifting of shelter-in-place orders, FIT screenings exceeded, and colonoscopy volumes nearly reached numbers from those same months in 2019. Overall, there was an 8.7% reduction in CRC cases diagnosed by colonoscopy in 2020. These data may help inform the development of strategies for CRC screening and diagnostic testing during future national emergencies.

Impact of the COVID-19 pandemic on faecal immunochemical test-based colorectal cancer screening programmes in Australia, Canada, and the Netherlands: a comparative modelling study.

BACKGROUND: Colorectal cancer screening programmes worldwide have been disrupted during the COVID-19 pandemic. We aimed to estimate the impact of hypothetical disruptions to organised faecal immunochemical test-based colorectal cancer screening programmes on short-term and long-term colorectal cancer incidence and mortality in three countries using microsimulation modelling. METHODS: In this modelling study, we used four country-specific colorectal cancer microsimulation models-Policy1-Bowel (Australia), OncoSim (Canada), and ASCCA and MISCAN-Colon (the Netherlands)-to estimate the potential impact of COVID-19-related disruptions to screening on colorectal cancer incidence and mortality in Australia, Canada, and the Netherlands annually for the period 2020-24 and cumulatively for the period 2020-50. Modelled scenarios varied by duration of disruption (3, 6, and 12 months), decreases in screening participation after the period of disruption (0%, 25%, or 50% reduction), and catch-up screening strategies (within 6 months after the disruption period or all screening delayed by 6 months). FINDINGS: Without catch-up screening, our analysis predicted that colorectal cancer deaths among individuals aged 50 years and older, a 3-month disruption would result in 414-902 additional new colorectal cancer diagnoses (relative increase 0·1-0·2%) and 324-440 additional deaths (relative increase 0·2-0·3%) in the Netherlands, 1672 additional diagnoses (relative increase 0·3%) and 979 additional deaths (relative increase 0·5%) in Australia, and 1671 additional diagnoses (relative increase 0·2%) and 799 additional deaths (relative increase 0·3%) in Canada between 2020 and 2050, compared with undisrupted screening. A 6-month disruption would result in 803-1803 additional diagnoses (relative increase 0·2-0·4%) and 678-881 additional deaths (relative increase 0·4-0·6%) in the Netherlands, 3552 additional diagnoses (relative increase 0·6%) and 1961 additional deaths (relative increase 1·0%) in Australia, and 2844 additional diagnoses (relative increase 0·3%) and 1319 additional deaths (relative increase 0·4%) in Canada between 2020 and 2050, compared with undisrupted screening. A 12-month disruption would result in 1619-3615 additional diagnoses (relative increase 0·4-0·9%) and 1360-1762 additional deaths (relative increase 0·8-1·2%) in the Netherlands, 7140 additional diagnoses (relative increase 1·2%) and 3968 additional deaths (relative increase 2·0%) in Australia, and 5212 additional diagnoses (relative increase 0·6%) and 2366 additional deaths (relative increase 0·8%) in Canada between 2020 and 2050, compared with undisrupted screening. Providing immediate catch-up screening could minimise the impact of the disruption, restricting the relative increase in colorectal cancer incidence and deaths between 2020 and 2050 to less than 0·1% in all countries. A post-disruption decrease in participation could increase colorectal cancer incidence by 0·2-0·9% and deaths by 0·6-1·6% between 2020 and 2050, compared with undisrupted screening. INTERPRETATION: Although the projected effect of short-term disruption to colorectal cancer screening is modest, such disruption will have a marked impact on colorectal cancer incidence and deaths between 2020 and 2050 attributable to missed screening. Thus, it is crucial that, if disrupted, screening programmes ensure participation rates return to previously observed rates and provide catch-up screening wherever possible, since this could mitigate the impact on colorectal cancer deaths. FUNDING: Cancer Council New South Wales, Health Canada, and Dutch National Institute for Public Health and Environment.

Telephone Reminders Improve Fecal Immunochemical Test Return Rates.

INTRODUCTION: The aim of this study was to investigate the effect of a structured telephone reminder system on completion rates of screening fecal immunochemical tests. METHODS: Fecal immunochemical test (FIT) return rates were compared among patients who received a telephone reminder after 14 days and those who did not receive a reminder. RESULTS: There was a significantly higher return rate among patients who received a telephone reminder. Automated FIT tracking processes failed to capture a significant percentage of returned FITs compared with manual tracking processes. DISCUSSION: These results support telephone reminders as an effective modality to increase FIT return rates.

Factors associated with colorectal cancer screening adherence and the impact of COVID-19 on screening patterns in Connecticut, USA.

Colorectal cancer (CRC) is one of the leading causes of cancer death worldwide. Many communities remain under the 80% CRC screening goal. We aimed to identify factors associated with non-adherence to CRC screening and to describe the effect of the COVID-19 pandemic in CRC screening patterns. A retrospective review of patients aged 50-75 years seen at the Griffin Faculty Physicians primary care offices between January 2019 and December 2020 was performed. Logistic regression models were used to identify factors associated with CRC screening non-adherence. Of 12,189 patients, 66.2% had an updated CRC screen. On univariable logistic regression, factors associated with CRC screening non-adherence included age ≤ 55 years [odds ratio (OR) 2.267, p < 0.001], White/Caucasian race (OR 0.858, p = 0.030), Medicaid insurance (OR 2.097, p < 0.001), morbid obesity (OR 1.436, p < 0.001), current cigarette smoking (OR 1.849, p < 0.001), and elevated HbA1c (OR 1.178, p = 0.004). Age, Medicaid insurance, morbid obesity, current smoking, and HbA1c ≥ 6.5% remained significant in the final multivariable model. Compared to 2019, there was an 18.2% decrease in the total number of CRC screening tests in 2020. The proportion of colonoscopy procedures was lower in 2020 compared to the proportion of colonoscopy procedures conducted in 2019 (65.9% vs 81.7%, p < 0.001), with a concurrent increase in stool-based tests. CRC screening rates in our population are comparable to national statistics but below the 80% goal. COVID-19 affected CRC screening. Our results underscore the need to identify patient groups most vulnerable to missing CRC screening and highlight the importance of stool-based testing to bridge screening gaps.

Participation in a government-subsidised colorectal cancer screening programme for asymptomatic individuals in Hong Kong.

BACKGROUND: A Government-subsidised colorectal cancer screening programme (CRCSP) was launched in Hong Kong. This study aimed to assess the participation rate in CRCSP among Chinese individuals between the ages of 50 and 75 years and to survey individuals' reasons for declining to participate in the CRCSP. METHODS: A cross-sectional study was performed. Asymptomatic Chinese individuals aged 50-75 years in Hong Kong who did not have a history of colorectal cancer were recruited. A survey was used to collect information about individuals' participation in the CRCSP. RESULTS: The survey was completed by 1317 participants. Of these, 432 (32.8%) joined the CRCSP and the remaining 885 participants (67.2%) did not join the CRCSP. The most common reason that participants provided for not joining the CRCSP was thinking that the screening was not necessary because they had no health problems (29.3%). Some (14.4%) of the participants claimed to lack information about the CRCSP and screening procedures. Some (12.5%) of them completed the screening before the CRCSP was launched, and the cost was covered by other sources. CONCLUSION: The participation in CRCSP for a screening among the Hong Kong population has generally increased, but obstacles to participating in screening programme remain.

Current and future colorectal cancer screening strategies.

Despite strong evidence of effectiveness, colorectal cancer (CRC) screening remains underused. Currently, there are several options for CRC screening, each with its own performance characteristics and considerations for practice. This Review aims to cover current CRC screening guidelines and highlight future blood-based and imaging-based options for screening. In current practice, the leading non-invasive option is the faecal immunochemical test (FIT) based on its high specificity, good sensitivity, low cost and ease of use in mailed outreach programmes. There are currently five blood-based CRC screening tests in varying stages of evaluation, including one that is currently sold in the USA as a laboratory-developed test. There are ongoing studies on the diagnostic accuracy and longitudinal performance of blood tests and they have the potential to disrupt the CRC screening landscape. Imaging-based options, including the colon capsule, MR colonography and the CT capsule, are also being tested in active studies. As the world attempts to recover from the COVID-19 pandemic and adapts to the start of CRC screening among people at average risk starting at age 45 years, non-invasive options will become increasingly important.

Modelling optimal use of temporarily restricted colonoscopy capacity in a FIT-based CRC screening program: Application during the COVID-19 pandemic.

OBJECTIVE: The COVID-19 pandemic forced colorectal cancer (CRC) screening programs to downscale their colonoscopy capacity. In this study, we assessed strategies to deal with temporary restricted colonoscopy capacity in a FIT-based CRC screening program while aiming to retain the maximum possible preventive effect of the screening program. DESIGN: We simulated the Dutch national CRC screening program inviting individuals between ages 55 and 75 for biennial FIT using the MISCAN-Colon model including the 3-month disruption in the first half of 2020 due to the COVID-19 pandemic. For the second half of 2020 and 2021, we simulated three different strategies for the total target population: 1) increasing the FIT cut-off, 2) skipping one screening for specific screening ages, and 3) extending the screening interval. We estimated the impact on required colonoscopy capacity in 2020-2021 and life years (LYs) lost in the long-term. RESULTS: Increasing the FIT cut-off, skipping screening ages and extending the screening interval resulted in a maximum reduction of 25,100 (-17.0%), 16,100(-10.9%) and 19,000 (-12.9%) colonoscopies, respectively. Modelling an increased FIT cut-off, the number of LYs lost ranged between 1,400 and 4,400. Skipping just a single screening age resulted in approximately 2,700 LYs lost and this was doubled in case of skipping two screening ages. Extending the screening interval up to 34 months had the smallest impact on LYs lost (up to 1,100 LYs lost). CONCLUSION: This modelling study shows that to anticipate on restricted colonoscopy capacity, temporarily extending the screening interval retains the maximum possible preventive effect of the CRC screening program.

Is qFIT a useful tool in prioritising symptomatic patients referred with suspect colorectal cancer in the COVID-19 era?

Background: The COVID-19 pandemic is an evolving healthcare challenge causing secondary disruption of cancer services. Quantitative Faecal Immunochemical Testing (qFIT) has been established as a screening method in asymptomatic patients. We aim to assess its utility as a triage tool to prioritise investigations in symptomatic patients with suspected colorectal cancer. Methods: At the commencement of the COVID-19 pandemic a database was established to include patients awaiting red flag outpatient consultation or colonic investigations and new red flag referrals from March to June 2020. Patients were supplied with qFIT kits and returned results categorised into 3 priority groups according to the qFIT value. Group 1 >150µg Hb/g, Group 2 ≥10 to ≤150µg Hb/g and Group 3 <10µg Hb/g. Subsequent colonic evaluation was offered by colonoscopy or cross-sectional imaging with urgency determined by qFIT priority group. When identified colorectal cancer, inflammatory bowel disease or high-risk polyps were recorded as "significant colorectal pathology." Findings: Three hundred and seventeen patients were identified with data analysed on 290 patients. Colorectal malignancy was identified in 17 patients; 94% of these patients were in Group 1. A qFIT result >150 µg Hb/g had a sensitivity and specificity for colorectal cancer of 94.12% (95% CI 71.31-99.85) and 91.21% (95% CI 87.20-94.29) respectively. No malignancy was detected in Priority Group 3; negative predictive value of 100% (95% CI 98.06-100). Conclusions: In symptomatic, suspect lower GI cancer patients qFIT is a useful adjunct for prioritising patients and can be used to determine the urgency of colorectal investigations.

Changes in Cancer Screening in the US During the COVID-19 Pandemic.

Importance: Health care was disrupted in the US during the first quarter of 2020 with the emergence of the COVID-19 pandemic. Early reports in selected samples suggested that cancer screening services decreased greatly, but population-based estimates of cancer screening prevalence during 2020 have not yet been reported. Objective: To examine changes in breast cancer (BC), cervical cancer (CC), and colorectal cancer (CRC) screening prevalence with contemporary national, population-based Behavioral Risk Factor Surveillance System (BRFSS) data. Design, Setting, and Participants: This survey study included respondents from the 2014, 2016, 2018, and 2020 BRFSS surveys who were eligible for BC (women aged 50-74 years), CC (women aged 25-64 years), and CRC (women and men aged 50-75 years) screening. Data analysis was performed from September 2021 to February 2022. Exposures: Calendar year. Main Outcomes and Measures: Self-reported receipt of a recent (defined as in the past year) BC, CC, and CRC screening test. Adjusted prevalence ratios (aPRs) comparing 2020 vs 2018 prevalence and 95% CIs were computed. Results: In total, 479 248 individuals were included in the analyses of BC screening, 301 453 individuals were included in CC screening, and 854 210 individuals were included in CRC screening, In 2020, among respondents aged 50 to 75 years, 14 815 (11.4%) were Black, 12 081 (12.6%) were Hispanic, 156 198 (67.3%) were White, and 79 234 (29.9%) graduated from college (all percentages are weighted). After 4 years (2014-2018) of nearly steady prevalence, past-year BC screening decreased by 6% between 2018 and 2020 (from 61.6% in 2018 to 57.8% in 2020; aPR, 0.94; 95% CI, 0.92-0.96), and CC screening decreased by 11% (from 58.3% in 2018 to 51.9% in 2020; aPR, 0.89; 95% CI, 0.87-0.91). The magnitude of these decreases was greater in people with lower educational attainment and Hispanic persons. CRC screening prevalence remained steady; past-year stool testing increased by 7% (aPR, 1.07; 95% CI, 1.02-1.12), offsetting a 16% decrease in colonoscopy (aPR, 0.84; 95% CI, 0.82-0.88) between 2018 and 2020. Conclusions and Relevance: In this survey study, stool testing increased and counterbalanced a decrease in colonoscopy during 2020, and BC and CC screening modestly decreased. How these findings might be associated with outcomes is not yet known, but they will be important to monitor, especially in populations with lower socioeconomic status, who experienced greater screening decreases during the COVID-19 pandemic.

Colorectal Cancer Screening with Mailed Fecal Immunochemical Tests and Telephone Outreach at a Community Health Center during the COVID-19 Pandemic.

Colorectal cancer (CRC) is a common cause of cancer death and disproportionately affects non-Hispanic Black patients. Routine screening with the fecal immunochemical test (FIT) decreases CRC incidence and mortality, and previous literature suggests pairing FIT with live outreach. Screening delays due to the COVID-19 pandemic will likely increase CRC incidence and mortality, especially in underserved communities. We implemented a quality improvement (QI) project at an urban community health center (CHC) in which FIT was paired with live telephone outreach. The intervention increased CRC screening at the CHC by five percentage points. Fecal immunochemical test completion rates significantly increased with successful contact (24.6% for at least one vs. 3.0% for none, p < .0001) and ordering a FIT kit during a patient interaction (28.4% vs. 15.7%, p < .001). This intervention addressed disparities in CRC screening, and the report may have general implications for addressing systemic racism in preventive medicine.

Modelling the impact of the coronavirus pandemic on bowel cancer screening outcomes in England: A decision analysis to prepare for future screening disruption.

The English Bowel Cancer Screening Programme invites people between the ages of 60 and 74 to take a Faecal Immunochemical Test every two years. This programme was interrupted during the coronavirus pandemic. The research aimed: (1) to estimate the impact of colorectal cancer (CRC) Faecal Immunochemical Test screening pauses of different lengths and the actual coronavirus-related screening pause in England, and (2) to analyse the most effective and cost-effective strategies to re-start CRC screening to prepare for future disruptions. The analysis used the validated Microsimulation Model in Cancer of the Bowel built in the R programming language. The model simulated the life course of a representative English screening population from 2019, by age, sex, socio-economic deprivation, and prior screening history. The modelling scenarios were based on assumptions and data from screening centres in England. Pausing bowel screening in England due to coronavirus pandemic is predicted to increase CRC deaths by 0.73% within 10 years and 0.13% over the population's lifetime, with excess deaths due to peak in 2023. More deaths are expected in men and people aged over 70. Pausing screening for longer would result in greater additional CRC cases and deaths. Postponing screening for everyone would be the most cost-effective strategy to minimise the impact of screening disruption without any additional endoscopy capacity. If endoscopy capacity can be increased, temporarily raising the Faecal Immunochemical Test threshold to 190 µg/g may help to minimise CRC deaths, particularly if screening programmes start from age 50 in the future.

A cohort study of duplicate faecal immunochemical testing in patients at risk of colorectal cancer from North-West England.

OBJECTIVES: We sought to investigate if duplicate faecal immunochemical testing (FIT) sampling improves the negative and positive predictive value of patients thought to be at risk of colorectal cancer (CRC). Specifically, we aimed to investigate whether the proportion of FIT-negative CRC missed by a single FIT test in symptomatic patients could be reduced by duplicate FIT testing. DESIGN: A retrospective service evaluation cohort study of the diagnostic accuracy of duplicate FIT testing. SETTING: Patients referred from primary care with suspected CRC to four secondary care trusts in North-West England. PARTICIPANTS: 28 622 patients over 18-years-old with lower gastrointestinal symptoms suggestive of CRC who completed two FIT samples. PRIMARY AND SECONDARY OUTCOME MEASURES: The performance of duplicate FIT for detecting CRC at a threshold of 10 µgHb/g. RESULTS: The sensitivity if either test was >10 µgHb/g was 0.978 (0.955-0.989), specificity was 0.662 (0.657-0.668), positive predictive value 0.031 (0.028-0.035) and negative predictive value 1.00 (0.999-1.00). Despite two-thirds of patients (18952) being negative following two tests, at this threshold only seven CRC were missed over a 26-month period. All seven patients had other high-risk features which should have prompted investigation. CONCLUSIONS: This study suggests that in routine NHS practice, a duplicate FIT sample strategy together with clinical evaluation for evidence of anaemia and weight loss is superior to a single FIT sample alone and would allow symptomatic patients to be managed in primary care without the need for urgent referral to secondary care for urgent colonic imaging.

Faecal immunochemical tests safely enhance rational use of resources during the assessment of suspected symptomatic colorectal cancer in primary care: systematic review and meta-analysis.

OBJECTIVE: Implementation of faecal immunochemical tests (FIT) as a triage test in primary healthcare may improve the efficiency of referrals without missing cases of colorectal cancer (CRC). We aim to summarise the performance characteristics of FITs for CRC in symptomatic patients presenting to primary healthcare. DESIGN: We performed a systematic literature review of Medline and EMBASE databases from May 2018 to November 2020. Previous related systematic searches were also adapted to this aim and completed with reference screening. We identified studies performed on adult patients consulting for abdominal symptoms in primary care which reported data such that the FIT diagnostic performance parameters for CRC could be obtained. Bivariate models were used to synthesise available evidence. Meta-regression analysis was performed to evaluate the causes of heterogeneity. RESULTS: Twenty-three studies (69 536 participants) were included (CRC prevalence 0.3%-6.2%). Six studies (n=34 691) assessed FIT as rule in test (threshold of ≥150 µg Hb/g faeces) showing a sensitivity of 64.1% (95% CI 57.8% to 69.9%) and a specificity of 95.0% (95% CI 91.2% to 97.2%). A threshold of 10 µg/g (15 studies; n=48 872) resulted in a sensitivity of 87.2% (95% CI 81.0% to 91.6%) and a specificity of 84.4% (95% CI 79.4% to 88.3%) for CRC. At a 20 µg Hb/g faeces threshold (five studies; n=24 187) less than one additional CRC would be missed per 1000 patients investigated compared with 10 µg Hb/g faeces threshold (CRC prevalence 2%). CONCLUSION: FIT is the test of choice to evaluate patients with new-onset lower gastrointestinal symptoms in primary healthcare.