Colorectal cancer screening in the USA in the wake of COVID-19

In the past two decades, we have made strides to boost colorectal cancer screening in the USA, with screening rates increased to 67% of eligible individuals.¹ Current efforts are directed towards boosting screening rates to 80%.

As a result of the COVID-19 pandemic, primary care visits have decreased substantially, and non-urgent and elective procedures are delayed. Subsequently, in March, 2020, the American Cancer Society recommended that no-one should go to a health-care facility for routine (non-diagnostic) cancer screening until further notification, which restricts the ability to screen average-risk individuals for colorectal cancer using colonoscopy or sigmoidoscopy. As a result, screening efforts have largely been suspended and screening rates have plummeted by 86% relative to the average before January, 2020.²

The USA is not unique in the sharp decrease in colorectal cancer screening; other high-income countries have also reported largely halting their colorectal cancer screening efforts. However, this is where the stories diverge. The USA is an outlier among high-income countries in a couple of ways. First, with a few exceptions, the USA does not have national, regional, or local organised programmes for colorectal cancer screening. Colorectal cancer screening is largely opportunistic—ie, requires a provider visit. Second, colonoscopy is the predominant method of screening, as opposed to tests, such as the faecal immunochemical test (FIT).

As we prepare for resumption of clinical services, we must meaningfully address the disparities in delivery and methods of colorectal cancer screening compared with other countries. Health-care systems and health service users should implement an organised, vigorous screening approach, by which we identify those eligible for colorectal cancer screening and reach out to them individually. Models for this approach already exist⁴ and have been successful in achieving screening rates of 80% and higher. These approaches can be tailored for the specific population's needs and are also cost-effective.⁵ Given that the USA is a patchwork of health-care systems and networks, the first step in this effort is to create local, regional, or statewide registries of individuals eligible for colorectal cancer screening. This endeavour will take enormous upfront effort and public cooperation between providers, non-profit organisations, and governments, but the dividends go far beyond one-time screening: these registries could evolve into living documents accessible by all health-care providers, similar to vaccination registries. In the long-term, this approach would also reduce overscreening.

The second crucial aspect to address is flexibility in screening methods. As the COVID-19 pandemic shows, activities that are difficult or inconvenient to do in person can still be done at home. Zoom (Zoom Video Communications, San Francisco, CA, USA) and other video conferencing platforms have been substitutes for unsafe in-person meetings. FIT-like tests have high sensitivity and specificity for detecting colorectal cancer⁶ and can be sent directly to patients, done in the safety of their homes, and posted back to the laboratory. With positivity rates of 4–8%, this approach would substantially reduce the number of individuals who must go through the trying task of scheduling and undergoing a colonoscopy, made even more risky by potential exposure to SARS-CoV-2. Approximately 88 million individuals are aged 50–75 years in the USA, at least 29 million of whom were not up to date with their colorectal cancer screening before March, 2020. With screening decreasing by 86%, FIT-like tests could offer a method of triaging this increasing backlog.

In the USA we have adapted to newer models of doing business, delivery of education, and health care since the pandemic began. The approaches we suggest here are safe, low cost, readily available, evidence based, and in keeping with guidelines for physical distancing. We believe that organised screening and FIT-like tests are the best path forward for colorectal cancer screening in the wake of COVID-19.