The pandemic of 2020/1 initially pushed colorectal and other cancer screening activity, ‘off-stage’. The political focus was on the logistics associated with the clinical and financial implications of COVID-19. The cessation of colorectal cancer screening was primarily because endoscopy resources had ‘dried up’ following redeployment of clinical staff to COVID related activities. The logistics enabling FIT kit distribution and analysis also proved challenging as did the provision of safe colonscopy investigations. The public themselves began to show reluctance, if invited, to attend colonoscopy clinics. By June 2020, both media and political focus had broadened and were showing an appreciation that our preoccupation with ‘deaths from COVID-19’ had displaced provision of routine preventative healthcare services like cancer screening and treatment (Lancet refs).
As the first COVID wave gave way to a short nadir and then to subsequent waves in this deadly pandemic, something happened to the provision of many screening programmes. Some programmes remained moribund, but most had modified their procedures and recommenced their screening invitations, their testing arrangements and their colonoscopy service provision. Of course, the challenge was substantial; to rebuild, under new demanding safety constraints, a service that had been ‘untidily’ interrupted (ceased at various stages), with an accumulated backlog of sometimes millions of invitations (1.8 million in the case of England), and then apply new or modified colonoscopy arrangements, frequently in different premises.
In March 2020 I initiated a candid exchange with colleagues who were leading and managing a diverse range of colorectal cancer screening programmes across the globe. This initiative evolved into an informal ‘Newsletter’ which ran to five ‘editions’ for a period of seven months and provided an insight into the challenges of supporting screening during a critical period in the COVID-19 pandemic. Very few programmes avoided a pause in their screening activities during the initial wave of the pandemic, but Taiwan was one. Taiwan suffered only a 10% dip in screening provision, their public had learnt from previous experience of SARS-CoV in 2002, as did South Korea with MERS-CoV in 2015. Denmark managed to maintain their screening service although public enthusiasm for screening waned with a 35% reduction in uptake during their spring. Most countries however, ceased screening as the first wave of the pandemic approached its peak, a few formally announced their decision in advance, and others, like England, made no formal announcement but responded appropriately to diminishing resources.
Whilst most FIT-based screening programmes stopped invitations, many maintained a laboratory service for returned FIT kits and a few provided a limited colonoscopy service although uptake was generally much diminished.
Primary screening by colonoscopy largely ceased, this was evident in the US and some centres substituted FIT screening or used FIT as a means of assessing risk and prioritising referral to colonoscopy. In the recovery phase of the first COVID-19 wave, some programmes considered using FIT concentration as a means of prioritising those at high risk. This approach was considered in England for those waiting for colonoscopy following a positive FIT result, but the priority was to avoid emergency admissions related to intestinal obstruction and therefore assessment of individual symptoms was applied.
The period of time that international screening programmes were paused varied considerably, the Netherlands and many other European programme recommenced in 8 weeks but in Norway it was 20 weeks. The length of the pause this was influenced by the priority given to screening, its organisational ‘robustness’, screening organisational arrangements, service capacity, and competing priorities. Primarily, the limiting factor was adequate colonoscopy resources which was generally a reflection of the impact that the pandemic was having upon general healthcare provision.
Subsequent COVID ‘waves’, are now proving as clinically challenging as in the initial wave, yet most screening programmes have maintained their services whilst addressing a considerable screening backlog. The development of robust screening arrangements can, to a degree, mitigate the clinical impact of future epidemics /pandemics and the characteristics that might make them robust, deserve consideration by existing programmes.
So, what has changed and what enhancements might this pandemic bring to the provision of CRC screening internationally?
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Centralised organisation enables a consistent policy during a period of disruptive
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The ability to make a timely response to an emerging health crisis makes best use of available resources, is less disruptive, provides better outcomes and maintains public confidence in the healthcare system and specifically in screening
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Formal reviews at designated frequency enables screening programmes to plan, make the best use of resources and maintain a constructive relationship with staff and the public
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Prior modelling of recovery options will enable timely informed decision making and provide confidence to those engaged in the recovery including the public and the media
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A comprehensive screening database proves an indispensable organisation tool to enable a range of recovery strategies to be uniformly applied
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Readily available participant telephone and email contact details enables effective communication during a period of changing policy and resources
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Pre-prepared draft public /patient literature that can be made available at short notice will enable timely and efficient communication with the public and increase confidence in the service.
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The advantages of FIT over colonoscopy screening in a pandemic are self-evident and being able to apply a variable FIT concentration threshold assists resource prioritisation and recovery
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9.
Distributing FIT by mail provides advantages over collection from hospital, clinic or family Dr., (public access was generally restricted)
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Centralised FIT laboratories systems proved efficient and effective and, by exploiting a centralised database resource, services can be focused on a reduced number of labs
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11.
Direct referral from a FIT +ve screen to a ‘screening’ colonoscopy provides a robust mechanism which is less susceptible to delays or loss and enables close centralised monitoring.
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Well-designed spacious colonoscopy facilities enables the transition to COVID-19 health and safety requirements without constraining throughput
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Attendance for colonoscopy requires public confidence in the safety of the service, without tangible evidence of such provision participation rates may be challenged.
The ‘Newsletter’ highlighted how the challenges and potential to recover from the pandemic are markedly influenced by the design and oversight of the programme. It is too early to assess whether the COVID experience will indeed provoke, or facilitated, enhancement to existing programmes. Those in South America that are in the early stage of development, have a unique opportunity to benefit from the lessons learnt from this extraordinarily challenging period.
Declaration of Competing Interest
I have no conflicts of interest.
Author contribution
Single author and hence the entire contribution is made by the author.