While colorectal cancers are among the most treatable forms of cancer, cases must be screened for and caught early enough in order to lessen mortality risk.
And in what was a difficult year in medicine for many, one of the biggest successes in gastroenterology during 2020 has been that despite obstacles created by the pandemic, experts do not anticipate annual colorectal screenings have decreased much at all.
This may be thanks to a collective push in recent years to promote early screenings and disease awareness. Lockdowns and reprioritization of in-person medical care this year presented a challenge for clinicians continue seeing the benefits of proactive colorectal cancer care.
In an interview with HCPLive®, James Church, MD, Director of the Sanford R. Weiss Center for Hereditary Colorectal Neoplasia in the Cleveland Clinic’s Digestive Disease and Surgical Institute, explained how despite the difficult circumstances, medical officials were able to prioritize colonoscopies for high-risk patients.
“The benefit of screening is to find cancer early, so you can cure it,” Church said. “But 2-3 months is not going to make a difference between cured or not cured. I can say pretty confidently that patients are not going to die, even if they have cancer in February, when we told them we can’t screen you until June.”
At the Cleveland Clinic, to preserve and ration supplies and to free up health care workers, elective procedures were shut down for March, April, and May this.This meant patients that were scheduled for colonoscopies during this three-month period were deferred to later dates.
Seeing a schedule crunch when appointments once again began, Cleveland Clinic officials began to create tiers for patients, in order to prioritize individuals at greater risk.
Typical Procedures for Colorectal Cancer
Patients are commonly screened for colorectal cancer between the ages of 50-60, though symptoms do not generally present.
Patient risk is often stratified by low, average or high grades, with higher risk patients generally individuals with a family history of colon cancer, those who had a polyp, and those with a history of cancer themselves.
Church said the chances of any individual patient without a family history or symptoms presenting of having colorectal cancer is very small.However, what the purpose of these screenings is, even in low risk patients, is to identify precancerous polyps that may take a decade to eventually turn into a cancer.
“Even patients at low risk, I personally called all of my patients and told them that we were having to defer them,” Church said. “And we would get them in as soon as possible and reschedule a delayed exam.”
Church said most of his patients were amenable to return to the medical facility for the colonoscopy in the truncated schedule. But there was a portion of patients who did not feel the risk of returning to the facility for a preventative screening was worthwhile. Much of their reasoning was borne out of a greater fear for coronavirus 2019 (COVID-19) than any they had for slight risk of cancer development.
“From the patient point of view, a lot of patients were scared to come to the hospital,” Church said. “So obviously we did everything we could to reassure them about that and overcome those fears and recommend that they don’t put the screening after interminably.”
Headed into a new year under the pandemic, concern over patients unwilling to visit a medical facility for treatment or screenings remains. Church suggested patients who are likely most scared to return likely do not have any communication with their healthcare providers.
For those who fit the bill, his team has an informal strategy for providing assurance.
“We have a protocol, where we routinely mentioned to the patients that are supposed to come into the hospital that the hospital is a very safe place,” he said. “And I’ve always felt safe here. I pass it on to the patients that we follow the guidelines of masks and social assistance, and hand washing.”
Significant Improvements Over Time
The promotion of colonoscopies and early screenings has had a drastic impact on decreasing both the rates of new cancers and the total number of new cancers in the US.
In fact, according to the US Centers for Disease Control and Prevention (CDC), the age-adjusted rate of new colorectal cancers per 100,000 persons has dropped by 52% from 1999-2017.
Coincidentally, approximately two-thirds of US adults between 50-75 years old were up to date with colorectal cancer screening guidelines by 2018, punctuating a gradual increase in new annual screening counts.
Church said an area that continues to warrant more monitoring going into this decade is younger patients.
It is becoming more and more prevalent for patients younger than 50 years old to receive a diagnosis of rectal or colon cancers, despite guidance suggesting they are at notably lesser risk than older patients. As such, some leading institutions have begun to adjust their screening age parameters to include those as young as 45.
Even with the changed guidelines, it may take several years before screening is common practice among this group.
While Church is confident that the brief delay and postponement of cancer screenings in the spring of 2020 ultimately will not increase the mortality rate of the disease, others are less certain.
“This is something you can actually extrapolate to different organs,” C. Roberto Simons-Linares, MD, MSc, also of the Cleveland Clinic, said. “Delaying for a couple months, I don’t think is a big deal in general. But I still think, in general, cancer screening and surveillance getting delayed is a question mark of exactly what the impact of this is.”
Should there be another lockdown or push to cancel certain procedures, Church believes that colonoscopies will still be conducted at a normal pace. Unlike last spring, the majority of facilities are well equipped with personal protective equipment to continue to treat patients.
Coupled with successes in maintaining colorectal cancer care during the pandemic, clinicians are confident their blueprint for cancer risk screening has been proven through this tumultuous year.
The issue of hospital avoidance during COVID-19 is one that experts like Church remain empathetic to, but matters may be more befuddled given the sheer rate of hospitalizations occurring due to the pandemic currently.
“It’s different now because we’re not doing surgery that requires an admission to hospital,” Church said. “So, it’s not the personal protective equipment that’s the issue now, it’s personnel and competing for beds, as more and more patients get admitted.”
The challenge changes in its obstacles, but remains the same in name: screen and treat the right colorectal cancer patients, when possible.