Estimating the Backlog of Colonoscopy due to Coronavirus Disease 2019 and Comparing Strategies to Recover in Ontario, Canada
Jill TinmouthSteven DongChristine StogiosLinda RabeneckMichelle ReyCatherine DubéMelissa CoulsonJulia GaoDan HeNathaniel JembereBronwen R. McCurdyJustine Wallace
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Coronavirus disease 2019 (COVID-19) has significantly affected gastrointestinal (GI) endoscopy, with jurisdictions reporting up to a 95% reduction in procedure volumes compared to before the pandemic.1Rutter MD et al. Gut [published online July 20, 2020]. https://doi.org/10.1136/gutjnl-2020-322179.Google Scholar In Ontario, Canada, a large volume of colonoscopies not performed during the first wave of the pandemic (the backlog) must now be managed (Supplementary Table 1). Ontario Health (Cancer Care Ontario) oversees colonoscopies performed in hospitals (70% of those performed in the province). Ontario Health's "COVID-19 Tip Sheet for Facilities Performing Gastrointestinal Endoscopy" (June 2020) recommended that individuals originally scheduled for low-yield colonoscopies (ie, average-risk screening colonoscopy or surveillance colonoscopy in those with a history of low-risk adenoma [LRA]) should instead receive the fecal immunochemical test (FIT)2Ontario Health. https://www.ontariohealth.ca/sites/ontariohealth/files/2020-05/A%20Measured%20Approach%20to%20Planning%20for%20Surgeries%20and%20Procedures%20During%20the%20COVID-19%20Pandemic.pdf.Google Scholar, 3Tinmouth J. et al.Colorectal cancer screening in average risk populations: evidence summary. Program in evidence-based care evidence summary no. 15-14. Cancer Care Ontario, Toronto, Canada2015Google Scholar, 4Dubé C. et al.Am J Gastroenterol. 2017; 112: 1790-1801Crossref PubMed Scopus (78) Google Scholar and be referred for colonoscopy only if the FIT result is abnormal. Ontario Health's surveillance guidelines recommend FIT as the follow-up test in those with a history of LRA based on recent evidence that the risk of colorectal cancer in these individuals is less than in the general population.5Dubé C et al. https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/38506.Google Scholar, 6Loberg M. et al.N Engl J Med. 2014; 371: 799-807Crossref PubMed Scopus (226) Google Scholar, 7Wieszczy P. et al.Gastroenterology. 2020; 158: 875-883Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar, 8Cross A.J. et al.Long-term colorectal cancer incidence after adenoma removal and the effects of surveillance on incidence: a multicentre, retrospective, cohort study.Gut. 2020; 69: 1645-1658Crossref PubMed Scopus (58) Google Scholar Our aims were to (1) estimate the volume of hospital-based outpatient colonoscopies not performed because of the pandemic and (2) compare the effect of 2 strategies, redirecting individuals from low-yield colonoscopy to FIT and increasing hospital colonoscopy capacity, on backlog recovery time. We used the GI Endoscopy Data Submission Portal, which receives monthly hospital colonoscopy data (including colonoscopy date and indication) to identify all outpatient hospital colonoscopies performed from January 2019 to August 2020. We estimated hospital-based outpatient colonoscopy volumes from March 2020 to February 2024 by calculating the difference between expected monthly colonoscopy volumes (derived from monthly 2019 volumes inflated by 1%/year) in the absence of the pandemic and observed or projected volumes during the pandemic. Volumes from March to August 2020 were obtained from the Gastrointestinal Endoscopy Data Sharing Portal ("observed") and projected for subsequent months by multiplying the expected volumes by assumptions of system capacity during the pandemic. We assumed that (1) colonoscopy volume in September 2020 would be 85% of that expected; (2) capacity would increase by 5%/month, reaching 100% in December 2020; and (3) the maximum capacity of 115% would be reached in March 2021, remaining stable thereafter. In any given year, 100% capacity was defined as the mean of expected monthly volumes for that year. Maximum system capacity was set at 115% based on the relative difference between the highest and average monthly volumes in 2019. Recovery time was defined as the number of months until the colonoscopy backlog was eliminated. Colonoscopies were added to the backlog after August 2020 in months where capacity was anticipated to be below 100%. We counted low-yield colonoscopies that would have been performed in the absence of the pandemic. All average-risk screening colonoscopies and 50% of surveillance colonoscopies were considered low yield. The latter assumption was required because we do not have data on pathology from the prior colonoscopy. A proportion of people redirected to FIT (OC-Sensor DIANA, Eiken Chemical Co) will have an abnormal result (Ontario target positivity range: 5%–6.5%) and require a colonoscopy (Ontario's prepandemic colonoscopy follow-up rate: 90%). Beginning in September 2020, redirected low-yield colonoscopies were subtracted, and abnormal FIT result colonoscopies resulting from redirection were added to expected hospital colonoscopy volumes. Corresponding recovery times, varying the proportion of low-yield colonoscopies redirected to FIT (25%, 50%, and 75%), were calculated. An alternative strategy for managing the backlog is to increase hospital endoscopy capacity. Again, we assumed (1) 85% capacity in September 2020 and (2) that capacity would increase by a constant rate each month until March 2021, when the maximum capacity would be reached and maintained thereafter. We then calculated the maximum expected increase in system capacity required to match the recovery times achieved by redirecting 25%, 50%, and 75% of low-yield colonoscopies to FIT. Before the pandemic, 18% and an estimated 13% of all colonoscopies were performed for average-risk screening and LRA surveillance, respectively (Supplementary Table 1). Estimated recovery times vary depending on the proportion of persons scheduled for low-yield colonoscopies who are redirected to FIT. The backlog is projected to take 41 months to recover without redirection, but redirecting 25%, 50%, and 75% low-yield colonoscopies to FIT will reduce recovery times to 28, 22, and 19 months, respectively (Figure 1A). If there was no redirection to FIT, hospitals would need to increase colonoscopy capacity to 124%, 134%, and 145% to recover the backlog in 28, 22, and 19 months, respectively (Figure 1B). As in other jurisdictions,1Rutter MD et al. Gut [published online July 20, 2020]. https://doi.org/10.1136/gutjnl-2020-322179.Google Scholar GI endoscopy services in Ontario have been profoundly affected by the COVID-19 pandemic, leading to a colonoscopy backlog that, absent any intervention, is estimated to take 41 months to recover. The impact to patients is consequential, particularly in terms of delays in diagnosis. The UK estimated 2828 fewer colorectal cancers diagnosed using lower endoscopy during the pandemic compared to the months leading up to COVID-19, representing a 72% absolute decrease.1Rutter MD et al. Gut [published online July 20, 2020]. https://doi.org/10.1136/gutjnl-2020-322179.Google Scholar We have presented 2 strategies to address the colonoscopy backlog and shown that redirecting persons originally scheduled for low-yield colonoscopy to FIT can substantially reduce the colonoscopy backlog and recovery time. To achieve a similar effect, colonoscopy capacity would need to exceed mean historical volumes by as much as 45%, which would be costly and challenging to achieve due to the constraints in the delivery of care introduced by COVID-19 (eg, physical distancing in recovery rooms). Limitations to this work include that we did not account for subsequent pandemic waves or for reduction in demand for colonoscopy during the study period because of patients' reluctance to undergo a colonoscopy, including follow-up procedures after an abnormal FIT result. Furthermore, although the FIT cutoff used to define a positive test can be adjusted to local colonoscopy capacity, we did not vary this cutoff in our analyses. Other jurisdictions facing a similar backlog in colonoscopy should consider redirecting individuals waiting for low-yield colonoscopy to FIT to mitigate the impact of the pandemic on access to colonoscopy. Other members of the ColonCancerCheck/Gastrointestinal Endoscopy COVID Working Group: Melissa Coulson, Julia Gao, Dan He, Nathaniel Jembere, Bronwen R. McCurdy, and Justine Wallace, all of Prevention and Cancer Control, Ontario Health (Cancer Care Ontario), Toronto, Ontario. Jill Tinmouth, MD, PhD (Conceptualization: Equal; Formal analysis: Supporting; Methodology: Lead; Supervision: Lead; Writing – original draft: Lead); Steven Dong, MA (Conceptualization: Supporting; Formal analysis: Lead; Writing – original draft: Equal); Christine Stogios, MSc (Project administration: Lead; Writing – original draft: Equal); Linda Rabeneck, MD, MPH (Conceptualization: Equal; Methodology: Equal; Writing – review & editing: Equal); Michelle Rey, MSc, PhD (Methodology: Supporting; Supervision: Supporting; Writing – review & editing: Equal); Catherine Dubé, MD, MSc (Conceptualization: Equal; Methodology: Equal; Writing – review & editing: Equal). Supplementary Table 1Impact of the COVID-19 Pandemic on Hospital Outpatient Colonoscopy Volumes in OntarioColonoscopy indicationHospital outpatient colonoscopy volumesBefore Pandemic, March–June 2019 n (%)Pandemic, March–June 2020 n (%)% change, 2020 vs 2019gFOBT+/FIT+4390 (4)4758 (13)8Symptomatic44,651 (42)19,501 (54)–56Family historyaIndividuals at increased risk due to a family history in 1 or more first degree relative(s) with colorectal cancer.10,855 (10)2134 (6)–80SurveillancebIndividuals with a prior polypectomy or colorectal cancer. Prior histology (ie, low- or high-risk adenoma) is not known.28,107 (26)6033 (17)–79Average-risk screeningcIndividuals at average risk for colorectal cancer (ie, no first degree relatives with colorectal cancer).19,031 (18)3603 (10)–81All colonoscopies107,034 (100)36,029 (100)–66FIT, fecal immunochemical test; gFOBT, guaiac fecal occult blood test.a Individuals at increased risk due to a family history in 1 or more first degree relative(s) with colorectal cancer.b Individuals with a prior polypectomy or colorectal cancer. Prior histology (ie, low- or high-risk adenoma) is not known.c Individuals at average risk for colorectal cancer (ie, no first degree relatives with colorectal cancer). Open table in a new tab FIT, fecal immunochemical test; gFOBT, guaiac fecal occult blood test.Keywords:
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Abstract Background and Aim Regular endoscopy or fecal immunochemical test (FIT) is ideal for screening colorectal cancer. However, only a limited number of individuals undergo regular screening. This study aimed to compare the cost‐effectiveness of a single colonoscopy with a single FIT performed for colorectal cancer screening. Methods A microsimulation model was constructed based on real‐world observational data collected from three institutions between 2019 and 2022 that compared colonoscopy‐based screening with FIT‐based screening. The total costs of diagnosis and treatment of the detected lesions using the two strategies were calculated. The incremental cost‐effectiveness ratio (ICER) per life year gained (LYG) of the colonoscopy‐based strategy was calculated. Results Data from 11 407 patients undergoing colonoscopies and 59 176 patients undergoing FITs were used to establish a model. In the base case analysis of screening strategies, colonoscopy was more cost‐effective than FIT (ICER 415 193 yen/LYG). The ICER of the colonoscopy‐based strategy among 60‐ to 69‐year‐old patients was lowest at 394 200 yen/LYG, whereas that in 20‐ to 29‐year‐old patients was highest. Monte Carlo simulations showed that the colonoscopy‐based strategy was more cost‐effective than the FIT‐based strategy (net monetary benefit [NMB]: 5 695 957 yen vs 5 348 253 yen). When the adenoma detection rate in the colonoscopy was over 30% or the positive FIT rate was lower than 8.6% in the FIT‐based strategy, the NMB of the colonoscopy‐based strategy exceeded that of the FIT‐based strategy. Conclusion In the microsimulation model, colonoscopy is recommended as a one‐time screening procedure in patients aged >60 years with >30% ADR or <8.6% positive FIT rate.
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Screening for colorectal cancer (CRC) using the fecal immunochemical test (FIT) has been rapidly implemented worldwide. Alongside primary colonoscopy, it is a first-tier recommended screening test. FIT testing offers several advantages, including noninvasiveness, high acceptance among the target population, and cost-effectiveness [1] [2] [3]. However, it is not without challenges, particularly concerning the management of individuals with a negative colonoscopy following a positive FIT result.
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Screening colonoscopy for early detection and prevention of colorectal cancer (CRC) is mostly used inefficiently. Here, we assessed the potential of an innovative approach to colonoscopy-based screening, by use of a single, low threshold fecal immunochemical test (FIT) as a "gateopener" for screening colonoscopy. Using COSIMO, a validated simulation model, we modeled scenarios including either direct invitation to screening colonoscopy or an alternative approach involving mailing a single ("gateopener") FIT along with an invitation to colonoscopy contingent on a FIT value above a low threshold yielding a 50% positivity rate (ie, every other pretest will be positive). Under plausible assumptions on screening offer adherence, we found that such "gateopener screening" (use of screening colonoscopy contingent on a positive, low threshold gateopener FIT) approximately doubled cancer detection rates vs conventional screening. In those spared from screening colonoscopy due to a negative gateopener FIT pretest, numbers needed to screen were 10-times higher vs those for individuals with a positive FIT, peaking in >2000 and >3800 (hypothetically) needed colonoscopies to detect one case of cancer in men and women, respectively. Gateopener screening resulted in 42%-51% and 59%-65% more prevented CRC cases and deaths, respectively. In summary, by directing colonoscopy capacities to those most likely to benefit, offering screening colonoscopy contingent on a "gateopener" low-threshold FIT would substantially enhance efficiency of colonoscopy screening.
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To assess patient preferences for colorectal cancer screening with stool-based tests after initial colonoscopy with suboptimal bowel preparation.An online scenario-based survey of adults aged 45 to 75 years at average risk for colorectal cancer was performed.When presented with a hypothetical scenario of screening colonoscopy with suboptimal bowel preparation, 59% of respondents chose stool-based testing as a next step, 29% preferred a repeat colonoscopy within a year, and 12% preferred a repeat colonoscopy in 10 years (N = 1,080).Clinicians should consider offering stool-based screening tests as an alternative to repeat colonoscopy after suboptimal bowel preparation.
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The morbidity of colorectal cancer has been increasing year by year in China.Screening test of colorectal cancer can effectively decrease the morbidity and mortality of it.However,the current screening technique has obvious defect.Screening of exfoliated colonocytes isolated from human stool for early detection of colorectal cancer is noninvasive and well tolerated by patients;it has a potential for colorectal cancer screening.
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To examine predictors of provider recommendations for colorectal cancer (CRC).We examined proportions of patients without prior screening for colonoscopy and their willingness to get a colonoscopy if recommended by a healthcare provider.The rate of CRC screening with a colonoscopy within the recommended guidelines was 35%; provider recommendation rate for colonoscopy screening was 34.9%; and never-screened patients would receive a colonoscopy 78% when recommended by a provider. Provider recommendation was the best predictor for receiving a screening colonoscopy (OR 4.19; 95% CI, 1.91-9.22, p < .01).Physician recommendation for colonoscopy is the most effective strategy to promote screening colonoscopy in the US, but only one third of eligible patients recall such counseling.
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Colorectal cancer is a significant public health issue all over the world. Screening has been shown effective in improving the survival rate and decreasing the deaths of colorectal cancer. Several organizations have released guidelines for colorectal cancer screening. However, detailed recommendations like the age to begin remain controversial. This paper summarizes the recommended different age groups in initiating the colorectal cancer screening program from a few guidelines and analyzes the reasons for the inconsistency, thus facilitating the drafting of colorectal cancer screening guidelines in China.结直肠癌已成为严重威胁人类健康的重要公共卫生问题之一，筛查可以提升结直肠癌生存率并降低人群死亡率。多个国家相继发布适合本国人群的结直肠癌筛查指南，但不同指南在筛查年龄等问题上尚存争议。本文针对结直肠癌适宜筛查开始年龄进行汇总，分析其产生差异的原因，为我国人群结直肠癌筛查指南的制定提供思路借鉴。.
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Aims Primary colonoscopy and fecal immunochemical testing (FIT) are considered first tier tests for colorectal cancer (CRC) screening. Although colonoscopy is considered the most efficacious test, FIT may achieve higher participation rates. We assessed diagnostic yield of FIT and colonoscopy after the first round of testing in the PICCOLINO study.
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Background: Colorectal cancer is increasing worldwide, especially in young populations. Objective: In this minireview, we discussed the different methods used in the screening of colorectal cancer in the general population. Conclusions: screening of colorectal cancer by different methods is an effective way to diagnose colorectal cancer in the early stages. Keywords: screening, colorectal cancer, minireview
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An important new test for colorectal cancer screening was evaluated by Imperiale et al. and reported in the April 4, 2014 New England Journal of Medicine entitled “Multitarget stool DNA testing for colorectal-cancer screening”. This editorial notes the favorable trend in the reduction of colorectal cancer incidence and mortality, and explores the significant issue of suboptimal patient uptake of existing colorectal cancer screening examinations. The findings of the multitarget stool DNA test study are summarized, put into perspective, and the potential interest in this examination is considered. By expanding colorectal cancer screening uptake, the multitarget stool DNA test may further reduce the burden of colorectal cancer.
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