10.1055/a-1159-0644
10.1055/a-1213-5761
The benefits of colorectal cancer (CRC) screening programs, in terms of cancer incidence
and mortality, are indisputable. The medicalization of a large segment of the healthy
and asymptomatic population is now well accepted as an investment to prevent future
health harms and costs in the small proportion of individuals that could otherwise
develop cancer. Indeed, CRC prevention has instigated a major shift in endoscopy practice.
However, it has also generated an overwhelming workload for endoscopy units, which
suffer from a limited and rigid capacity.
“… the findings confirm that there is no immediate need to rush a colonoscopy after
a positive FIT result and that it is preferable to accept longer post-FOBT time lapses
for colonoscopy scheduling than to pause population screening programs.”
The COVID-19 pandemic represents an unprecedented health crisis. During the first
wave, endoscopy activity has been limited to mostly emergency procedures. A recent
study from the UK National Endoscopy Database, which is populated by automated real-time
capture of endoscopy reports and contains over 2.5 million endoscopy records, revealed
that the first weeks of the UK lockdown saw a reduction in endoscopy activity to 5 %
of normal, with activity only recovering to 20 % of pre-COVID-19 levels in the subsequent
weeks [1]. After the lockdown, endoscopy services face two immense challenges: 1) the adaptation
of endoscopy units and workflows to COVID-19 prevention measures, which include social
distancing, enforced downtime, and additional cleaning between procedures, all of
which reduce patient throughput; and, simultaneously, 2) the absorption of all postponed
procedures into the already overloaded endoscopy agenda. Gastroenterology societies
such as the European Society of Gastrointestinal Endoscopy have recommended that endoscopies
be rescheduled according to indication, with therapeutic and diagnostic procedures
in symptomatic patients scheduled before screening and surveillance procedures [2].
To avoid increasing the pressure on already saturated endoscopy departments, CRC population
screening programs have been paused in most European countries. However, for patients
with cancer, a delay in diagnosis and treatment has the real potential to increase
the likelihood of diseases being found at more advanced stages, with some patients’
tumors progressing from curable (with near-normal life expectancy) to non-curable
(with limited life expectancy). Indeed, a recent modeling study indicated that even
modest delays in cancer surgery of 3 to 6 months might significantly impact survival,
particularly for stage 2 or 3 cancers [3]. As a matter of fact, the recent article from the UK National Endoscopy Database
revealed a dramatic and worrying effect of the fall in endoscopy activity on cancer
diagnosis, with up to 72 % of expected CRCs not being detected [1]. Accordingly, major concern has arisen regarding the appropriateness of interruptions
to such valuable programs.
In fecal occult blood test (FOBT)-based CRC screening programs, a delay between a
FOBT-positive result and colonoscopy is associated with an increased risk of advanced
CRC and mortality. A simulation model study estimated that a delay of 12 months could
reduce the total years of life gained from screening by nearly 10 % vs. a colonoscopy
performed within 2 weeks after a positive FOBT [4]. Thus, it has been proposed that colonoscopy be delivered as soon as possible in
patients with a likelihood of CRC and within 1 month in individuals with a positive
FOBT. According to European guidelines, colonoscopy in FOBT-positive individuals should
be scheduled within 31 days, and achievement of a ≤ 30-day post-FOBT colonoscopy interval
in ≥ 90 % of cases is used as a quality indicator to audit the adequacy of population-based
screening programs [5]. This highly demanding requisite is a cause of stress for endoscopy services, with
post-FOBT colonoscopies having to compete with the other indications. This requirement
may represent a currently insurmountable pressure and might lead to the interruption
of CRC screening programs.
In this issue of Endoscopy, Zorzi et al. [6] report on the population-based screening program for CRC in the Veneto region of
Italy and provide us with highly pertinent information on the current situation. The
study included 123 138 individuals who complied with an invitation to undergo post-fecal
immunochemical test (FIT) colonoscopy. Despite the local recommendations, only 41 %
of patients had a time to colonoscopy < 30 days, and 58 % had a time between 31 and
180 days. Although the detection rate for invasive CRC was stable for waiting times < 180
days, a statistically significant excess was observed after a 270-day cutoff (odds
ratio 1.75, 95 % confidence interval 1.15 – 2.67). Moreover, the CRC stage was stable
in relation to a waiting time < 270 days.
The fact that a time to colonoscopy after FOBT up to 6 months was not associated with
any increase in CRC prevalence or in CRC stage progression supports the overall safety
of an extended time to colonoscopy after a positive FOBT. Despite the intrinsic limitations
of the study by Zorzi et al. (a retrospective design with confounding factors that
hamper causality deductions, a minority of patients with long delays, and an unknown
CRC stage in one-third of cases), the findings are consistent with those of a large
study from the USA [7] and another from Asia [8] that have evaluated CRC outcomes associated with variations in follow-up times.
According to the report by Corley et al. [7], concerns regarding an increased risk of CRC and late-stage CRC arise about 10 months
after a positive FIT result. Overall, the findings confirm that there is no immediate
need to rush a colonoscopy after a positive FIT result and that it is preferable to
accept longer post-FOBT time lapses for colonoscopy scheduling than to pause population
screening programs. The present situation provides the ideal scenario to implement
the prioritization of colonoscopies for FOBT-positive patients based on the previously
identified risk factors for advanced neoplasia [9].
The results obtained by Zorzi et al. suggest that God does indeed temper the wind
to the shorn lamb, with FOBT-positive patients able to safely wait up to 6 months
before undergoing colonoscopy. Unexpectedly, the COVID-19 pandemic is affording us
the opportunity to fine-tune our endoscopy activity by better adjusting it to the
established indications and by tailoring waiting lists to procedures that evidently
improve outcomes in terms of relevant diagnoses and life years saved.
