Projected long-term effects of colorectal cancer screening disruptions following the COVID-19 pandemic

Optimal Stopping Ages for Colorectal Cancer Screening

Importance

Prior studies have shown that the benefits, harms, and costs of colorectal cancer (CRC) screening at older ages are associated with a patient's sex, health, and screening history. However, these studies were hypothetical exercises and not directly informed by data on CRC risk.

Objective

To identify the optimal stopping ages for CRC screening by sex, comorbidity, and screening history from a cost-effectiveness perspective.

Design, Setting, and Participants

This economic evaluation first validated the MISCAN-Colon (Microsimulation Screening Analysis-Colon) model against community-based CRC incidence and mortality rates for 2 subcohorts of the PRECISE (Optimizing Colorectal Cancer Screening Precision and Outcomes in Community-Based Populations) cohort. Subsequently, different CRC screening scenarios were simulated in older individuals. Cohorts of US adults aged 76 to 90 years varied by sex and comorbidity status (none, low, moderate, or severe). Statistical and sensitivity analyses were performed from March 2023 to May 2024.

Exposures

CRC screening histories including fecal immunochemical test (FIT) or colonoscopy, such as a negative colonoscopy result from 10, 15, 20, 25, or 30 years before the index age; 1 to 5 negative FIT results within 5 years of the index age, with different patterns of recency; or a combination of negative colonoscopy and negative FIT results.

Main Outcomes and Measures

The main outcomes included estimated lifetime clinical outcomes, incremental costs, and quality-adjusted life-years gained (QALYG) associated with 1 additional FIT or colonoscopy. Optimal stopping age for screening, defined as the oldest age for which the incremental cost-effectiveness ratio was still below the willingness-to-pay threshold of $100 000 per QALYG, was evaluated.

Results

The first of the 2 PRECISE subcohorts used in validating the simulation model included 25 974 adults (15 060 females [58.0%]; 54.7% aged 76 to 80 years) with a negative colonoscopy result 10 years before the index date. The second subcohort consisted of 118 269 adults (67 058 females [56.7%]; 90.5% aged 76 to 80 years) with a negative FIT result 1 year before the index date. Older age, male sex, higher comorbidity levels, and recent CRC screenings were associated with reduced incremental benefit and cost-effectiveness of additional screening. For the reference cohort of 76-year-old females without comorbidities and a negative colonoscopy result 10 years before the index age, 1 additional colonoscopy cost $38 226 per QALYG. For cohorts with otherwise equivalent characteristics, associated costs increased to $1 689 945 per QALYG for females at age 90 years without comorbidities and a negative colonoscopy results 10 years before the index age, $51 604 per QALYG for males at age 76 years without comorbidities and a negative colonoscopy result 10 years before the index age, and $108 480 per QALYG for females at age 76 years with severe comorbidities and a negative colonoscopy result 10 years before the index age and decreased to $16 870 per QALYG for females without comorbidities and a negative colonoscopy result 30 years before the index age. The optimal stopping ages across different cohorts ranged from younger than 76 to 86 years for colonoscopy and younger than 76 to 88 years for FIT.

Conclusions and Relevance

In this economic evaluation, age, sex, screening history, comorbidity, and future screening modality were associated with the clinical outcomes, cost-effectiveness, and optimal stopping age for CRC screening. These results can inform guideline development and patient-directed informed decision-making.

DISTRIBUTED MODEL EXPLORATION WITH EMEWS

As high-performance computing resources have become increasingly available, new modes of applying and experimenting with simulation and other computational tools have become possible. This tutorial presents recent advancements to the Extreme-scale Model Exploration with Swift (EMEWS) framework. EMEWS is a high-performance computing (HPC) model exploration (ME) framework, developed for large-scale analyses (e.g., calibration, optimization) of computational models. We focus on three new use-inspired EMEWS capabilities, improved accessibility through binary installation, a new decoupled architecture (EMEWS DB) and task API for distributing workflows on heterogeneous compute resources, and improved EMEWS project creation capabilities. We present a complete worked example where EMEWS DB is used to connect a Python Bayesian optimization algorithm to worker pools running both locally and on remote compute resources. The example, including an R version, and additional details on EMEWS are made available on a public website.

Resilience Gap in Gastrointestinal Endoscopy Activity during the COVID-19 Pandemic in South Korea

This study assessed the impact of distancing measures during the COVID-19 pandemic on cancer diagnostic activities, including gastrointestinal endoscopy (GIE). It analyzed GIE volumes from 2020 to 2022 in comparison to 2018-2019, considering variations in resilience linked to socioeconomic status (SES). The analysis utilized data from the Korean Health Insurance Review and Assessment Services database, covering the entire population and medical facilities. Diagnostic GIE rates (2018-2022) in Gwangju Metropolitan City and Jeonnam province were examined, comparing age-standardized rates (ASRs) by area, gender, and SES. The results indicated a decline in ASRs for colonoscopy and endoscopic gastroduodenoscopy (EGD) in 2020 compared to 2018-2019, followed by an increase in 2021-2022, except for EGD in the medical aid population. SES based and rural-urban disparities were evident in the recovery of GIE rates. The findings suggest that equity-focused strategies are needed to ensure equitable healthcare access among different socioeconomic groups after pandemic.

Disentangling the relationship between cancer mortality and COVID-19 in the US

Cancer is considered a risk factor for COVID-19 mortality, yet several countries have reported that deaths with a primary code of cancer remained within historic levels during the COVID-19 pandemic. Here, we further elucidate the relationship between cancer mortality and COVID-19 on a population level in the US. We compared pandemic-related mortality patterns from underlying and multiple cause (MC) death data for six types of cancer, diabetes, and Alzheimer's. Any pandemic-related changes in coding practices should be eliminated by study of MC data. Nationally in 2020, MC cancer mortality rose by only 3% over a pre-pandemic baseline, corresponding to ~13,600 excess deaths. Mortality elevation was measurably higher for less deadly cancers (breast, colorectal, and hematological, 2-7%) than cancers with a poor survival rate (lung and pancreatic, 0-1%). In comparison, there was substantial elevation in MC deaths from diabetes (37%) and Alzheimer's (19%). To understand these differences, we simulated the expected excess mortality for each condition using COVID-19 attack rates, life expectancy, population size, and mean age of individuals living with each condition. We find that the observed mortality differences are primarily explained by differences in life expectancy, with the risk of death from deadly cancers outcompeting the risk of death from COVID-19.

Racial/ethnic and socioeconomic disparities in colorectal cancer screening in a large organization with universal insurance before and during the coronavirus disease 2019 pandemic

OBJECTIVES

Israel is regarded as a country with a developed economy and a moderate income inequality index. In this population-based study, we aimed to measure the inequalities in colorectal cancer screening within Clalit Health, an organization with universal insurance, before and during the coronavirus disease 2019 pandemic.

SETTING

Retrospective analysis within Clalit Health Services, Israel.

METHODS

We evaluated the rate of being up to date with screening (having a colonoscopy within 10 years or a fecal occult blood test within 1 year) and the colonoscopy completion rate (having a colonoscopy within 6 months of a positive fecal occult blood test) among subjects aged 50-75 in 2019-2021.

RESULTS

In 2019, out of 918,135 subjects, 61.3% were up to date with screening; high socioeconomic status: 65.9% (referent), medium-socioeconomic status: 60.1% (odds ratio 0.81, 95% confidence interval 0.80-0.82), low-socioeconomic status: 59.0% (odds ratio 0.75, 95% confidence interval 0.74-0.75); Jews: 61.9% (referent), Arabs: 59.7% (odds ratio 0.91, 95% confidence interval 0.90-0.92), Ultraorthodox-Jews: 51.7% (odds ratio 0.77, 95% confidence interval 0.75-0.78). Out of 21,308 with a positive fecal occult blood test, the colonoscopy completion rate was 51.8%; high-socioeconomic status: 59.8% (referent), medium-socioeconomic status: 54.1% (odds ratio 0.79, 95% confidence interval 0.73-0.86), low-socioeconomic status: 45.5% (odds ratio 0.60, 95% confidence interval 0.56-0.65); Jews: 54.7% (referent), Ultraorthodox-Jews: 51.4% (odds ratio 0.91, 95% confidence interval 0.90-0.92), Arabs: 44.7% (odds ratio 0.77, 95% confidence interval 0.75-0.78). In 2020-2021, there was a slight drop in the rate of being up to date with screening, while most of the discrepancies were kept or slightly increased with time.

CONCLUSIONS

We report significant inequalities in colorectal cancer screening before and during the coronavirus disease 2019 pandemic in Israel, despite a declared policy of equality and universal insurance.

Effect of the SARS-CoV-2 pandemic on colorectal cancer diagnosis and prognosis

BACKGROUND AND STUDY AIMS

Our aim was to determine the impact of the SARS-CoV-2 pandemic on the diagnosis and prognosis of colorectal cancer (CRC).

PATIENTS AND METHODS

This prospective cohort study included individuals diagnosed with CRC between March 13, 2019 and June 20, 2021 across 21 Spanish hospitals. Two time periods were compared: prepandemic (from March 13, 2019 to March 13, 2020) and pandemic (from March 14, 2020 to June 20, 2021, lockdown period and 1 year after lockdown).

RESULTS

We observed a 46.9% decrease in the number of CRC diagnoses (95% confidence interval (CI): 45.1%-48.7%) during the lockdown and 29.7% decrease (95% CI: 28.1%-31.4%) in the year after the lockdown. The proportion of patients diagnosed at stage I significantly decreased during the pandemic (21.7% vs. 19.0%; p = 0.025). Centers that applied universal preprocedure SARS-CoV-2 PCR testing experienced a higher reduction in the number of colonoscopies performed during the pandemic post-lockdown (34.0% reduction; 95% CI: 33.6%-34.4% vs. 13.7; 95% CI: 13.4%-13.9%) and in the number of CRCs diagnosed (34.1% reduction; 95% CI: 31.4%-36.8% vs. 26.7%; 95% CI: 24.6%-28.8%). Curative treatment was received by 87.5% of patients diagnosed with rectal cancer prepandemic and 80.7% of patients during the pandemic post-lockdown period (p = 0.002).

CONCLUSIONS

The COVID-19 pandemic has led to a decrease in the number of diagnosed CRC cases and in the proportion of stage I CRC. The reduction in the number of colonoscopies and CRC diagnoses was higher in centers that applied universal SARS-CoV-2 PCR screening before colonoscopy. In addition, the COVID-19 pandemic has affected curative treatment of rectal cancers.

Changes in Health Care Access and Preventive Health Screenings by Race and Ethnicity

Importance

The COVID-19 pandemic led to unprecedented disruptions in health care. Little is known about whether health care access and preventive health screenings among US adults have recovered to prepandemic levels, and how patterns varied by race and ethnicity.

Objective

To evaluate health care access and preventive health screenings among eligible US adults in 2021 and 2022 compared with prepandemic year 2019, overall and by race and ethnicity.

Design, Setting, and Participants

This cross-sectional study used data from US adults aged 18 years or older who participated in the National Health Interview Survey in 2021 and 2022. Survey weights provided by the National Health Interview Survey were used to generate nationally representative estimates. Data were analyzed from May 23 to November 13, 2023.

Main Outcomes and Measures

Measures of health care access included the proportion of adults with a usual place for care, those with a wellness visit, and those who delayed or did not receive medical care due to cost within the past year. Preventive health screening measures included eligible adults who received blood pressure, cholesterol, or blood glucose screening within the past year (2021), as well as colorectal, cervical, breast, and prostate cancer screenings based on US Preventive Services Task Force guidelines.

Results

The unweighted study population included 89 130 US adults. The weighted population included 51.6% females; 16.8% Hispanic, 5.9% non-Hispanic Asian (hereafter, Asian), 11.8% non-Hispanic Black (hereafter, Black), 62.8% non-Hispanic White (hereafter, White) individuals; and 2.9% individuals of other races and ethnicities (including American Indian, Alaska Native, Native Hawaiian or other Pacific Islander, or multiracial). After adjusting for age and sex, having a usual place for health care did not differ among adults in 2021 or 2022 vs 2019 (adjusted rate ratio [ARR] for each year, 1.00; 95% CI, 0.99-1.01). However, fewer participants had wellness visits in 2022 compared with 2019 (ARR, 0.98; 95% CI, 0.97-0.99), with the most pronounced decline among Asian adults (ARR, 0.95; 95% CI, 0.92-0.98). In addition, adults were less likely to delay medical care (ARR, 0.79; 95% CI, 0.73-0.87) or to not receive care (ARR, 0.76; 95% CI, 0.69-0.83) due to cost in 2022 vs 2019. Preventive health screenings in 2021 remained below 2019 levels (blood pressure: ARR, 0.95 [95% CI, 0.94-0.96]; blood glucose: ARR, 0.95 [95% CI, 0.93-0.96]; and cholesterol: ARR, 0.93 [95% CI, 0.92-0.94]). Eligible adults were also significantly less likely to receive colorectal cancer screening (ARR, 0.88; 95% CI, 0.81-0.94), cervical cancer screening (ARR, 0.86; 95% CI, 0.83-0.89), breast cancer screening (ARR, 0.93; 95% CI, 0.90-0.97), and prostate cancer screening (ARR, 0.86 [0.78-0.94]) in 2021 vs 2019. Asian adults experienced the largest relative decreases across most preventive screenings, while Black and Hispanic adults experienced large declines in colorectal cancer screening (ARR, 0.78; 95% CI, 0.67-0.91) and breast cancer screening (ARR, 0.83; 95% CI, 0.75-0.91), respectively. Differences in preventive screening rates across years persisted after additional adjustment for socioeconomic factors (income, employment status, and insurance coverage).

Conclusions and Relevance

Results of this cohort study suggest that, in the US, wellness visits and preventive health screenings have not returned to prepandemic levels. These findings support the need for public health efforts to increase the use of preventive health screenings among eligible US adults.