Assessment of Effectiveness of a COVID-Adapted Diagnostic Pathway for Colorectal Cancer to Mitigate the Adverse Impact on Investigation and Referrals

Abstract

Background: The Coronavirus-19 (COVID-19) pandemic continues to impose formidable challenges on healthcare services. The dramatic curtailment of endoscopy and CT colonography capacity has adversely impacted on timely diagnosis of colorectal cancer (CRC). We describe a COVID-adapted pathway rapidly implemented to mitigate risk and maximise cancer diagnosis in patients referred with symptoms of suspected CRC during the pandemic.Methods: The “COVID-adapted pathway” integrated multiple quantitative faecal immunochemical tests (qFIT), to enrich for significant colorectal disease. CT with oral contrast was used to detect gross pathology. Patients reporting ‘high-risk’ symptoms were triaged to qFIT+CT and the remainder underwent initial qFIT. Prospective data collection comprised referral category, symptoms, blood results, medical history, time to first test, qFIT and CT results. Outcomes comprised cancer detection frequency. Findings: Compared to the same time period (1st April – 31st May) in 2017-2019, we observed a 43% reduction in primary care referrals with suspected CRC (1071 referrals expected reducing to 609). Overall 422 patients (median age 64 years, 220 females) were triaged using this pathway. Most (84·6%) were referred as ‘urgent suspicious of cancer’. Of the 422 patients, 202 (47·9%) were triaged to CT and qFIT, 211 (50·0%) to qFIT only, eight (1·9%) to outpatient clinic, and one to colonoscopy. Fifteen (3·6%) declined investigation and seven (1·7%) were deemed unfit. We detected 13 cancers (3·1%); similar to the mean cancer detection rate from all referrals in 2017-2019 (3·3%). Interpretation: The response to the COVID-19 pandemic resulted in a marked reduction in referrals and cessation of key diagnostic services. Although this COVID-adapted pathway mitigated the adverse effects on diagnostic capacity, the overall reduction in expected diagnoses is very substantial. It is clear that the adverse impact of measures taken to constrain the pandemic will lead to many undetected cancers due to the decrease in referrals.Funding: Scottish Government/NHS Lothian.Declaration of Interests: The authors declare no conflicts of interest.Ethics Approval Statement: Ethical approval to report pathway outcomes was not required given it was part of clinical care.