Colorectal Cancer Screening and COVID-19

As the COVID-19 pandemic spread throughout the United States, the San Francisco Health Network, an urban integrated safety-net health system, rapidly altered how it delivered care. Routine outpatient visits were converted to telehealth appointments, and nonurgent endoscopic procedures were cancelled, resulting in dramatic declines in colorectal cancer (CRC) screening. With ongoing surges of COVID-19, prolonged social distancing and limitations on procedures will likely be necessary. Without prompt action, the impact of missed diagnoses and resultant excess mortality could be substantial. San Francisco Health Network serves ;90,000 individuals through multisite clinics and a specialty referral center, Zuckerberg San Francisco General Hospital. Between February and May 2020, total adult primary care in-person visits decreased by 70% (from 6,800 to 2,000 visits/wk). Telehealth visits increased from 1.2% of adult primary care visits in the first week of March to 60% by April (from 40 to 3,000 visits/wk) (Figure 1). Coinciding with the decrease of inperson visits was a drastic reduction in CRC screening tests. Fecal immunochemical test (FIT) volume decreased by ;85% (from 370 tests ordered per week in February to 60 tests per week by April) and colonoscopy volume declined by ;90% (from 150 to 200 cases per month to less than 15). Reduced screening and delays in colonoscopies, especially for those with positive FIT, will lead to increased incident and later-stage CRC diagnoses (1). Estimates suggest that if decreased screening persisted through early June, there could be nearly 19,000 fewer CRC diagnoses and over 4,000 excess deaths from CRC nationally because of the effects of the COVID-19 pandemic (2,3). A concerted effort is needed tomitigate the decline in CRC screening by shifting to organized outreach programs. Most cancer screening in the United States operates on an opportunistic visit-based model; however, there is a growing need for organized cancer screening independent of in-person clinic visits. Organized outreach is more effective than provider-initiated screening with CRC screening rates improving from ;40% to over 80% after