COVID-19 Pandemic Had Minimal Impact on Colonoscopy Completion After Colorectal Cancer Red Flag Sign or Symptoms in US Veterans

Joshua Demb, Lin Liu, Ranier Bustamante, Jason A Dominitz, Ashley Earles, Shailja C Shah, Andrew J Gawron, Maria Elena Martinez, Samir Gupta, Joshua Demb, Lin Liu, Ranier Bustamante, Jason A Dominitz, Ashley Earles, Shailja C Shah, Andrew J Gawron, Maria Elena Martinez, Samir Gupta

Abstract

Background: Delays in colonoscopy work-up for red flag signs or symptoms of colorectal cancer (CRC) during the COVID-19 pandemic are not well characterized.

Aims: To examine colonoscopy uptake and time to colonoscopy after red flag diagnosis, before and during the COVID-19 pandemic.

Methods: Cohort study of adults ages 50-75 with iron deficiency anemia (IDA), hematochezia, or abnormal stool blood test receiving Veterans Health Administration (VHA) care from April 2019 to December 2020. Index date was first red flag diagnosis date, categorized into "pre" (April-December 2019) and "intra" (April-December 2020) policy implementation prioritizing diagnostic procedures, allowing for a 3-month "washout" (January-March 2020) period. Outcomes were colonoscopy completion and time to colonoscopy pre- vs. intra-COVID-19, examined using multivariable Cox models with hazard ratios (aHRs) and 95% confidence intervals (CIs).

Results: There were 52,539 adults with red flag signs or symptoms (pre-COVID: 25,154; washout: 7527; intra-COVID: 19,858). Proportion completing colonoscopy was similar pre- vs. intra-COVID-19 (27.0% vs. 26.5%; p = 0.24). Median time to colonoscopy among colonoscopy completers was similar for pre- vs. intra-COVID-19 (46 vs. 42 days), but longer for individuals with IDA (60 vs. 49 days). There was no association between time period and colonoscopy completion (aHR: 0.99, 95% CI 0.95-1.03).

Conclusions: Colonoscopy work-up of CRC red flag signs and symptoms was not delayed within VHA during the COVID-19 pandemic, possibly due to VHA policies supporting prioritization and completion. Further work is needed to understand how COVID-19 policies on screening and surveillance impact CRC-related outcomes, and how to optimize colonoscopy completion after a red flag diagnosis.

Keywords: COVID-19; Colonoscopy; Colorectal cancer; Diagnosis; Symptoms.

Conflict of interest statement

We have read and understood the ICMJE policy on declaration of conflicts of interests and declare we have no conflict of interest. The contents of this work do not represent the views of the Department of Veterans Affairs or the United States Government.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Cumulative colonoscopy completion in a national sample of US Veterans with red flag signs and symptoms of CRC pre- vs. intra-COVID-19 pandemic. Survival curves, estimated via Kaplan–Meier approach for the outcome of time to colonoscopy completion, are shown for individuals with red flag signs or symptoms pre- vs. intra-COVID-19 pandemic. The curves demonstrate a similar cumulative proportion with colonoscopy completion for individuals with red flag signs/symptoms post vs. pre-COVID-19 pandemic. Red flags included abnormal FIT/gFOBT, iron deficiency anemia, and hematochezia
Fig. 2
Fig. 2
Time to colonoscopy pre- and intra-COVID-19 pandemic, stratified by red flag sign/symptom of CRC, in a national sample of 45,012 individuals receiving VHA care. Median time to colonoscopy among colonoscopy completers with red flag signs and symptoms of CRC was shorter in the pre- vs. intra-COVID-19 pandemic period overall. In analyses stratified by red flag, individuals with iron deficiency anemia had significantly shorter time to colonoscopy in the intra- vs. pre-COVID-19 pandemic period. Abbreviation: Fecal immunochemical test/guaiac fecal occult blood test, FIT/gFOBT

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