Short‐term outcomes of a COVID‐adapted triage pathway for colorectal cancer detection

  1. Janice Miller
  2. Yasuko Maeda
  3. Stephanie Au
  4. Frances Gunn
  5. Lorna Porteous
  6. Rebecca Pattenden
  7. Peter MacLean
  8. Colin L. Noble
  9. Stephen Glancy
  10. Malcolm G. Dunlop
  11. Farhat V. N. Din

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Abstract

Aim

The dramatic curtailment of endoscopy and CT colonography capacity during the coronavirus pandemic has adversely impacted timely diagnosis of colorectal cancer (CRC). We describe a rapidly implemented COVID‐adapted diagnostic pathway to mitigate risk and maximize cancer diagnosis in patients referred with symptoms of suspected CRC.

Method

The ‘COVID‐adapted pathway’ integrated multiple quantitative faecal immunochemical tests (qFIT) to enrich for significant colorectal disease with judicious use of CT with oral contrast to detect gross pathology. Patients reporting ‘high‐risk’ symptoms were triaged to qFIT+CT and the remainder underwent an initial qFIT to inform subsequent investigation. Demographic and clinical data were prospectively collected. Outcomes comprised cancer detection frequency.

Results

Overall, 422 patients (median age 64 years, 220 women) 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%). Compared with the period 1 April–31 May in 2017–2019, we observed a 43% reduction in all primary care referrals (1071 referrals expected reducing to 609).

Conclusion

This COVID‐adapted pathway mitigated the adverse effects on diagnostic capacity and detected cancer at the expected rate within those referred. However, the overall reduction in the number of referrals was substantial. The described risk‐mitigating measures could be a useful adjunct whilst standard diagnostic services remain constrained due to the ongoing pandemic.

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  1. Version published to 10.1111/codi.15618
  2. ScreenIT

    SciScore for 10.1101/2020.11.23.20236778: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Statistical analysis: All pathway patients were prospectively entered into a Microsoft EXCEL spreadsheet.
    Microsoft EXCEL
    suggested: (Microsoft Excel, RRID:SCR_016137)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    qFIT is a useful test to prioritise access to endoscopy and CTC, with the caveat that symptomatic patients with a negative test will ultimately require investigation in the long term25. Limitations: It was not possible to validate the use of qFIT or CT minimal-preparation scan at this time given the inability to compare it to a reference standard. Our approach was based on the ability of the tests to diagnose gross pathology and as such this data will become available over time. We have focussed solely on the detection of overt CRC, with the detection rate of advanced polyps currently unknown. The sensitivity of qFIT for advanced adenomas has been shown to be low at 35·7%26. The value of qFIT is known to be significantly lower for more proximal adenomas and cancers compared to those found distally, with double qFIT testing enriching for pathology26. Although there were three cancers diagnosed in patients with a negative qFIT only one was a caecal malignancy, the others being sigmoid and anorectal lesions. The number of cancers diagnosed in those with two negative qFITs was too small to comment on whether double-testing enriched for pathology. Throughout the devolved nations different thresholds have been used to determine what constitutes a positive result for screening patients (80μg/g in Scotland, 120μg/g in England and 150μg/g in Wales)27. The threshold for determining an abnormal result is lower (10μg/g) in the symptomatic population28. It is used to enrich information an...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  3. Version published to 10.1101/2020.11.23.20236778v1 on medRxiv