Prioritisation by FIT to mitigate the impact of delays in the 2-week wait colorectal cancer referral pathway during the COVID-19 pandemic: a UK modelling study
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Abstract
To evaluate the impact of faecal immunochemical testing (FIT) prioritisation to mitigate the impact of delays in the colorectal cancer (CRC) urgent diagnostic (2-week-wait (2WW)) pathway consequent from the COVID-19 pandemic.
Design
We modelled the reduction in CRC survival and life years lost resultant from per-patient delays of 2–6 months in the 2WW pathway. We stratified by age group, individual-level benefit in CRC survival versus age-specific nosocomial COVID-19–related fatality per referred patient undergoing colonoscopy. We modelled mitigation strategies using thresholds of FIT triage of 2, 10 and 150 µg Hb/g to prioritise 2WW referrals for colonoscopy. To construct the underlying models, we employed 10-year net CRC survival for England 2008–2017, 2WW pathway CRC case and referral volumes and per-day-delay HRs generated from observational studies of diagnosis-to-treatment interval.
Results
Delay of 2/4/6 months across all 11 266 patients with CRC diagnosed per typical year via the 2WW pathway were estimated to result in 653/1419/2250 attributable deaths and loss of 9214/20 315/32 799 life years. Risk–benefit from urgent investigatory referral is particularly sensitive to nosocomial COVID-19 rates for patients aged >60. Prioritisation out of delay for the 18% of symptomatic referrals with FIT >10 µg Hb/g would avoid 89% of these deaths attributable to presentational/diagnostic delay while reducing immediate requirement for colonoscopy by >80%.
Conclusions
Delays in the pathway to CRC diagnosis and treatment have potential to cause significant mortality and loss of life years. FIT triage of symptomatic patients in primary care could streamline access to colonoscopy, reduce delays for true-positive CRC cases and reduce nosocomial COVID-19 mortality in older true-negative 2WW referrals. However, this strategy offers benefit only in short-term rationalisation of limited endoscopy services: the appreciable false-negative rate of FIT in symptomatic patients means most colonoscopies will still be required.
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SciScore for 10.1101/2020.04.28.20083170: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement not detected. Randomization not detected. Blinding not detected. Power Analysis not detected. Sex as a biological variable not detected. Table 2: Resources
No key resources detected.
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:Limitations of analysis: The accuracy of our predictions is predicated on the validity of assumptions and estimates used for parameterisation, as for any model-based analysis. Our approach is solely survival-focused: a more …
SciScore for 10.1101/2020.04.28.20083170: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement not detected. Randomization not detected. Blinding not detected. Power Analysis not detected. Sex as a biological variable not detected. Table 2: Resources
No key resources detected.
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:Limitations of analysis: The accuracy of our predictions is predicated on the validity of assumptions and estimates used for parameterisation, as for any model-based analysis. Our approach is solely survival-focused: a more elaborate model capturing stage-transition may offer additional utility for healthcare planning. We have not considered the possibility of complex, serial, or interdependent bottle-necks, instead modelling a simple total delay to treatment. We have assumed that all urgent 2WW colorectal referrals from primary care result in colonoscopy; data are not available to specify the proportion diverted in secondary care to alternative investigation. In total 0·6% of 2WW colorectal referrals lead to the eventual diagnosis of another cancer type8. We have not captured the impact of delay on diagnoses of these cancers, nor how a FIT-based triage would impact on this. We have not evaluated the impact of any changes in systemic anti-cancer therapy (SACT), bearing in mind that SACTs makes comparatively limited contribution to CRC survival, in particular for rectal cancer. As the primary focus of our analysis is delay to surgery with curative intent, we have not modelled impact of delay on stage 4 outcomes, instead making the assumption that treatment delay has no impact on mortality (i.e. that any survival benefit from SACT management of stage 4 disease would be counterbalanced by risk of COVID-related mortality). We have also focused exclusively on detection of invasive...
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.
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