Projected long-term effects of colorectal cancer screening disruptions following the COVID-19 pandemic
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eLife assessment
This important study uses two well-established colorectal cancer models to estimate the potential impact of disruptions in screening caused by the COVID-19 pandemic. By dividing the population into separate cohorts based on age and pre-pandemic screening status, the authors provide convincing evidence for the adverse impact of delays in screening, switching regimens, and screening discontinuation. The finding that discontinuation has a much greater impact on screening-associated gains in life expectancy than shorter-term delays or switching of regimens suggests that access-related barriers to screening resumption may lead to the worsening of current disparities.
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Abstract
The aftermath of the initial phase of the COVID-19 pandemic may contribute to the widening of disparities in colorectal cancer (CRC) outcomes due to differential disruptions to CRC screening. This comparative microsimulation analysis uses two CISNET CRC models to simulate the impact of ongoing screening disruptions induced by the COVID-19 pandemic on long-term CRC outcomes. We evaluate three channels through which screening was disrupted: delays in screening, regimen switching, and screening discontinuation. The impact of these disruptions on long-term CRC outcomes was measured by the number of life-years lost due to CRC screening disruptions compared to a scenario without any disruptions. While short-term delays in screening of 3–18 months are predicted to result in minor life-years loss, discontinuing screening could result in much more significant reductions in the expected benefits of screening. These results demonstrate that unequal recovery of screening following the pandemic can widen disparities in CRC outcomes and emphasize the importance of ensuring equitable recovery to screening following the pandemic.
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eLife assessment
This important study uses two well-established colorectal cancer models to estimate the potential impact of disruptions in screening caused by the COVID-19 pandemic. By dividing the population into separate cohorts based on age and pre-pandemic screening status, the authors provide convincing evidence for the adverse impact of delays in screening, switching regimens, and screening discontinuation. The finding that discontinuation has a much greater impact on screening-associated gains in life expectancy than shorter-term delays or switching of regimens suggests that access-related barriers to screening resumption may lead to the worsening of current disparities.
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Reviewer #1 (Public Review)
This paper utilizes two well-established mathematical models of colorectal cancer (CRC) screening to estimate the impact of disruptions in screening caused by the COVID-19 pandemic on long-term outcomes related to CRC. For screening, the authors use two recommendations from the US Preventive Services Task Force (USPSTF) (which were informed by the results of these models): screening colonoscopy every 10 years at ages 50, 60, and 70, and annual fecal immunochemical tests (FIT) from ages 50-75. Separate model runs were performed for 8 different cohorts at the time of the pandemic based on age, screening history, and adherence to screening. For each cohort, microsimulations were performed for 3 different scenarios--no disruption, delays in screening, or discontinuation from screening. The primary outcome was …
Reviewer #1 (Public Review)
This paper utilizes two well-established mathematical models of colorectal cancer (CRC) screening to estimate the impact of disruptions in screening caused by the COVID-19 pandemic on long-term outcomes related to CRC. For screening, the authors use two recommendations from the US Preventive Services Task Force (USPSTF) (which were informed by the results of these models): screening colonoscopy every 10 years at ages 50, 60, and 70, and annual fecal immunochemical tests (FIT) from ages 50-75. Separate model runs were performed for 8 different cohorts at the time of the pandemic based on age, screening history, and adherence to screening. For each cohort, microsimulations were performed for 3 different scenarios--no disruption, delays in screening, or discontinuation from screening. The primary outcome was life-years gained (LYG) from screening.
In general, severe prolonged disruptions in any screening led to the largest loss of benefit from screening - for example, unscreened 50-year-olds forced to wait until age 65 (Medicare eligibility) had the largest absolute and relative loss in screening-associated LYG compared to shorter delays of 18 months or less. Losses were also higher in those who were semi-adherent to screening recommendations. The prolonged disruption had a consistently much greater impact than short-term reductions, changes in regimen, or assumptions about test sensitivity. The results are consistent between the two models. The authors point out that, since pandemic-induced disruptions in insurance coverage had a greater impact on minority populations already at risk for reduced access to screening and other preventive services, the pandemic may lead to further exacerbations in existing disparities in CRC incidence and mortality.
The strengths of this paper include the use of well-validated models, the consistent results between the models, the relatively intuitive nature of the findings, and the use of LYG, a commonly used metric for screening recommendations. As the authors point out, estimates of the population impact of the pandemic given the current age structure of the US would be helpful, these would be inherently speculative given the lack of empirical data on pandemic effects on screening. Although prioritizing screening individuals with long pandemic-induced delays is clearly the optimal policy approach, how this might be achieved is unclear.
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