Late-Stage CRC Spiked in Second Year of Pandemic

M. Alexander Otto, PA, MMS

November 30, 2022

Diagnoses of late-stage colorectal cancer (CRC) increased substantially during the COVID-19 pandemic, according to a review of almost 18,000 patients at 81 medical centers in Italy.

There was an increase in locally advanced cancers during the first year of the pandemic in 2020, but this was followed by "a more definitive increase [in] advanced cases," particularly metastatic disease, in the second year of the pandemic, during the period January–December 2021. This was after lockdowns had ended in Italy and vaccination campaigns had begun, lead investigator Matteo Rottoli, MD, PhD, a colorectal surgeon at the University of Bologna, Italy, told Medscape Medical News.

One of the reasons is that even after screening programs were back to normal in the second half of 2020, the overall number of people getting screened for CRC was "much lower" than in previous years, he said.

Among other factors, it's likely people were still "afraid" to visit their doctor's office to have symptoms checked ― symptoms that previously "would have pushed them to go to the doctor immediately, before the pandemic," Rottoli explained.

As a result, "a proportion of the population has definitely lost their window to undergo effective screening," which would have caught CRC early. "These people will likely be diagnosed with advanced cancer," Rottoli said, and it's possible that this will lead to the first drop in CRC survival in 20 years.

The findings were published online on November 21 in JAMA Network Open.

Approached for comment, Janice Rafferty, MD, a colorectal surgeon at Christ Hospital in Cincinnati, Ohio, said these findings from Italy reflect her own experience. It "seems that many more [people] presented with advanced disease" during the pandemic. "I think it's because [they] put off evaluation of symptoms.... Another issue was difficulty getting evaluated due to scheduling issues and staff and physician shortages."

In their article, Rottoli and his team called for a "large-scale response" to mitigate the situation, but he told Medscape Medical News that what this would involve is "the million-dollar question" ― perhaps increased awareness among the public of the importance of being screened, he suggested.

Worrisome Findings

For their study, the team, analyzed data on patients with CRC who had undergone surgery (including resections, palliative procedures, or exploratory surgery). They compared the data on 10,142 CRC patients who underwent surgery before the pandemic (form January 1, 2018, to February 29, 2020) with 7796 CRC patients who underwent surgery during the pandemic (from March 1, 2020, to December 31, 2021).

Patients who underwent surgery during the pandemic had 7% higher odds of presenting with advanced-stage CRC, 32% higher odds of presenting with more aggressive disease, 15% higher odds of presenting with stenotic lesions, and 10% higher odds of presenting with distant metastases.

The greater likelihood of metastatic disease is a particularly "worrisome finding, because metastatic disease is strongly associated with cancer-related mortality," the investigators say.

Also asked for comment, Philip Paty, MD, a gastrointestinal cancer surgeon at Memorial Sloan Kettering Cancer Center, New York City, noted the study's limitations, including the fact that there are no mortality data to confirm an impact on overall survival. As the authors note, follow-up was only 30 days, which is too short to assess any impact on survival.

Even so, Paty said the study highlights the need for ways of screening for CRC that are less invasive than colonoscopy "and less easily disrupted by pandemics and other stresses on the healthcare system."

Scott Steele, MD, chair of colorectal surgery at the Cleveland Clinic, Ohio, also had concerns about the study's methodology and added, "The true impact of the pandemic may not be known for quite a long time."

No source of funding was reported. Rottoli has disclosed no relevant financial relationships. One co-author has received personal fees from Johnson & Johnson and Takeda. Rafferty, Paty and Steele have disclosed no relevant financial relationships.

JAMA Netw Open. Published online November 21, 2022. Full text

M. Alexander Otto is a physician assistant with a master's degree in medical science and a journalism degree from Newhouse. He is an award-winning medical journalist who worked for several major news outlets before joining Medscape. Alex is also an MIT Knight Science Journalism fellow. Email: aotto@mdedge.com

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