NHS England recently published specialty advice for endoscopy services, advocating continuation of both the rapid access cancer referral pathway and bowel cancer screening with FIT:
During the COVID-19 pandemic, rapid access two week wait colorectal cancer referrals will continue. Changes to our usual methods of managing these patients will have to be made because:
- Only therapeutic emergency and essential endoscopy is being carried out given the risks of aerosol generating procedures (AGP). Colonoscopy, flexible sigmoidoscopy and rigid sigmoidoscopy are currently classified as procedures that may be deferred during the pandemic. The British Society of Gastroenterology and Joint Advisory Group guidance on Endoscopy during COVID-19 is available here.
- Use of virtual colonoscopy (CT colonography) should also stop unless there is explicit local agreement amongst all relevant stakeholders that capacity exists to continue a reduced service. There will undoubtedly be increased demand for diagnostic and screening CT scanning for patients with confirmed or suspected COVID-19 infection. The British Society Gastrointestinal and Abdominal Radiology advice is available here.
- Hospital footfall increases the risk of contracting COVID-19 infection, with the biggest risk of associated mortality applying to older and/or comorbid patients.
- Many patients with newly diagnosed colorectal cancer may have treatment deferred until healthcare resources recover, unless they develop complications requiring emergency admission.
ACPGBI recognises that the yield of new colorectal cancer diagnoses from the current rapid access pathway is low at 3-4%, and many patients are diagnosed through other routes. The low cancer yield from the rapid access pathway means that a complete shift in emphasis is required during COVID-19 restrictions on healthcare practices to identify patients with high risk of colorectal cancer that might precipitate need for urgent or emergency admission rather than providing a cancer exclusion service. Benign neoplasia and early colorectal cancer treatments may be deferred for a few months without risk of major disease progression in most. Delaying treatment in cancer patients until it can be offered in a lower risk, and appropriately resourced, healthcare environment may also be in the patient’s best interest during the COVID-19 pandemic:
Once a local strategy has been agreed, this should be communicated to general practice colleagues and local Clinical Commissioning Groups, outlining the rationale for the change and providing clear mechanisms for safety-netting of patients for the duration of the crisis. An “urgent patient only” colorectal cancer clinic stream established locally should prioritise clinical acumen and high level of clinical suspicion on the part of both General Practitioners and clinicians in secondary care, all of whom will be making assessments remotely without opportunity for clinical examination or basic investigations. Where available and provided delivered remotely, FIT testing may help assess level of cancer risk. Dialogue between community referrer and secondary care clinician prior to referral is encouraged. An urgent referral with high index of clinical suspicion may be made to allow further triage in secondary care. Patients with concerning symptoms or a high FIT test result may also be referred for consideration of deferred investigation. The proposed pathway is outlined in Figure 1.
Figure 1: Infographic outlining streamlined urgent referral pathway for colorectal cancer patients based on remote clinical triage, investigation with CT alone in high risk patients, and deferred colonoscopy in prioritise patient groups.