Australia has one of the highest rates of bowel cancer in the world; it is estimated that 1 in 13 Australians will develop the disease in their lifetime. During the COVID-19 crisis, cancer testing has declined significantly, with testing and screening levels for some cancers reportedly falling by more than 50% in Australia during April 2020, the first month the majority of procedures were suspended.

While bowel cancer represents the country’s second deadliest cancer and claims the lives of over 100 Australians per week, it’s also one of the most treatable types of cancer. Early detection is critical, as a delay in diagnosing the condition can significantly affect the outcome of cancer, leading to worse outcomes, higher costs for treatment and additional suffering for patients.

While no figures are available on the COVID-19 impact on diagnostic procedures used to diagnose bowel cancer specifically, such as colonoscopy, a recent article published in the Sydney Morning Herald paints the bigger picture for cancer. The article refers to nationally representative figures from major private pathology labs, which showed that tissue testing – including biopsies for breast cancer, colon cancer, prostate cancer, skin cancer and lung cancer – had dropped by 56% in early April 2020, compared to the February average which represents more normal conditions.

The figures also showed that cervical cancer screening had fallen by 71% and blood tests for prostate cancer by 58% over the same period. While the number of tests performed has increased from the end of May onwards, testing remains well below the February average, and the level could be even lower for the public sector. Reasons include a shortage of PPE, beds and equipment leading to a cancellation of tests and procedures, as well as patients cancelling appointments due to concerns about contracting the virus.

Cancer screening paused

The fact that some cancer screening programmes have been suspended is also a concern, particularly given that participation rates were far from high before the pandemic. To return to bowel cancer, the National Bowel Cancer Screening Program (NBCSP), which was established in 2006, has recently been expanded to provide optional 2-yearly screening for all Australians between the ages of 50–74.

Significant progress has been made since the expansion, which was completed in 2020, but according to figures recently released by the AIHW, the NBCSP participation rate remains low at just over 42% in 2017/18. Put another way, this means that out of more than 5 million people invited to participate in the program, around 3 million people declined to take part.

Furthermore, out of those that received a positive result, only 66% were recorded as receiving a follow-up colonoscopy. There is now a worry that the recent progress in participation rates for the program and access to colonoscopy procedures may have been reversed during the pandemic.

Waiting times are increasing

Another issue that is causing concern is potential delays to waiting times. Even before the COVID-19 pandemic, diagnostic testing waiting times already exceeded medical guidelines for some tests used to diagnose cancer. In 2018, Bowel Cancer Australia reported that 90% of NBCSP participants with a positive screening were waiting between 116 and 181 days for a colonoscopy, with the wait time varying depending on where the patient lived.

This was against the official recommendation that patients be referred within a maximum of 120 days to avoid risk of a poorer clinical outcome, with 30 days seen as desirable. Waiting times are likely to be have been impacted negatively during the initial COVID-19 outbreak and the subsequent second wave in Victoria, which has also led to lower activity levels.

In late March, when the Prime Minister announced elective surgery would be restricted to Category 1 (urgent cases) and urgent Category 2 (semi-urgent cases) in both public and private hospitals from 1 April, the Gastroenterological Society of Australia (GESA) also advised specialists to defer routine 1, 3- or 5-year polyp or IBD surveillance colonoscopies, as well as colonoscopies following a positive FIT test result, if a previous high-quality colonoscopy had been performed in the past four years.

While restrictions are in place, the selection of patients that undergo procedures is made on the basis of clinical assessment against a number of criteria, with ideal cases representing low risk and high value care. Cancer is classified as urgent in the healthcare system, so many colonoscopies will be taking place, but both surgery and tests to diagnose or ‘stage’ bowel cancer may be delayed if the risk of infection outweighs the benefits of the procedure – given that cancer patients are deemed vulnerable.

There are also concerns that the delay in testing and diagnosis will lead to a backlog of ‘hidden’ referrals, in cases where patients have ignored symptoms or have chosen to put off attending appointments with their GP or following up on referrals, due to the risk of exposure to the virus. The full impact of the pandemic on colonoscopy waiting times will probably not be visible for years, since there is a lag in collecting and reporting this data at central level.

A global issue

The potentially substantial impact of COVID-19 on bowel cancer is a global issue. A recent World Economic Forum report estimated that 38% of global cancer surgery had been postponed or cancelled due to the coronavirus pandemic. In the UK, the number of endoscopies undertaken in May 2020 during the suspension of elective procedures was over 80% below the figure for May last year.

The increasing trend for bowel cancer incidence is also relatively similar across developed countries. Worldwide, over 1.8 million new cases of colorectal cancer were estimated to have been diagnosed in 2018, while the global burden is expected to increase by 60% to more than 2.2 million new cases and 1.1 million deaths by 2030.

Early detection is critical

Even though the National Cabinet agreed on 15 May 2020 to restart elective procedures, the recent reversal and reintroduction of restrictions in the state of Victoria shows that the pandemic is far from over. Restrictions in Victoria may need to be in place for some time continuing to affecting colonoscopy activity levels, and as we’ve already seen, the rate of recovery is likely to vary between regions, states and countries and will depend on the risk of local outbreaks.

Since productivity is reduced, and there is an ongoing risk of diagnostic and surgical activity being suspended, it is crucial to increase both diagnostic and surgical capacity at least on a temporary basis. Additional, external capacity can help protect endoscopy and other procedures from COVID-19 related impact, allowing activity to continue and preventing the backlog from becoming unmanageable.

If this is not done, the potential consequences are many. Most importantly, the opportunity for early detection can be lost if a positive test is not followed up by a prompt colonoscopy. Almost 99% of bowel cancer cases can be treated successfully – but only providing the cancer is detected at an early stage. Lifesaving cancer treatments and care can also become more costly over time, if cases progress and more advanced treatments or surgery is required.