‘Delayed, delayed, delayed’
Doctors see increase in colorectal cancer after pandemic postponed screenings
Dr. Mark Soliman was late to a November interview about how missed colonoscopies are increasing cancer, but he had a good reason.
“The reason I was late for this — I almost had to cancel this — [was] because I had a lady that delayed, delayed, delayed her colonoscopy for over a year now,” he said. “Finally, she was diagnosed with colon cancer, I get to her ... the degree of the tumor invasion that this person had was not picked up on the imaging we had preoperatively.”
When Soliman, medical director of colorectal surgery for the AdventHealth Digestive Health and Surgery Institute, operated on his patient, he saw her cancer had spread, and during surgery he had to remove her appendix and a portion of her bladder and ovary.
“This is what we’re seeing [with] the cancers,” Soliman said. “They’re not just there, they are there with a vengeance. We are having to do a lot more radical, curative surgeries to take care of them.”
Colorectal cancer is the third-most-common cancer and second-most common cause of cancer deaths in the U.S., according to the American Cancer Society. The group estimates 11,220 people in Florida will get it in 2022, and 4,110 will die.
When a patient’s colon cancer spreads to nearby organs, as Soliman’s patient’s had, they are 71% as likely as people who don’t have that cancer to live for at least five more years, according to the American Cancer Society. The group’s website says if there aren’t signs of cancer remaining, doctors normally recommend follow-up tests every three to six months for the first couple years after treatment, then every six months for several more years.
Death is often preventable through regular screenings because colorectal cancer takes up to 10 to 15 years to develop from a collection of cells called a polyp, according to Tampa’s Moffitt Cancer Center.
Patients have a 91% chance of surviving five more years when the cancer is caught before it spreads, according to the American Cancer Society. Screening is done through stool-based tests or a colonoscopy, a procedure where a small camera is inserted through the lower portion of the digestive tract while the patient is under local or general anesthesia.
The problem is that during the COVID19 pandemic, many Americans delayed their colonoscopies or had them canceled alongside many other procedures considered nonurgent, said Orlando Health Cancer Institute medical oncologist Dr. Sreeram Maddipatla. Researchers from the Fred Hutchinson Cancer Research Center in Seattle estimate as of April 2021 there was a 50% decrease in colonoscopies, and that number was as high as 90% earlier in the pandemic.
Likely as a result of delayed diagnoses over the last two years, Orlando Health and AdventHealth doctors say they see more patients showing up with advanced colorectal cancer that is harder to treat, and they worry that missed screenings will increase
cancer for years to come.
“Cancer is often curable if it’s caught at an early stage,” Maddipatla said. “I think this is going to have a domino effect for the next few years because we missed out on this crucial two-year period where we would have diagnosed more cancers.”
Dr. John Monson, executive director for colorectal surgery at AdventHealth Orlando, agrees.
He points to research from the University of Bologna in Italy that found if someone has developed cancer since their last screening, delaying a colonoscopy more than four months means cancer has time to progress from treatable to severe or even fatal. The researchers estimate that a year’s delay increases the proportion of advanced colorectal cancer from 26% to 33% for colon cancer patients.
“A lot of those patients are in a state of very traumatic, deep regret,” Monson said. “Every aspect of the blame game exists in there: The system let them down, the doctor let them down [and] the patient let themselves down.”
Even now that AdventHealth is performing procedures
as normal, Monson said some people who didn’t get their scheduled colonoscopy never rescheduled.
“If only it was just a matter of catching up,” he said. “Many patients got lost in the system.”
Missed screenings were a problem even before the pandemic.
“The biggest reason ... when we ask patients is ... ‘we don’t want to be under anesthesia,’ ” Maddipatla said. “Some are because of educational issues: They feel like ‘we don’t have it in my family, I don’t eat that much red meat [and] I eat healthy so I shouldn’t be getting them.”
Maddipatla noted that while obesity, inactivity and a low-fiber, highly-processed diet are risk factors for colon cancer, colon cancer can happen to anyone and everyone should be screened.
About 1 in 3 people in the U.S. who are at risk of colorectal cancer have never been screened, according to the American Cancer Society. From 2014 to 2018, Florida averaged 9,907 cases per year. About one-third of those cases were detected early, but over 57% weren’t detected until they were in their late stages and harder to treat, according to the Florida Cancer Data System.
“We have to get screenings to 100%,” Maddipatla said.
There is significant evidence that along with regular screening, lifestyle changes can alter cancer risk.
An analysis of 57 studies in 2013 found that obese people are at higher risk of developing many cancers, including colorectal cancer. American Cancer Society researchers found from 2013 to 2016 one out of 10 cases of colon cancer were associated with lack of exercise and that five hours of moderate-intensity level exercise per week can reduce cancer risk.
Exercise could help because it reduces inflammation and insulin, which are linked to some cancers, or because it produces endorphins, which can fight cancer, Maddipatla explained. As for diet, he said growing research suggests gut bacteria could influence the development of colon cancer. Processed food and sugary drinks could rid the colon of good bacteria, he added.
People should look out for cancer symptoms such as abdominal pain, changes in bowel habits such as diarrhea or constipation, or blood in the stool. The Centers for Disease Control and Prevention recommends getting screened for colon cancer starting at age 45.