COVID-19: Underserved Populations Disproportionally Affected by Delay of Nonessential Procedures

Interior treatment room with digital endoscope for diagnosis of hollow organs, colonoscopy, gastroscopy in multidisciplinary Clinic.
Physicians, researchers, and patient advocates should prepare now to mitigate the downstream effects of the suspension of nonessential medical procedures in response to the COVID-19 pandemic.

Guidance from the Surgeon General of the United States in response to the global coronavirus disease 2019 (COVID-19) pandemic to delay nonessential medical procedures and surgeries will lead to noticeable downstream effects for the medically underserved communities, according to a perspective statement authored by a group of gastroenterologists, researchers, and patient advocates and published in Gastrointestinal Endoscopy.

The mandatory shift in clinical priorities resulted in an 86% drop in colorectal cancer (CRC) screenings across Federally Qualified Health Centers (FQHCs), which provide care to over 22 million individuals.

At FQHCs, the preferred screening modalities are low-cost methods, including fecal immunochemical tests (FIT) and fecal occult blood tests (FOBT). Due to social distancing requirements, FQHCs have either discontinued CRC screenings or are attempting to identify different methods. Sending FIT samples through the mail has the potential to increase CRC screening participation; however these programs are rare among FQHCs. As such, the statement authors advised that more FQHCs implement FIT mail programs. For centers where a mail program is not feasible, the authors recommended establishing contract-free pick-up and drop-off boxes for FIT kits.

When abnormal FIT/FOBT results are detected, colonoscopies should be coordinated without delay, as a longer time to colonoscopy is associated with an elevated risk for CRC. Although coordinating colonoscopies will remain challenging until health centers reestablish previous capacities, FQHCs need to stratify patients into risk categories and prioritize individuals with the highest FIT values or those who have developed CRC-associated symptoms.

COVID-19 has also hampered CRC research in underserved communities. Previous studies have indicated that underserved populations in the United States are less likely to have access to preventive care, to have a diagnostic colonoscopy after an abnormal FIT, to be counseled after CRC screening, and to have treatment for CRC after a diagnosis.

Community-based participatory research is frequently implemented to build strong relationships between researchers and underserved communities, thereby ensuring that the populations most affected by particular diseases are represented. During the pandemic, the increase of telehealth has limited the effectiveness of community-based participatory research efforts to recruit patients for CRC screening studies. To maintain quality research of underserved communities, the authors recommended prioritizing telephone contact over more potentially inaccessible technological platforms. Once COVID-19 cases begin to decline, researchers should signal that they are eager to re-engage with participants.

General community outreach has also been disrupted due to the pandemic. During this time, the authors noted that creative tactics are necessary not only due to the consequences of COVID-19, but also due to the current social unrest, which disproportionately affects African Americans, Native Americans, and Hispanic populations who are at increased risk for CRC.

“[W]e have observed the unequal impact that COVID-19 has had on medically underserved populations and now prepare for the likely downstream effects on CRC prevention through reduced access to care, suspended research efforts, and limited opportunities for [community outreach and engagement] and advocacy,” the researchers concluded, emphasizing that strategies must be developed to improve long-standing CRC incidence, screening, and outcome disparities.

Follow @Gastro_Advisor


Balzora S, Issaka RB, Anyane-Yeboa A, Gray DM, May FP. The impact of COVID-19 on colorectal cancer disparities and the way forward [published online June 20, 2020]. Gastrointest Endosc. doi: 10.1016/j.gie.2020.06.042