Prioritisation by FIT to mitigate the impact of delays in the two-week wait colorectal cancer referral pathway during the COVID-19 pandemic: a UK modelling study

Amit Sud, Michael Jones, John Broggio, Stephen Scott, Chey Loveday, Bethany Torr, Alice Garrett, David L. Nicol, Shaman Jhanji, Stephen A. Boyce, Matthew Williams, Georgios Lyratzopoulos, Claire Barry, Elio Riboli, Emma Kipps, Ethna McFerran, Mark Lawler, David C. Muller, Muti Abulafi, Richard HoulstonClare Turnbull

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Objective: To evaluate the impact of faecal immunochemical testing (FIT) prioritisation to mitigate the impact of delay in the 2-week-wait (2WW) colorectal cancer (CRC) urgent diagnostic pathway consequent from the Coronavirus disease 2019 (COVID-19) pandemic. Design: We modelled the reduction in CRC survival and life years lost resultant from per-patient delays of 2-6 months in the 2WW pathway. We stratified by age-group, individual-level benefit in CRC cancer survival versus age-specific nosocomial COVID-19-related fatality per referred patient undergoing colonoscopy. We modelled mitigation strategies using thresholds of FIT triage of 2, 10 and 150 ug Hb/g to prioritise 2WW referrals for colonoscopy. To construct the underlying models, we employed 10-year net CRC survival for England 2008-2017, 2WW pathway CRC case and referral volumes and per-day-delay hazard ratios generated from observational studies of diagnosis-to-treatment interval. Results: Delay of 2/ 4/ 6 months across all 11,266 CRC patients diagnosed per typical year via the 2WW pathway were estimated to result in 653/ 1,419/ 2,250 attributable deaths and loss of 9,214/ 20,315/ 32,799 life years. Risk-benefit from urgent investigatory referral is particularly sensitive to nosocomial COVID-19 infection rates for patients aged >60. Prioritisation out of delay for the 18% of symptomatic referrals with FIT >10 ug Hb/g would avoid 89% of these deaths attributable to delay, whilst reducing immediate requirement for colonoscopy by >80%. Conclusions: Delays in the pathway to CRC diagnosis and treatment have potential to cause significant mortality and loss of life years. FIT-triage of symptomatic patients in primary care could streamline access to colonoscopy, reduce delays for true-positive CRC cases and reduce nosocomial COVID-19 mortality in older true-negative 2WW referrals. However, this strategy offers benefit only in short-term rationalisation of limited endoscopy services: the appreciable false-negative rate in symptomatic patients of FIT means colonoscopy is still required in the majority.
Original languageEnglish
Early online date27 Aug 2020
Publication statusEarly online date - 27 Aug 2020


  • COVID19
  • Colorectal cancer
  • Model evaluation
  • Two week wait
  • Diagnosis
  • Delayed diagnosis
  • Delayed Diagnosis/statistics & numerical data
  • faecal immunochemical testing
  • Colonoscopy

ASJC Scopus subject areas

  • Oncology
  • Gastroenterology
  • Health Policy


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