Covid 19 coronavirus: Fears colonoscopy delays will worsen bowel cancers

Aaron Madden and his partner Nancy Howe have both been affected by the delays. Photo / supplied

Covid-19's re-emergence has health advocates worried about life-threatening delays for people needing elective procedures including to rule out cancer.

Bowel Cancer NZ says the first lockdown had worsened backlogs, which are still being worked through and will cost lives.

"People will get diagnosed later. And we know that late diagnosis leads to poorer outcomes. So, yes, patients will be harmed. And no doubt inevitably patients will die - as a result of the delays, and the immense slow down that came with the Covid lockdown," said Bowel Cancer NZ medical adviser Professor Frank Frizelle.

After colonoscopy referral, DHBs categorise patients including into "urgent" and "non-urgent", with urgent patients including older patients with certain symptoms lasting over six weeks, or whose cancer or suspected cancer is apparent on imaging or a rectal examination, for example.

According to referral guidelines, non-urgent symptomatic patients include people with long-lasting symptoms but who are younger than 50, and some symptomatic older patients who don't meet the urgent criteria. They should have the procedure within six weeks.

New Ministry of Health figures show that, nationally, only 44 per cent of "non urgent" patients were seen within this timeframe, up from the low 30s over April and May.

That proportion is even lower in Auckland DHB (27 per cent) and Waitematā (37 per cent), which have been caught by the region's move to level 3.

People needing surveillance colonoscopies, including because of family or medical history, have also been affected: nationally, nearly half are waiting longer than the 12 week target.

Frizelle, professor of colorectal surgery at the University of Otago, said almost no non-urgent colonoscopies were done for six to eight weeks over lockdown, creating a backlog in a system already at capacity.

"It's now like a flood of patients trying to get in the door, which is no wider than it was, because units were already working their maximum."

He suspected the existing backlogs would take about 12 months to clear. He'd normally do 20-25 colonoscopies a week; a number that nearly doubled immediately following the nationwide lockdown, and was now around 30-35.

Evening and weekend work could help bring down delays, he said, as could more outsourcing to the private sector (and DHBs paying competitive rates) and use of CT machines to do what are sometimes called virtual colonoscopies; helping confirm patients who actually need the full colonoscopy procedure.

Nationwide about 153,000 surgeries and procedures, radiology scans and specialist appointments need to be done to catch up from the first lockdown alone, and Budget 2020 provided a one-off boost of $283m over three years to clear that backlog.

New registrations of all types of cancer almost halved in April 2020 compared to April 2019 (1031 fewer), a report by the Government's recently-created Cancer Control Agency (Te Aho o Te Kahu) found, with breast cancer registrations falling 62 per cent, prostate by 65 per cent and colorectal by 45 per cent. Cancer registrations fell by 70 per cent in Southern DHB in April.

"The sudden unplanned disruption in usual care will inevitably lead to a backlog of unmet need," the report stated. "Any disruption will have an impact on cancer patients in general and may have a disproportionate impact on those who already experience greater barriers to accessing care, particularly Māori and Pacific peoples."

Professor Diana Sarfati, Te Aho o Te Kahu chief executive, said there were fewer colonoscopies performed this year compared to 2019, but "the gap is closing" thanks to the dedication and innovation of health workers.

"The cancer sector worked exceptionally hard when Covid-19 first hit to ensure cancer patients were still able to access treatment. We are confident this will continue if we find ourselves in a similar position again."

Deborah Woodley, the ministry's deputy director general for population health, said there had been a marked improvement in wait times for urgent colonoscopies, with 92 per cent of such patients treated in 14 days or less in June, up from 82 per cent in April (Nelson-Marlborough is an outlier, at just 53 per cent in June).

"Patients requiring urgent colonoscopies were treated first, followed by those with a positive test result, in the 10 DHBs offering bowel screening, then non-urgent patients followed by surveillance colonoscopies.

"It is important to note that anyone who requires an urgent colonoscopy, because of symptoms suggestive of bowel cancer, is prioritised."

Professor Philip Bagshaw co-founded the Canterbury Charity Hospital, which has stepped up to provide treatment for people under 50 with rectal bleeding, a symptom of colorectal cancer.

He said patients deemed urgent by DHBs were acute cases. Others with nonetheless significant symptoms suggestive of disease were deemed non-urgent.

The bowel cancer screening programme that's rolling out nationwide and currently in 10 of 20 DHBs was much-needed, Bagshaw said, but started without proper resourcing for a system already near buckling point.

There had been some improvement to funding, but not enough to balance decades of under-investment in health.

"Covid is now a wonderful excuse for being able to say, we're in trouble and it's all due to the virus. The virus has made things worse but it was in desperate trouble before the virus ever came along."

Woodley said the ministry was working on ways to reduce demand for colonoscopies, which had boomed by about 60 per cent since 2012/13, partly because of increased awareness of bowel cancer. That included safely spacing out surveillance procedures and potentially using faecal immunochemical tests to triage those most at risk of disease.

Sarfati said she was excited by that work's potential to save lives.

"By reducing demand on our endoscopy resource those who really need it will get one sooner."

Aaron Madden in hospital during his treatment for bowel cancer. Photo / supplied

Couple caught in Covid-caused backlog

Aaron Madden was told at 38 he was too young to have bowel cancer, and only got a colonoscopy after collapsing at home.

That confirmed cancer was the cause of the symptoms he'd had for well over a year and been to the GP multiple times about.

Catching it late meant he'd be off work for two years and endure multiple surgeries, including the removal of his large intestine. Gruelling rounds of chemotherapy had long-term side effects including nerve damage.

His partner, Nancy Howe, didn't want to delay when she got symptoms in January, including bleeding and a change in bowel movements.

Her GP referred her for a colonoscopy, but Canterbury DHB told her there'd be a five month wait - something she accepted, despite the stress of ongoing symptoms. Then Covid struck, and that date was pushed out to the end of the year.

"I was having trouble sleeping, it was affecting my work," the Rangiora resident told the Herald. "There are a lot of people out there who get diagnosed too late."

She contacted Bowel Cancer NZ and the Canterbury Charity Hospital, and soon afterwards the DHB booked a colonoscopy in June - which thankfully found a polyp, but no cancer.

Howe feels for others caught in the delays, and worries for Madden, now 42, who is at higher risk because of a genetic condition and is meant to have a surveillance procedure each year. That was due in May but there's been no indication when it will happen.

Bowel cancer symptoms

Symptoms may include:

• Bleeding from the bottom (rectal bleeding)
• Change of bowel motions/habits that come and go over several weeks
• Anaemia
• Severe persistent or periodic abdominal pain
• A lump or mass in the abdomen
• Tiredness and loss of weight for no obvious reason

Source: Bowel Cancer NZ