Cancer care and prevention services have been badly disrupted worldwide because of the COVID-19 pandemic.
In the United States, screenings for breast and cervical cancers dropped 94 percent and colon cancer screenings were down 86 percent from January 2020 to April 2020. In fact, the chair of internal medicine at the University of Michigan reported a backlog of over 5,000 colonoscopies at their health system alone after April 2020.
There was also a steep decline in cancer screenings in the United Kingdom. During the first six months of lockdown, cancer screenings in the National Health Service (NHS) fell by three million, and 300,000 fewer patients were referred for cancer treatment.
The precipitous drop has led some medical experts to push for greater use of at-home testing for some of the world’s deadliest cancers, such as colon cancer.
Colorectal cancers are expected to claim the lives of 52,980 Americans in 2021, so having a reliable, routine, preventative diagnostic test is important.
A standard colonoscopy cancer screening test, or endoscopy, is an invasive procedure carried out in a hospital and requires a highly trained doctor.
During the test, a long, flexible tube called a colonoscope is guided through the large bowel which is expanded with air for the procedure. The colonoscope has a miniature camera mounted on it to view any abnormalities. Polyps can be removed by a tiny wire loop passed through the scope.
Patients usually require some type of sedative to avoid discomfort during the procedure.
However, the inability to get face-to-face appointments during the pandemic, a reluctance to enter the hospital environment, and the curtailment of many medical services meant many patients missed or skipped their test. This led the United Kingdom’s NHS to fast-track a high-tech, at-home bowel cancer screening test that’s called colon capsule endoscopy (CCE).
Colon capsule endoscopy hailed a game
changer in cancer screening
This at-home colon cancer screening starts with a brief visit to a local clinic where a nurse fits a special belt and receiver under the patient’s clothing, which is later returned. The patient is also given a small capsule containing two tiny cameras.
Once back at home, the patient swallows the capsule and the cameras inside take up to 400,000 pictures (32 per second) during the capsule’s journey through the bowel. These pictures are captured on the receiver. The pictures are uploaded from the receiver, made into a video, and remotely viewed by a trained doctor who issues a report.
The information is then reviewed by the patient's gastroenterologist who discusses the results with the patient. A diagnosis can be provided within hours.
As for the high-tech camera capsule? It passes through the colon, out of the body and is flushed down the toilet.
Easy, painless and highly accurate
Experts report that CCE is potentially faster and more cost-effective, less invasive, highly accurate, painless, eliminates unnecessary travel, and provides early and effective screening.
NHS Chief Executive, Sir Simon Stevens, said, "...we're now trialing these ingenious capsule cameras to allow more people to undergo cancer investigations quickly and safely. What sounds like sci-fi is now becoming a reality..."
Prof. Martin Marshall, chair of the Royal College of General Practitioners, added, “We’re aware that some patients are reluctant to seek help for certain cancers because the diagnostic tests available can be invasive, so this is a fascinating development, and we will be very interested to see the results of the trial.
"General practitioners are preparing for an upsurge in cases of suspected cancer post-COVID, and the capsule cameras...could enable more patients to monitor and manage their own health at home without embarrassment or discomfort."
Consultant gastroenterologist Ed Seward, who specializes in endoscopy at University College London, has already started using the procedure.
"Not only does colon capsule increase our diagnostic capacity, because it doesn’t require the resources of a dedicated hospital space to do the examination, it also allows us to do the examination in the patient’s home, so patients who may be shielding or cautious about going to a hospital, can perform the procedure in the comfort of their own homes."
Dr. Alastair McKinlay, President of The British Society of Gastroenterology, continues, "Colon capsule is a promising new technology that may offer a real advantage for some patients."
Other experts have described CCE as "cutting edge technology" that "has the potential to make a huge difference."
Bowel prep or cleaning still required
A review of studies published in April concluded that "CCE provides high diagnostic accuracy in an adequately cleaned large bowel."
This cleaning procedure could still be off-putting to many and might explain why researchers found "mixed evidence on whether or not CCE might be accepted by average risk screening individuals."
This point was emphasized by Prof. Andrew Goddard, president of the Royal College of Physicians, when he said, "...we hope this will save some people from having to have a colonoscopy. But they will still need to have bowel preparation, which many say is the worst part of a colonoscopy..."
Bowel preparation begins a few days before CCE and includes consuming foods that help soften the stools. Strong laxatives are needed on the day before the test and again on the morning of the test.
These laxatives can cause some patients to be sick and become dehydrated. However, complications related to the capsule itself are said to be rare. These side effects include when the capsule doesn't make it all the way around the large bowel before the battery runs out, or a blockage is caused by the capsule.
CCE is already being used in Scotland where it's called The ScotCap Test. The NHS will soon roll it out in England to test the procedure in 11,000 patients. In the U.S., the CCE is not yet widely available.
Although it's too soon to make a final judgment about CCE, it will, as Prof. Goddard noted, "save people" from undergoing a colonoscopy.
His words are apt because there are certainly good reasons to be wary of this procedure even if there was no COVID-19 pandemic.
Life-threatening complications from
traditional colonoscopy
Colonoscopy is considered the gold standard for colon cancer screening and is performed on about 15 million Americans each year, but it doesn't come without complications.
These include perforations of the colon or intestine, bleeding, infections, breathing problems related to sedatives for conscious sedation (used in the U.K.) and heart failure related to deep sedation, which is the preferred method in the U.S.
A review published in 2016 by researchers at Yale found that for every 1,000 colonoscopies in outpatients over the age of 65, there were, on average, 16.3 unplanned hospital visits following the procedure.
The numbers varied widely across the medical centers studied, suggesting that some facilities are sloppy in the way they carry out colonoscopies. This led the Yale researchers to develop a quality measure to track the variation in colonoscopy quality in outpatient facilities.
Dr. Elizabeth Drye, who led the research, said the frequency of complications may appear low "but not when you think of how so many healthy people have these procedures."
Her concerns were echoed by South Korean researchers who wrote that the rate of adverse events is low but is likely to be under-reported and "should not be underestimated."
"In particular," they wrote, "perforations are associated with high rates of morbidity and mortality."
Other colon cancer screening tests are available as an alternative, but none are considered as robust as a colonoscopy. For instance, some people opt for a safer procedure called flexible sigmoidoscopy, which examines the lower colon only. But one study found the incidence of cancer was reduced by 59 percent with colonoscopy but only 22 percent for sigmoidoscopy.
Another study found the sigmoidoscopy was only half as effective in reducing deaths from colon cancer.
Safety concerns over colonoscopy could soon be a thing of the past however, thanks to a second new colon cancer screening test on the horizon. This one is an exciting new version of colonoscopy that uses robotics.
“New” robotic colonoscopy reduces risks
A team of scientists at Vanderbilt University, Nashville, and the University of Leeds in the U.K. have created a semi-autonomous robotic system to carry out the colonoscopy procedure. It's fast, easier to operate, painless, and more comfortable for the patient.
This colonoscopy involves the use of a magnetic capsule with built-in imaging capability that is propelled forwards through the body by an external magnetic robot arm with a flexible endoscope.
The operator can drive the capsule forward or backwards with a joystick, but there's also an automated version that only requires the touch of a button. A hybrid version is also an option where the computer can be over-ridden by the operator.
This robotic colonoscopy test still must be performed in a hospital or clinical setting.
Pietro Valdastri, a professor of robotics and autonomous systems who is overseeing the research, said, "What we have developed is a system that is easier for doctors or nurses to operate and is less painful for patients.
"We can also levitate the capsule, so it is in the middle of the column and doesn’t even touch the tissue. The camera allows the operator to look backwards as well as forwards, impossible with a conventional scope, so that polyps and cancer which is hidden behind folds in the gastric column can be seen."
His colleague, Dr. Bruno Scaglioni, says, "Robot-assisted colonoscopy has the potential to revolutionize the way the procedure is carried out."
Patient trials of the new robotic colonoscopy system will begin this year. My team and I will continue to follow the research and track any new developments in colon cancer screening to keep you updated.
Best regards,
Lee Euler,
Publisher
References:
- https://www.scientificamerican.com/article/the-pandemic-is-delaying-cancer-screenings-and-detection/
- https://www.england.nhs.uk/2021/03/nhs-rolls-out-capsule-cameras-to-test-for-cancer/
- https://www.nhsinform.scot/tests-and-treatments/non-surgical-procedures/colon-capsule-endoscopy
- https://www.sciencedaily.com/releases/2016/02/160201141907.htm New method can assess quality of centers performing colonoscopies
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6337013/ Adverse events related to colonoscopy: Global trends and future challenges
- https://pubmed.ncbi.nlm.nih.gov/31152198/ Screening flexible sigmoidoscopy versus colonoscopy for reduction of colorectal cancer mortality
- https://pubmed.ncbi.nlm.nih.gov/31805156/ Screening colonoscopy and flexible sigmoidoscopy for reduction of colorectal cancer incidence: A case-control study
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8041571/ Second-generation colon capsule endoscopy for detection of colorectal polyps: Systematic review and meta-analysis of clinical trials
- https://eps.leeds.ac.uk/medical-electronics/doc/robotic-technology-transforming-colonoscopy-
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