• endoscopy
• gastroscopy
• colonoscopy
• gastrointestinal cancer
• colorectal cancer

We read the study by Rutter et al 1 with interest. The substantial decrease in the cancer detection rate in the UK as a consequence of a reduction in endoscopy activity during the COVID-19 era is alarming. Early in the lockdown, UK endoscopy activity dropped to as low as 5% of pre-COVID levels, with activity only increasing to 20% after 10 weeks. More selective screening did significantly increase the per-procedure cancer detection rate (pre-COVID 1.91%; COVID-19 impacted 6.61%; p<0.001); however, despite this, endoscopic cancer detection reduced by 58% overall, with a concerning 72% detection reduction for colorectal cancer. Similarly, in the USA, a recent report found a 50% reduction in colorectal diagnosis as a result of the pandemic.2

COVID-19 remains an ongoing worldwide pandemic. Gastrointestinal (GI) endoscopy is considered an aerosol-generating procedure for SARS-CoV-2 transmission.3 There remain limited data to provide insight into creating a safe model for rationing of GI endoscopy that does not compromise patient care. At the beginning of the COVID-19 pandemic, our hospital in Melbourne, Australia, mobilised a model of care that deferred all non-urgent category 2 and all category 3 cases, alongside specific clinics created with experienced endoscopists to re-triage outstanding cases. Screening colonoscopy as part of the national bowel cancer screening programme following positive faecal occult blood tests (FOBTs) was largely continued as per the Gastrointestinal Society of Australia Guidelines.4 5 We have evaluated the outcomes of this model of care. Endoscopic and histological data were collected on all patients who had an emergency or elective gastroscopy or colonoscopy during our 5-week lockdown period (26 March to 1 May 2020) and the same analysis was performed on all those who underwent an endoscopic procedure during the exact period 12 months prior (26 March to 1 May 2019).

Sixty-six per cent less procedures were performed during the COVID-19 era (n=141 (79% category 1, 21% category 2) vs 410 (45% category 1, 45% category 2, 10% category 3; p=<0.001)) in the pre-COVID era (table 1). Colonoscopy was reduced to 46% of pre-COVID levels and gastroscopy to 25%. Despite this, a comparable number of highly significant pathology was found. The six new malignancy diagnoses in the COVID-19 era were in keeping with our median monthly cancer rate of 5.5 (IQR 3–6.3) over the last 2 years. Of the 4621 gastroscopies and 4573 colonoscopies performed in the past 2 years, 94% of the newly diagnosed upper and lower GI cancers were triaged as category 1 endoscopies and only 6% were category 2.

Compared with the UK, Australia has experienced a far less intensive COVID-19 crisis to date, although a substantial reduction in endoscopy has also occurred. Our findings suggest the risk of missing significant and time-critical pathology can be mitigated by a model of care prioritising category 1 and urgent category 2 upper and lower GI endoscopies. Thus, increasing from minimal endoscopic activity up to 34% of usual levels may achieve a dramatic increase in malignancy diagnosis while still preserving capacity for COVID-19 patient care within the hospital system. Questions remain regarding the duration of the shutdown and its impact. Additionally, the pandemic’s influence on screening programmes including FOBT and visits to primary care for concerning GI symptoms are yet to be evaluated.

With COVID-19 remaining a worldwide pandemic, its impact on endoscopy services and cancer detection will undoubtedly become increasingly significant. For that reason, continuing to perform diagnostic endoscopic procedures above a minimum threshold will be critical to prevent a cancer healthcare crisis in the future.