# Impact of COVID-19 on Universal Tumor Screening, Referral Rates and Attendance at Cancer Genetic Counseling at a Safety-Net University Hospital

## TL;DR

This study examines how the COVID-19 pandemic affected tumor screening and genetic counseling for colorectal cancer patients at a university hospital.

## Contribution

The study identifies suboptimal genetic counseling attendance and referral rates during and after the pandemic.

## Key findings

- Universal tumor screening rates remained high during the pandemic, with over 93% of cases screened.
- Only about 20-36% of eligible patients attended cancer genetic counseling, with scheduling difficulties being a major barrier.
- Referral rates to genetic counseling varied between 60-71%, but attendance remained consistently low.

## Abstract

In order for a genetic cause behind colorectal cancer (CRC) to be identified, a lot of healthcare systems have implemented universal tumor screening (UTS). UTS is an approach according to which every CRC is tested in order to identify those patients who are more probable to have genetics as the cause of their disease. Those patients should then be referred for further evaluation by genetic counsellors (GCs). It is known that the pandemic caused unprecedented stress to healthcare systems, but to this day, it remains unclear how the COVID-19 pandemic affected UTS. For this reason, we decided to perform this study in the hope that we will identify areas of weakness and opportunities for improvement of UTS. Our results show that, in our institution, several components of UTS work well, while others, such as the referral and attendance of patients to meetings with GCs, have room for improvement. We believe that improvement in these areas could be achieved by the earlier involvement of GCs in the process of identifying patients that may benefit from genetic evaluation.

Universal tumor screening (UTS) of all newly diagnosed colorectal cancers (CRCs) for the identification of Lynch syndrome (LS) is recommended. We explored the impact of the COVID-19 pandemic on the UTS process in a safety-net university hospital to identify areas of vulnerability and opportunities for improvement. Patients undergoing resection of a primary CRC were categorized into three cohorts based on surgery date relative to the pandemic (pre-[2018,2019], early-[2020,2021] and late-[2022]). Data regarding (1) UTS performance of immunohistochemistry (IHC) for LS genes and microsatellite instability (MSI) testing; (2) referrals to cancer genetic counseling (CGC) based on mismatch repair deficient (dMMR) status and/or age < 50 years at diagnosis; (3) attendance at CGC; and (4) reasons for not attending CGC were extracted. Between 2018 and 2022, 342 patients underwent resection of a CRC. During the three time periods (pre-, early- and late-pandemic), 93%, 94% and 96% of cases were screened with at least MMR IHC, respectively. Of the patients eligible for referral to CGC in each time period, 60%, 71% and 63% had a referral submitted. Of these, 23%, 36% and 20% in each time period did not attend CGC, with the most common reason for not attending being the inability of schedulers to reach the patient. Although the COVID-19 pandemic did not cause significant variation in the different steps of the UTS process, CGC utilization remained suboptimal throughout the three time periods. Further research on barriers preventing physicians from referring patients to CGC as well as schedulers inability to reach eligible patients should be pursued.