Colonoscopy Use Declined Following Covid, While Stool DNA Testing Increased

Among commercially insured patients undergoing colorectal cancer screening, utilization of colonoscopy and fecal immunochemical testing (FIT) declined following the Covid-19 pandemic, while use of stool DNA testing increased, according to findings from a large, retrospective cohort study.

Data on close to 25 million Blue Cross Blue Shield beneficiaries between the ages of 50 and 75 years were included in the analysis, published in JAMA Network Open.

Males were more likely than females to have colonoscopies during the time period studied (2017 and 2024), while females were more likely to use commercially available stool DNA testing products, such as Cologuard.

"Areas with high socioeconomic status and metropolitan area residents had higher use of colonoscopy and stool DNA tests, although use of FIT was higher among low socioeconomic status (SES) areas," wrote researcher Sunny Siddique, MD, PhD, of Yale School of Public Health, New Haven, Connecticut, and colleagues. "The heterogeneity in screening modality use based on population subgroups warrants tailored interventions to increase screening participation for all."

The researchers noted that while colonoscopy remains the most widely use screening tool for colorectal cancer (CRC), "several recent events have impacted the evolving landscape of CRC screening."

"During the early phase of the Covid-19 pandemic (March to May 2020), colonoscopy was estimated to decrease by 85% in the U.S.," they wrote. "Although this decline was potentially counterbalanced by an increase in stool-based testing at the peak of the pandemic, the extent to which alternative screening modalities were used after screening colonoscopies resumed remains unclear."

Their aim in conducting the retrospective cohort study was to assess recent patterns in CRC screening among commercially insured adult patients with an average CRC risk by comparing changes in screening modality use prior to, during, and following the Covid-19 pandemic. Time frames studied included the pre-Covid onset period (Jan. 1, 2017-Feb. 28, 2020) and the post-onset period (July 1, 2020-Dec. 31, 2024).

Auto-regressive integrated moving average models, adjusted for temporal autocorrelation and seasonality were used to evaluate changes in screening by modality.

Data on a total of 24,973,642 Blue Cross Blue Shield beneficiaries (mean [SD] age, 57.3 [4.27] years; 51.21% female), were included in the analysis.

Among the main findings, the study authors reported:

• "Use of colonoscopy (mean [SD], 1.29% [0.09%]-1.14% [0.07%]; P < .001) and fecal immunochemical test (FIT) decreased between the 2 periods (mean [SD], 0.54% [0.03%]-0.38% [0.07%]; P < .001). However, stool DNA test use increased (mean [SD], 0.19% [0.13%]-0.61% [0.16%]; P < 0.001).
• "Males had higher use of colonoscopy than females (mean [SD], 1.21% [0.07%] versus 1.07% [0.07%]; P < 0.001), while females were more likely to use stool DNA test than males (mean [SD], 0.68% [0.16%] versus 0.55% [0.15%]; P < 0.001) and FIT (mean [SD], 0.43% [0.08%] versus 0.33% [0.05%]; P < 0.001).
• "Areas with socioeconomic status in the top 20% had higher use of colonoscopy compared with areas where a marker of SES was in the bottom 20% (mean [SD], 1.37% [0.09%] versus 0.91% [0.06%]; P < 0.001) and stool DNA test (mean [SD], 0.65% [0.17%] versus 0.48% [0.13%]; P < 0.001) and lower use of FIT (mean [SD], 0.36% [0.09%] vs 0.48% [0.06%]; P < 0.001)."
• "Metropolitan area residents, compared with non-metropolitan area residents, more frequently underwent colonoscopy (mean [SD], 1.18% [0.08%] versus 0.97% [0.06%]; P < 0.001) and FIT (mean [SD], 0.41% [0.08%] versus 0.25% [0.04%]; P < 0.001); however, their use of stool DNA test were similar (mean [SD], 0.61% [0.16%] versus 0.64% [0.16%]; P = 0.51)."

Study strengths included the large sample size, nationally-representative sample, and longitudinal design. A study limitation was the potential lack of generalizability to patients who did not have commercial insurance.

Blue Cross Blue Shield beneficiaries included in the analysis were also not required to be continually enrolled during the entire study period, meaning screening conducted outside the insurer was not captured.

Funding for this research was provided by the National Cancer Institute. Siddique reported no relevant disclosures.

Siddique S, et al "Changes in colorectal cancer screening modalities among insured individuals" JAMA Netw Open 2025; DOI: 10.1001/jamanetworkopen.2025.38578.