publication date: Feb. 5, 2021

Trials & Tribulations

The Delaware experience:

Keeping in contact with those at risk is key to colorectal and breast cancer screening during COVID-19

Nicholas Petrelli

Nicholas Petrelli, MD

Bank of America endowed medical director,

Helen F. Graham Cancer Center & Research Institute, ChristianaCare



Nora Katurakes, MSN, RN, OCN 

Manager, Community Health Outreach and Education Program,

Helen F. Graham Cancer Center & Research Institute, ChristianaCare



Rose Mili

Senior marketing communications manager,

Helen F. Graham Cancer Center & Research Institute, ChristianaCare



Charlene Marinelli, RN, OCN

Screening nurse navigator,

Helen F. Graham Cancer Center & Research Institute, ChristianaCare


COVID-19 continues to ramp on and has affected just about all aspects of the health care system in our country.

This has led to a decrease in cancer diagnosis since the early spring of 2020, when the pandemic started. In general, one would like to see a decrease in cancer diagnosis as a result of a decrease in cancer incidence, but what has happened since the COVID-19 pandemic is that individuals have been staying home and are concerned about contracting the virus by going through standard cancer screening procedures.

This is especially true for colorectal and breast cancer screening with colonoscopy and mammography. This is critical because these cancers can be detected in an early stage, and are potentially curable and preventable.

In 2020, during the early time of the pandemic, the United States Centers for Disease Control and Prevention and several medical professional societies recommended cancer screening be postponed unless the risks outweighed the benefits.

Elective procedures were canceled so health care systems could prepare for the incoming waves of COVID-infected patients. Many hospitals were managing COVID patients by crisis, with a lack of necessary materials and personnel.

During the height of the COVID-19, NCI stated that the pandemic would result in nearly 10,000 additional deaths due to colorectal and breast cancer over the next ten years.

I think we can all imagine that this is probably an underestimate. In view of the fact that we are still learning about the full impact, both short term and long term, of COVID-19 infections, and it will take continued research and experience to better define the impact of this virus on cancer care.

Hence, the pandemic’s global impact on commonly performed cancer prevention and control measures is still unknown.

In Delaware, we have one of the most successful cancer control programs in the United States. In 2016, Delaware ranked 12th highest in the United States for colorectal screenings. In comparing 2001-2005 to 2011-2015, Delaware’s colorectal cancer incidence rate decreased 30% while the national rate decreased 22%. In 2016, Delaware stood 31st and 35th in colorectal cancer incidence and mortality.

It was imperative that despite COVID-19, we needed to find a way to continue the successful colorectal screening program during the pandemic.

Hence, from July 1 to Dec. 31, 2020, a colorectal cancer campaign evolved, which included a colorectal cancer risk assessment through an organic social media campaign from July 27 to Sept. 4, followed by paid digital and social media campaigns from Sept. 14 to Dec. 31, 2020.


Colorectal cancer awareness and risk assessment

During the COVID-19 pandemic, our community outreach team at the Helen F. Graham Cancer Center and Research Institute knew it was important to remind people to still get care including their cancer screenings and in this case colonoscopies.

In partnership with our marketing team, we had recently completed work on a free online colorectal cancer risk assessment. The risk assessment hosted by HealthAware was completed with the assistance of one of the community outreach oncology nurse navigators.

With 15 plus years of experience, the nurse navigator knew that the individuals we were trying to reach about the importance of cancer screenings are impacted by social determinants of health, health literacy, and screening options.

Individuals who committed to screening find it helpful to connect with the navigator to have their questions answered, discuss options and plan next steps.

Others, who are not ready for screening, may contact the navigator in the future when the have decided to take the next steps.

As a result of COVID-19, we found individuals sometimes felt the need to reschedule or change their choice of screening option. The key is to have a reliable contact to help navigate through these COVID times and not stop screening.


Background on the design of the assessment

Knowing the importance of reaching individuals about the risks of colorectal cancer, especially those at high risk who may not know it, we worked on creating a new and free risk assessment.

In late 2019, in collaboration with external affairs and marketing, and The Helen F. Graham Cancer Center’s nurse navigator, an outdated Colorectal Cancer Risk Assessment was reworked utilizing evidence based references such as the American Cancer Society, National Comprehensive Cancer Network and Christiana Care Genetic Consultation and Risk Assessment Program to create a #12 Screen easy to complete online CRA questionnaire.

Question themes included: age; height/weight; family history of cancer and colon polyps; personal history of cancer, inflammatory bowel syndrome, genetic syndromes, having 10 or more colon polyps removed over time; alcohol consumption; smoking status; exercise; diabetes; colorectal cancer screening tests completed; whether the individual has a primary care provider; and marketing source.

Based on the question responses, a report was created to determine low, medium or high risk in each the following categories: early detection, age, family history, alcohol, and smoking.

A report was generated, and the participants were encouraged to take the time to review the results with their primary care doctor.

If the assessment found them at high risk, they could choose to have the nurse navigator follow up with them. If this was the case, a report was generated and forwarded to the nurse navigator so she could follow up with the individual.

Additionally, embedded in the individuals’ report were ChristianaCare and community resources for tobacco cessation programs, finding a doctor and contacting the ChristianaCare Genetic Consultation and Risk Assessment Program.

We began to market the assessment in March 2020, for Colorectal Cancer Awareness Month, when the pandemic started, and we pulled back all marketing/advertising around March 15.

As we progressed through the pandemic, we realized we still needed to keep in touch with our community about the importance of people getting back to care and getting their screenings. Hence, we developed a digital marketing campaign to provide education about colorectal cancer awareness and our free online risk assessment.

Results of assessment marketing campaign and navigator outreach

  • Completed the Assessment: 422

  • At risk of those that completed assessment: 333

  • Agreed to be contacted for assessment follow up by nurse navigator: 97

Patient journey

  • Colonoscopy completed or scheduled: 12

  • Cologuard completed or scheduled: 3

  • In process: 4

  • Value added Services:

  • Education plus a referral for colorectal cancer screening: 51

  • Education only not eligible for colorectal cancer : 33

  • Mammography completed: 7

  • Referral to gastroenterology: 7

  • Referral for genetic testing: 2

  • Referral for evaluation with primary care: 1

The outreach navigators learned that COVID had a large impact on our community work and referrals from our community partners.

We did not get discouraged, but sought other ways to move forward and continue our work. In this case, turned to a digital platform. This promotion/push brought great results and touched a good number of our community members.

Although the numbers are small in many areas, the critical outcome of this project was the contacts made to those individuals at risk who will be contacted in the coming months to remind them of the importance of cancer screening and making sure they get scheduled for the screening procedure .

Next steps:

  • Roll out the campaign again in March 2021 for Colorectal Cancer Awareness Month.

  • Included ChristianaCare employees as a target audience through a new Caregiver Connect mobile application.

Copyright (c) 2021 The Cancer Letter Inc.