Advanced-stage colorectal cancer in the context of coronavirus disease-19, highlighting socioeconomic disparities and outcomes: a case report.

Abstract

Background: This is a case report about how pre-coronavirus disease-19 pandemic health disparities in African Americans with colorectal cancer were compounded and exacerbated by the pandemic's associated delays in screening.

Case presentation: A 69-year-old African American male patient presented with a primary concern of hematochezia for 1 week. His history revealed multiple risk factors for colorectal cancer, including obesity, diabetes mellitus, and a family history of colorectal cancer in his grandfather. Of note, his father had prostate cancer. On colonoscopy, the patient was found to have a 3-cm fungating, ulcerated, partially obstructing mass in the sigmoid colon, histologically confirmed as well-differentiated adenocarcinoma with mismatch repair proficiency. Imaging studies demonstrated a 2.4-cm hepatic lesion consistent with metastatic disease. Despite a history of benign polyps, removed 10 years earlier, the lack of follow-up colonoscopy led to a delayed diagnosis. The patient was diagnosed with stage IV colorectal adenocarcinoma with hepatic metastases. Initial treatment involved systemic chemotherapy with the folinic acid, fluorouracil, and oxaliplatin regimen to address micrometastatic disease. A laparoscopic hepatectomy and sigmoid colectomy with primary anastomosis was subsequently performed. After surgery, the patient underwent additional chemotherapy with folinic acid, fluorouracil, and oxaliplatin and bevacizumab for 3 months. Despite this, surveillance imaging revealed disease progression within 4 months, including new lung nodules and remnant liver disease. At this stage, therapy was escalated to folinic acid, fluorouracil, and irinotecan and cetuximab owing to the tumor's microsatellite stability and K-RAS/BRAF wild-type status. Unfortunately, the patient's disease progression reflects the aggressive nature of advanced-stage colorectal cancer and highlights the challenges of managing such cases when diagnosis is delayed.

Conclusion: This case underscores the critical role of timely colorectal cancer screening and follow-up in preventing late-stage presentations, particularly among African Americans, who already face a disproportionate burden of colorectal cancer incidence and mortality. Socioeconomic barriers, compounded by disruptions during the coronavirus disease-19 pandemic, were key contributors to the patient's delayed diagnosis and subsequent poor outcome. This highlights the need for comprehensive approaches to improve healthcare access, including patient navigation programs, policy changes to expand insurance coverage, and community outreach initiatives to increase awareness about the importance of screening. In addition, early and consistent communication of family cancer history, even involving second-degree relatives, may impact surveillance schedules. This case is also of relevance to the general population as the coronavirus disease-19 pandemic-associated colorectal cancer screening delays affected all populations and as such, preventative strategies need to be put in place to address missed screenings and diagnoses.