Colorectal Cancer Screening: How to Increase Rates

Colorectal Cancer Screening: How to Increase Rates

Offering colorectal cancer (CRC) screening to patients when they come to the clinic for wellness visits may be the standard of care, but relying solely on that strategy will leave out many patients who do not access care regularly .

Although the CRC is the second cause of death from cancer In the United States, screening rates have not met public health goals. He The American Cancer Society and other groups called for reaching 80% in 2012. coverage in all communities by 2018, but that threshold remains unmet. Only 72% of adults between 50 and 75 years old were up to date on CRC screening for 2021.

One reason is the rigors of colonoscopy, which is invasive and requires both unpleasant bowel prep before the procedure and a day off work to recover. Stool-based testing may be a more viable option for many patients, but the Centers for Disease Control and Prevention (CDC) and other groups have found that increasing screening rates also requires a shift to actively identify and reach patients who are not A today.

Systematic approach

Patients seem to respond well to the choice. In a recent study, a team from the University of Pennsylvania in Philadelphia offered patients who were behind on their screenings the option of having a colonoscopy or stool screening using a fecal immunochemical test (FIT) at the time of initial contact by mail.

Informational materials describing colonoscopy and FIT were included, and patients received text messages directing them to additional resources for more information.

Nearly twice as many patients completed the stool test as those offered endoscopy alone. Six months after initial referral, 5.6% of patients in the colonoscopy-only group had been screened compared to 11.3% in the FIT-only group and 12.8% of patients in the colonoscopy-only group. patients who were given a choice of modalities.

Shivan Mehta, MD, MBA, associate director of innovation at Penn Medicine, worried that offering patients a choice would overwhelm them. “As a doctor, if I talk to a patient, I can explain the pros and cons of different tests,” Mehta said. “But it may not be so easy to talk about those two different approaches when you send letters to people.”

photo by Shivan Mehta, MD
Shivan Mehta, MD, MBA

For Mehta, the key to success was simplicity: “Making it easy for patients to participate, whether by sending them reminders, mailing fitting kits, or facilitating the scheduling process to complete the colonoscopy.”

in a pretrial, sent letters to patients who were not up to date on screenings. Patients who received a letter recommending that they call their provider to schedule a colonoscopy were less likely to be screened than those who were initially mailed a FIT kit or who received the kit in the mail a month after not receiving it. respond to the initial letter.

By following up with patients who did not respond to mailed letters, Mehta learned that the method of communication is also critical.

“Text messages have been very effective for us,” Mehta said. “Even in community health center settings, where they may not have insurance, most have a cell phone with text messaging capabilities.”

And text messages can be automated, requiring fewer resources than having clinic staff make follow-up phone calls.

Ma Somsouk, MD, said another way to increase rates is to focus on patients who are newly eligible for testing. Somsouk, a professor of medicine in the Division of Gastroenterology at the University of California, San Francisco, has had success with FIT reach sent by mail among patients between 50 and 51 years old. In a recent study, he found that these newly eligible patients were more likely to complete testing (58%) than patients 52 years or older who were overdue for testing (41%).

photo by Ma Somsouk, MD
Ma Somsouk, MD

The older group was “more refractory to screening,” said Somsouk, who concluded that newly eligible patients may benefit more from targeted care.

“We know that in the absence of an organized approach to screening, we are allowing people to fall through the cracks,” Somsouk said.

Its goal is to promote organized screening programs by leveraging digital data collected in most electronic health record systems.

“We have several ways we can tell people who are eligible and not up to date for cancer screening. We can look back and find when they had their last FIT or their last colonoscopy, and then we can provide services that can be scaled and automate for individuals,” he said.

Another critical aspect to reducing CRC rates is coordination of care between primary care and gastroenterology to ensure adequate follow-up of patients with positive FIT results. Somsouk said clinics should prioritize follow-up and monitoring efforts for these patients.

“We as a health system need to recognize that they need to get a colonoscopy, otherwise they are at risk of late-stage cancer,” Somsouk said.

All exams are local and national

CDC has relied on population-based approaches to CRC screening since 2009, when Congress began funding the agency’s program. Colorectal cancer control program. Previously, the agency had focused on a pilot screening program that provided testing kits to low-income adults whose insurance did not cover CRC screening. Thomas Frieden, MD, MPH, then the agency’s director, pushed the program in a new direction with the additional funding.

“We were encouraged to do evidence-based clinical interventions, more of a systems change model, which is what we do now,” said Lisa Richardson, MD, MPH, director of the CDC’s Division of Cancer Prevention and Control.

photo by Lisa Richardson, MD, MPH
Lisa Richardson, MD, MPH

The agency currently funds 35 partners, such as state health departments and tribal organizations, to work with clinics serving high-needs populations. They typically rely on a menu of evidence-based interventions (EBIs), such as expanding clinic hours, opening additional locations, and offering patient navigators to provide individualized assistance to help patients access screening and follow-up treatment if necessary.

Clinics are also encouraged to incorporate reminders into electronic medical records that a patient is due for evaluation or to provide feedback to providers about their performance. According to Richardson, the responsibility for increasing screening should not fall on individual doctors.

“It’s really about changing the way the clinic does business,” he said.

A review of data from the Colorectal cancer control program demonstrated that implementation of a single EBI did not increase detection rates. The largest increase, 7.2% in 1 year, occurred in settings that use at least one intervention from each of these three strategies: customer reminders, provider evaluation and feedback, and reduction of structural barriers such as simplification of administrative procedures or prior authorization requirements.

“The more they are implemented, the greater the increase in the prevalence of screening will be,” Richardson said.

Choose your method

He US Preventive Services Task Force it does not indicate a preference for either a stool test or a colonoscopy.

The research showed The FIT test is more attractive to patients. Although colonoscopies have long been the gold standard screening method, new cancers or polyps have occasionally been found in patients undergoing repeat colonoscopies. studies have found.

The FIT detects antibodies against hemoglobin and has approximately 75% better sensitivity than the older guaiac fecal occult blood test (gFOBT). The FIT is also easier for patients to perform at home because the gFOBT test requires submission of three stools and abstinence from certain foods and medications.

New stool-based DNA tests Detect genetic transfer of neoplasms to feces. Research has shown that these tests have a sensitivity greater than 90%, but the false positive rate of the stool DNA test (13%) is higher than that of the FIT (5%).

Studies have shown that although A single FIT is less sensitive than colonoscopy, higher participation rates lead to similar rates of cancer detection and decreased mortality.

“In comparative studies that analyze FIT versus colonoscopy“In general, what we see is that not many people do colonoscopy,” Somsouk said.

Somsouk said he tries to avoid recommending one test over another when seeing patients.

“It is more important to complete the test than to choose or find the exact test,” he said. “Any test is better than none.”

Mehta reported receiving funding from Guardant Health and the American Gastroenterological Association. Somsouk reported receiving funding from Guardant Health and Freenome. Richardson did not report any relevant disclosures.

Ann Thomas, a former pediatrician and disease detective, is a freelance science writer living in Portland, Oregon.

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