Close to 50,000 Americans will die from colorectal cancer (CRC) in 2016, making it the second-leading cause of cancer-related death in this country (behind only lung cancer).1
What makes the statistic so staggering is that CRC is one type of cancer we can detect at a very early stage - provided patients are screened on a regular basis. Unfortunately, providers are lax in recommending screening while patients are often reluctant to undergo recommended procedures.
Amid widespread concern over low CRC screening rates, there is good news. More screening options are now available—including several non-invasive choices—and health regulators are taking action to broaden patient access to these tests while rewarding providers, payers and health systems for leading the effort to get more Americans tested.
CRC Screening Landscape
The American Cancer Society (ACS) recommends all Americans at average risk for CRC begin screening at age 50, while individuals at increased/high risk begin screening at an earlier age.2 Screening is critical because of the slow development of precancerous polyps,3 which, if identified and removed early, can effectively prevent cancer from forming. Further, because most polyps and early-stage cancers cause no symptoms, the only way to detect them early is through regular screening. For people whose CRC is detected at an early (localized) stage, the five-year survival rate is greater than 90 percent.4
Twenty-three million Americans in the recommended age group do not get screened.5 In fact, America's CRC screening rate has been nearly stagnant since 2005, hovering between 50-60 percent.6 Among some groups—including Hispanics, African-Americans, Medicare patients and low income Americans—the rates are even lower. While data show more than half of CRC-related deaths could be avoided with regular screening,7 the lack of patient compliance means a significant number of CRC cases are not detected until the late stages when treatment is difficult and the five-year survival rate a mere 13 percent.8
Historically, the screening options available to patients were limited. While colonoscopy still remains the gold standard for screening, many patients are reluctant to undergo the challenges related to an invasive procedure, unpleasant preparation, sedation and associated costs. Inadomi, et. al. estimate compliance with colonoscopy is around 38 percent.9
New Measures Promote Choice in Colon Cancer Screening
Now, less invasive tests are available and there is a growing body of data supporting efficacy, as well as a groundswell of regulatory action aimed to expand access to these innovations.
In June 2016, the U.S. Preventive Services Task Force (USPSTF) issued final colorectal cancer screening recommendations with the primary messaging: there is "convincing evidence that screening for colorectal cancer provides substantial benefit for adults aged 50 to 75 years, and a sizable proportion of the eligible US population is not taking advantage of this effective preventive health strategy." In light of the critical importance of improving screening rates, the USPSTF opted not to rate individual tests and instead give an "A" rating to screening in general for all adults aged 50-75 at average risk.
The update recommends newer screening methods, such as the at-home stool-DNA test (also known as FIT-DNA and Cologuard) and virtual colonoscopy. Both tests are now considered equally beneficial as other previously recommended methods. Per the Affordable Care Act, screening modalities included in the USPSTF guidelines must be included in the preventive services package of all U.S healthcare insurers with no associated patient out-of-pocket expenses, meaning no copays and deductibles.10 Medicare and a growing number of private insurers already cover the FIT-DNA test.
In addition to the updated USPSTF guidelines, the National Committee for Quality Assurance (NCQA) recently updated the Healthcare Effectiveness Data and Information Set (HEDIS) with new guidance on CRC screening. HEDIS quality measures are used by more than 90 percent of health plans and promote evidence-based health care and quality service to patients by assessing the performance of health plans on multiple measures. CRC screening compliance and patient satisfaction are two measures evaluated to generate an overall quality score. The new guidelines give health care providers (HCP), health systems and health plans greater incentive to offer and cover multiple screening methods, including newer options like the FIT-DNA and virtual colonoscopy. HCPs who increase the number of patients screened for CRC through June 2017 will receive higher quality ratings during their 2017 HEDIS audit. Consequently, HCPs with higher rates of patient CRC screening will be eligible for quality-of-care bonuses.
The new USPSTF and HEDIS updates align with CRC screening guidelines from other preeminent organizations, including the American Cancer Society (ACS),11 the National Comprehensive Cancer Network, the combined ACS/U.S. Multi-Society Task Force/American College of Radiology12 and the American College of Gastroenterology13. All of the mentioned organizations recognize the use of FIT-DNA as an effective screening modality with a three-year interval. This inclusion is based in large part on compelling clinical data from a prospective, 90-site, 10,000-patient pivotal study, "Multitarget Stool DNA Testing for CRC Screening." Published in in the New England Journal of Medicine in April 2014, the study found that the FIT-DNA test has an impressive sensitivity and specificity of 92 and 87 percent.
Practice Improvement Ideas
Practice improvement to meet the new CRC clinical guidelines requires changes in habits by the entire health care team: front desk, back office nursing personnel, information specialists and other HCPs. As such, engaging all members of the health care team is imperative. Following are a few examples of how to improve CRC in a primary care practice. Consider:
1. Assign an office champion to help the office meet CRC screening guidelines for patients;
2. Periodically (every six months) query the electronic medical record (EMR) for patients for whom clinical guidelines recommend screening (>50 years old, family history of colorectal cancer);
3. Contact identified patients via post cards, Email, text, phone requesting they make an appointment for CRC screening;
4. Incorporate the new FIT-DNA test into health maintenance templates (templates tend to drive provider behavior). Adding FIT-DNA CRC screening to the template will improve compliance with recommendations, allow the practice to monitor quality and drive HCP behavior;
5. Greet patients at the front desk with CRC packets of information related to the FIT-DNA test;
6. Create a FIT-DNA test prescription template in the EMR to facilitate HCPs actually handing the patient a prescription.
Implications of New Measures on Patient Care
In practice, the updated measures further validate expanded screening options and signal a new framework to urge and incentivize HCPs to consider all available tests when discussing and prescribing screening to patients. Primary HCPs are in a unique position to facilitate recommended CRC screening procedures tailored to patient needs and life situations. For those not wanting to undergo colonoscopy, the FIT-DNA test provides a safe, highly sensitive/specific alternative. Consequently, it is incumbent on HCPs to educate patients about the alternatives.
About the Author:
Dr. Mackey is a Professor of Clinical Nursing at the University of Texas School of Nursing at Houston. He is a practicing family nurse practitioner and one of the nation's leaders in nurse-practitioner-managed clinics. Until recently, Dr. Mackey served as the Associate Dean for Practice at the University of Texas School of Nursing at Houston for 25 years.
1 American Cancer Society, Cancer Facts & Figures 2016 http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-047079.pdf
2 Centers for Disease Control and Prevention (CDC): "Vital Signs: CRC Screening" http://www.cdc.gov/vitalsigns/colorectalcancerscreening/
3 American Cancer Society CRC Prevention and Early:
Detection: http://www.cancer.org/acs/groups/cid/documents/webcontent/003170-pdf.pdf
4 American Cancer Society, Cancer Facts & Figures 2016 http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-047079.pdf
5 Centers for Disease Control and Prevention (CDC): "Vital Signs: CRC Screening": http://www.cdc.gov/vitalsigns/colorectalcancerscreening/
6 Centers for Disease Control (CDC) National Health Interview Survey (NHIS) results as published in the CDC's Morbidity and Mortality Weekly Report (MMWR) between 2006 and 2015.
7 Centers for Disease Control and Prevention (CDC): "CRC Screening Saves Lives" brochure: http://www.cdc.gov/cancer/crccp/pdf/EmployersGuideFinal.pdf
8 American Cancer Society Colorectal Cancer Facts & Figures 2014-2016
http://www.cancer.org/acs/groups/content/documents/document/acspc-042280.pdf
9 Inadomi JM, Vijan S, Janz NK, Fagerlin A, Thomas JP, Lin YV, Muñoz R, Lau C, Somsouk M, El-Nachef N, Hayward RA. Adherence to Colorectal Cancer Screening, a Randomized Clinical Trial of Competing Strategies. Arch Intern Med. 2012;172(7):575-582.
10 The U.S. Preventive Services Task Force (USPSTF). "Screening for Colorectal Cancer US Preventive Services Task Force Recommendation Statement," June 21, 2016. http://jama.jamanetwork.com/article.aspxarticleid=2529486#jus160003t1
11 American Cancer Society recommendations for CRC early detection http://www.cancer.org/cancer/colonandrectumcancer/moreinformation/colonandrectumcancerearlydetection/colorectal-cancer-early-detection-acs-recommendations
12 http://pubs.rsna.org/doi/full/10.1148/radiol.2483080842
13 American College of Gastroenterology, "Colorectal Cancer Screening." http://gi.org/guideline/colorectal-cancer-screening/
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