This year, colorectal cancer (CRC) is projected to kill more than 52,000 people in the United States.1 Thousands of these deaths will occur among patients under 50. Many of these deaths will be preventable.2
Clinicians and healthcare leaders are aware of both the current rates of CRC and the condition’s preventability. Still, this awareness has not translated into elevated rates of screening. If everyone who needed a colorectal cancer screening received one, an estimated 53,000 deaths could be prevented in 2022.3
It is possible that low rates of CRC screening are partially attributable to insufficient patient engagement efforts. One recent study identified “fear” or “worry” as the most common barrier to CRC screening as reported by patients. The study’s authors concluded that new communication and intervention strategies may be needed help improve CRC screening.4
Organizations like Pennsylvania-based Geisinger Community Medicine, Primary Care and Florida-based Sanitas Medical Center, which includes 37 clinics in FL and clinics in TX, NJ and TN, are two organizations putting patient communication and choice based shared-decision making at the center of their CRC screening efforts.
To better understand how and why these organizations have made choice central to CRC screening, Becker’s Hospital Review recently spoke with Cybele Pacheco, MD, Medical Director for Quality and Innovation in Primary Care at Geisinger, and Martha Duarte, MD, MHSA an epidemiologist with Sanitas Medical Center.
Updated screening guidelines support shared decision-making5,6
To bolster CRC screening rates, the American Cancer Society (ACS) and the U.S. Preventive Services Task Force (USPSTF) recommend CRC screening modalities including noninvasive tests, such as Exact Sciences’ Cologuard® mt-sDNA test.†
The current ACS guidelines were updated in 2018. This update — in addition to USPTF’s long-standing recommendations — opens the door to actively involving patients in shared decision-making (SDM). Dr. Pacheco discussed how Geisinger staff engage patients in conversations about CRC screening.
“Providers are triggered in the electronic health record (EHR) when a patient meets criteria for colorectal cancer screening,” she said. “Based on this, we offer a variety of options from invasive testing to noninvasive sampling.”
In Dr. Pacheco’s experience most patients prefer noninvasive screening. The hospital leverages an algorithm to identify when a patient meets the criteria for a noninvasive screening and then elevates this information for physicians in the EHR via a best practice alert. Then, physicians can directly make this option available to the patient. The hospital also embeds sustained prompting into the EHR, so physicians are empowered to have conversations about CRC during subsequent patient visits should a patient decline screening.
“If a patient refuses, the best practice alert remains and no matter what type of visit they have after that — whether it’s for a sinus infection or an eye appointment — if the patient is in the Geisinger system, the provider will be triggered to have that conversation again,” she said. “We make every effort not to lose track of patients who decline to have a CRC screening.”
Federal guidance around CRC screening continues to make it easier for providers to empower patients with choice. New regulations enacted as part of the CARES Act to help patients get access to screenings amid the pandemic will require most health insurers to cover the costs of the full CRC screening continuum - including a noninvasive test - without a copay by 2023.7
Organizations like Geisinger are making the most of these shifts in the CRC screening landscape and empowering patients to become more active participants in their care. “We’re having really layered conversations with patients and provide them all the necessary information,” Dr. Pacheo said. “Then we can really have a shared decision-making approach.”
Noninvasive CRC screening supports cultural competency for vulnerable patients
Dr. Duarte, whose medical center serves a community with large Hispanic and Caribbean diaspora populations, understands the importance of cultural competency when discussing screening options with patients. Speaking to the disparity gaps that could be exacerbated by not participating in SDM, she said that Sanitas — a multicultural and multinational company with a presence in seven countries — is continuously training, sensitizing and supporting its staff, most of whom are bilingual or multilingual, on how to present CRC screening options. The goal is to reduce the CRC screening gap, which according to the latest report by the American Association for Cancer Research, only 63.7 percent of white Americans are screened, 59.3 percent of African Americans and 47.4 percent of Hispanics.8
The EHR and the Power of Choice: 3 CRC screening tips from Geisinger and Sanitas
- Leverage best practices alerts in the EHR to prompt conversations about appropriate CRC screening options with patients.
- Engage patients where they are by informing them about CRC screening options via email, text messages and phone calls.
- Create a preventive health task force to follow up with patients and identify screening gaps.
“Many of our patients are immigrants and in some countries CRC screenings are not widely disseminated,” Dr. Duarte said. “Beliefs, practices, diet, hereditary factors and [a lack of] widespread knowledge of CRC screenings can influence whether a CRC screening is performed or not. That’s why cultural sensitivity is very important and education, understanding the needs of our patients and giving them options has been key to increasing CRC screening rates.”
Dr. Duarte noted that offering options to patients in a culturally appropriate way has led to more patients being screened and has decreased disparities. She credits Exact Sciences’ mtsDNA screening test — which is Sanitas’ preferred non-invasive screening option recommended to patients who qualify — and the combination of other tests and practices such as Fast Track Colonoscopy, with raising CRC screening rates.9 Sanitas began offering mt-sDNA in the first half of 2018; prior to then the organization’s screening rates were well below its peers, according to Dr. Duarte. “It was disheartening to see that we were so behind and that many of our patients needed this screening and we couldn’t find a way to deal with it. But by the end of 2018, we not only [caught up], but we exceeded expectations,” she said, pointing out that the CRC screening rate at her facility jumped to over 55 percent by the end of that year.
Making early gains permanent requires optimizing technology and patient follow-up
To actively involve patients in shared decision-making for CRC screening over time, both Sanitas and Geisinger have optimized the technology that enables and supports layered and culturally competent conversations.
For Sanitas, this has meant integrating its EHR platform with Exact Sciences’ platform and creating a common interface, which allows Sanitas to send orders when a mt-sDNA test is prescribed and to receive the results from the providers who ordered those tests. The organization also leverages its EHR platform and internal patient portal to support campaigns that target specific populations for CRC screening and to send reminders to those patients who are prescribed for a CRC screening with mt-sDNA and who have the mt-sDNA kit at home but have yet to send in the sample for testing.
Additionally, Sanitas and Exact Sciences are running a pilot project to identify patients whose primary language is not English, so that they can be engaged and involved in shared decision-making in their preferred language. To facilitate this process, Sanitas has a dedicated team of “colorectal trackers” — staff members with clinical experience who help patients follow the screening recommendation they have been given, whether for Cologuard, another noninvasive test or for a colonoscopy. “We expect this improvement will facilitate communication, understanding of the process and hopefully translate into more patients getting screened,” Dr. Duarte said.
For Geisinger, technology is seen as an indispensable aide to physicians. “My top priority as a quality director is to remind providers to have the conversation about CRC screening no matter what kind of appointment the patient is in for,” Dr. Pacheco said. “What I love about our system is that the reminders pop up whether a patient is here for a Pap smear or something else. It’s on everybody’s task list and having that conversation is on everyone’s to-do list, no matter why a patient comes in. We’re set up for success — and technology is the basis.”
Choice and the power of shared decision-making
The need for deeper engagement with patients is frequently invoked by health systems and health policymakers. Achieving this level of engagement, however, remains a strategic challenge. Geisinger and Sanitas exemplify two organizations making headway in the pursuit of more fruitful patient engagement. These organizations understand the appeal of choice and the power of shared decision-making, and this understanding is yielding tangible results in the form of better CRC screening rates.
“It was necessary to rethink the way we were offering CRC screening to our patients,” Dr. Duarte said. “The [government’s] idea of integrating the different types of tests in a comprehensive way provides our patients and providers with choices to do the CRC screening and ways to support patients until a diagnosis is done and beyond.”
Dr. Pacheco agreed.
“I think this will be huge,” she said. “At the end of the day, what we want to do is get patients screened for a disease that’s preventable or least treatable before it progresses too far.”
References
†Guidelines may refer to mt-sDNA by different names including FIT-Fecal DNA, sDNAand sDNA-FIT.
1 Key Statistics for Colorectal Cancer, American Cancer Society, www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html#:~:text=Deaths%20from%20colorectal%20cancer,about%2052%2C580%20deaths%20during%202022.
2 Siegel, Rebecca L. “Colorectal cancer statistics, 2020.” CA: A Cancer Journal for Clinicians, May 2020, acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21601#:~:text=In%202020%2C%20approximately%20147%2C950%20individuals,aged%20younger%20than%2050%20years.
3 Siegel, RL, Miller, KD, Fuchs, HE, Jemal, A. Cancer statistics, 2022. CA Cancer J Clin. 2022. https://doi.org/10.3322/caac.21708.
4 Muthukrishnan, Meera. “Patients’ self-reported barriers to colon cancer screening in federally qualified health center settings.” Prev Med Rep, 15 Sept. 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC6531912/.
5 Davidson KW, Barry MJ, Mangione CM, et al. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(19):1965-1977.doi: 10.1001/jama.2021.6238.
6 Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin.2018;68(4):250-281.
7 Faqs About Affordable Care Act Implementation Part 51, Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security Act Implementation, www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-51.pdf.
8 CancerDisparitiesProgressReport.org [Internet]. Philadelphia: American Association for Cancer Research; ©2020 2022 March. Available from http://www.CancerDisparitiesProgressReport.org/.
9 Siegel, RL, Miller, KD, Fuchs, HE, Jemal, A. Cancer statistics, 2022. CA Cancer J Clin. 2022. https://doi.org/10.3322/caac.21708.