The first priority of an expert panel looking at increasing the number of people being screened for colorectal cancer was to “Eliminate financial barriers to colorectal cancer screening and appropriate follow up.”
Meeting for two days in Washington in February, a National Institutes of Health State-of-the-Science conference considered what is known– and not known– about why people choose or avoid screening, how to improve screening quality, and what the healthcare capacity is to deliver colorectal cancer screening to the US population.
At the end of the meeting, the panel released a consensus statement with their recommendations for enhancing the use and quality of colorectal cancer screening.
While the panel found that colorectal cancer screening rates were increasing, they still remain too low. Rates moved from 20 to 30 percent of eligible people in 1997 to 55 percent in 2008, leaving millions of the population unscreened by any method.
To close the gap in screening, the panel identified the following priorities:
- Eliminate financial barriers to colorectal cancer screening and appropriate follow up.
- Widely implement interventions that have proven effective at increasing colorectal cancer screening, including patient reminder systems and one-on-one interactions with providers, educators, or navigators.
- Conduct research to assess the effectiveness of tailoring programs to match the characteristics and preferences of target population groups to increase colorectal cancer screening.
- Implement systems to ensure appropriate follow-up of positive colorectal cancer screening results.
- Develop systems to assure high quality of colorectal cancer screening programs.
- Conduct studies to determine the comparative effectiveness of the various colorectal cancer screening methods in usual practice settings.
In addition to underuse of screening, the panel found situations of overuse: colonoscopies performed more often than guidelines recommend or patients with serious illness or limited life expectancy being screened without possible benefit.
They also identified misuse of screening when FOBT screening was done in an office setting rather using the recommended home tests.
The most important patient factors in getting screened, the panel discovered, were having insurance and having a usual source of medical care. Higher income and socioeconomic levels also contributed to being screened. Although there were lower rates of screening for African Americans and Hispanics, these disparities almost disappeared when insurance and socioeconomic factors were considered.
A recommendation from a physician was the only physician-related factor found that improved screening. Practices that had electronic medical record reminder systems, staff who could facilitate follow-up arrangements, and patient navigators were the most successful in getting their patients screened.
Two healthcare systems had high screening rates. Kaiser Permanente achieved a 75 percent screening rate for their Medicare patients, and the Veterans Administration system screens 75 percent of their eligible patients. Both systems mail FOBT kits directly to patients, use focused reminders, and carefully follow-up all positive tests with colonoscopies.
The panel was concerned about capacity for colonoscopies, particularly for following up positive FOBT results. They wrote:
Because it is unlikely that current capacity is sufficient for strategies other than universal FOBT screening, expansion of endoscopic capacity may be needed. A first step may be to examine the feasibility of increasing productivity or efficiency of existing facilities. Expanding high-quality endoscopy training to more providers, including nonphysicians, may also be warranted. Such expansion would require careful consideration of quality and patient satisfaction. Also needed is evaluation of the role of incentives, disincentives, and third-party payment policies for performing endoscopy.
In conclusion, the State-of-the-Science Panel wrote,
The panel found that despite substantial progress toward higher colorectal cancer screening rates nationally, screening rates fall short of desirable levels. Targeted initiatives to improve screening rates and reduce disparities in underscreened communities and population subgroups could further reduce colorectal cancer morbidity and mortality. This could be achieved by utilizing the full range of screening options and evidence-based interventions for increasing screening rates. With additional investments in quality monitoring, Americans could be assured that all screening achieves high rates of cancer prevention and early detection.