Goooooooood morning!

Today is a big day. Our advocates at the 2013 Call-on Congress head to Capitol Hill. Meetings with senators, house representatives and subcommittee members abound!

It’s going to be a great day!

Not so fast… we need YOUR help.

Yes – you… if you’re reading this post, we’re talking to YOU.

Please help us boost the power of our advocates on the Hill today. We’ve got big priorities and big asks – and there’s a particular issue we need your help with.

Most likely – colorectal cancer impacted your life, or the life of your loved one.

So get involved in the fight with us today.

Here’s the scoop:

• Please call 1-866-615-3375

• Enter your zip code – you will be directed to your representative

• Tell them your name and where you are from

• Tell them:  You want them to support and co-sponsor the HR 1070 act (eliminates co-pays for screening colonoscopies in Medicare patients)

Your call will help us boost the message that colonoscopy screening should be available to millions.

If you don’t call and help us put colorectal cancer on the map … nobody will.

So call today!

Not so fast…

Before you go, a few things to remember:

• You will be calling your House of Representatives member.
• You can help spread the word – encourage others in your household, workplace, dinner party – whatever – to call in and vote.
• This will only take a few minutes of your time.

“The voices of people pulling together have got to be louder than the voice of those people pulling us apart.” – Martin B. Gold, MPA, JD

Call today – help us take the next step in our fight against colorectal cancer!

After you call – tweet at us and let us know you joined the fight!

A study published in the March 11 JAMA-Internal Medicine suggests that 23 percent of over-75-year-olds have colonoscopies that may be “potentially inappropriate” according to national guidelines which include an upper age limit, as well as how often negative colonoscopies should be repeated.

In a retrospective population study, University of Texas researchers looked at billings for 100 percent of colonoscopies performed in Medicare beneficiaries in Texas who were aged 70 years and older who had a colonoscopy in 2008 or 2009. They also examined a nationwide sample of 5% of Medicare claims. Colonscopies were classified as “screening” if records (including claims from 2000 to 2009) did not indicate a diagnosis, or any visits for related symptoms in the previous 3 months.

Colonoscopies were labeled “potentially inappropriate” based on patient age over 75, or because the procedure was done less than 10 years after a previously negative colonoscopy. (The study population did not include anyone with a history of colon cancer, inflammatory bowel disease, colon resection, or whose procedure was performed during a hospital admission or emergency room visit.)

Among Texas residents, overall percentages of potentially unnecessary colonoscopies were:

• Age 70-75: 9.9 % of procedures done
• Ages 76-85: 38.8%
• Aged 86-plus: 24.9%.

There was wide variation in geographic areas of Texas, plus among individual doctors doing the screening procedures. The researchers did note that reasons for doing a colonoscopy in an individual patient cannot be assumed from billing information alone. (In fact only 15% of the claims included a screening code, although experts believe about two-thirds of colonoscopies are for routine screening.) The authors noted that there might be poor communication between a primary care doctor and the gastroenterologist; there could be financial incentives to do the procedure, or doctors might disagree with the national guidelines.

What are the guidelines?

In fact, there are different sets of guidelines. The U.S. Preventive Services Task Force (and recently, the American College of Physicians) specify age limits. The USPSTF says “For adults aged 76 to 85 years, there is moderate certainty that the net benefits of screening are small….and [for] adults older than age 85 years, there is moderate certainty that the benefits of screening do not outweigh the harms.”

However, joint guidelines developed by the American Cancer Society, the U.S. Multi-Society Task force on Colorectal Cancer, and the American College of Radiology do not include age limits. Part of the problem is lack of evidence: experts note that far too few population studies and clinical trials include those over age 75, even though about 30% of colorectal cancers are diagnosed in those 75 or older.

Increased risks might outweigh benefits for colonoscopy in those over age 75

Although the USPSTF urges caution in any screening over age 75, colonoscopy itself carries higher risks to elderly patients. Both this study’s authors and guideline developers urge extra caution—especially in unnecessary procedures—in the elderly who face higher risks from the preparation (fluid imbalance, start of a diarrhea/constipation cycle, dizziness or a rush to bathroom causing falls) plus effects of anesthesia in elderly patients.

Some over 75 will benefit

A caveat common among the experts: Among those who have never been screened, a screening colonoscopy might be indicated—especially if the older person is healthy, active, has few other diseases, and has an expected lifespan of more than 7 years.

Another study in the March 5 2013 Annals of Internal Medicine showed that in four HMOs, screening among people aged 55 to 85 did reduced the risk of advanced colorectal cancer by 70% in average-risk adults. However, the study showed that annual stool samples in this population (particularly when reminders and stool-sample kits were mailed to people’s homes) were as effective as colonoscopy.

What to do?

Probably the Centers of Disease Control & Prevention says it best: “The decision to be screened after age 75 should be made on an individual basis. If you are older than 75, ask your doctor if you should be screened.”

Patient Take-Away

• All guidelines recommend a colonoscopy only every 10 years, unless you have symptoms, family history, or a previous removal of polyps or an adenoma. (In those cases, plan your “surveillance colonoscopy” with your doctor.)
• People aged 75 or older should pause to consider the need for a routine screening colonoscopy, especially if it’s less than 10 years since a previous negative colonoscopy. You can also consider other screening methods, such as a yearly stool sampling that is very effective at finding early cancer.
• Discussions about cancer (and other) preventive screening probably are best with your primary-care doctor, who knows all of your other health conditions, your general fitness level, etc.
• If you do have a colonoscopy, it’s best to get your own written record of the results, including number and type of any polyps. A common cause of getting too-frequent colonoscopies could be that a different doctor doesn’t know the results of your previous test(s).

As always, stay tuned for updates on both screening and colorectal cancer treatment in the elderly: As boomers age in, and hopefully more seniors are included in clinical and prevention studies, the science will get clearer.

For More information:

* CDC brief summary of guidelines

* Choosing Wisely: on colonoscopies

* Who is the USPSTF? “A Conversation with Dr. Virginia Moyer, Chair, U.S. Preventive Services Task Force, Nov. 27 2012 NCI Cancer Bulletin.

Sources:

“Potentially Inappropriate Screening Colonoscopy in Medicare Patients,” Kristin M. Sheffield, Ph.D. et al,  JAMA Internal Medicine, published online March 11, 2013

Other coverage of this study includes: “Seniors Getting Unnecessary Colonoscopies: Study,” Monday, Mar. 11 HealthDay News; and “Many Colonoscopies for Seniors May be Inappropriate,” Christian Nordqvist, 12 Mar. 2013 Medical News Today.

See previous Research News blogs, including the Feb. 14 2013 “Colorectal Cancer is (or Could Be) the Poster Child for Cancer Prevention” and
the May 16 2011 “Fight CRC Site Update: Some People Getting Colonoscopy Screening Too Often.”

Other recent articles about screening: “CRC Screening Tools—The Data and the Guidelines,” Linda Rabeneck, M.D., M.P.H., at January 2013 ASCO GI-Symposium; and  “Screening Colonoscopy and Risk for Incident Late-Stage Colorectal Cancer Diagnosis in Average-Risk Adults,” March 5 Annals of Internal Medicine .

Some people who go in for a routine screening colonoscopy (fully covered by most insurance) can end up with a surprise bill of several hundred dollars, if the doctor detected and removed one or more polyps.

Under current law, Medicare beneficiaries must pay a coinsurance when their screening colonoscopy also involves the removal of polyps or other tissue—because it is reclassified as a “treatment” procedure. Additionally, while current law also requires most private payers to cover colorectal cancer screenings without cost-sharing (copays/ coinsurance/ deductible), private payers have interpreted the rules differently. Some private payers waive cost- sharing when a screening involves the removal of polyps or other tissue; others do not.

Two weeks ago, we scored a partial victory. The Department of Health and Human Services issued a regulation change stating that private insurance companies cannot charge patients for the removal of a polyp during a screening colonoscopy. The HHS ruling this week was a result of a very productive meeting that we had at HHS last summer with a cooperative group of patient advocacy organizations and professional doctors’ associations.

This is progress, but this ruling doesn’t fix the Medicare policy—yet.

This is what Fight Colorectal Cancer does: Fight for you

For those of you who are new to Fight Colorectal Cancer, you’ll quickly learn that one of our strengths is being a respected, well-known voice in Congress and key federal agencies (e.g., National Cancer Institute, the FDA, Centers for Medicare and Medicaid Services, Dept. of Defense). Our staff and advocates monitor events 24/7 and work behind the scenes—often for months or years–on tedious details and complex issues with the decision makers. We’ve been partnering with other organizations since 2012 on this particular, knotty problem.

In last year’s Congress, Fight Colorectal Cancer was instrumental in the introduction of legislation in the House (H.R. 4120) that would correct Medicare law, and has lobbied the Department of HHS for a change in regulation.

We are working with our congressional allies to see if this HHS ruling may somehow spur the Medicare fix, while also continuing to work toward the reintroduction of a House bill (and a Senate bill) to get the job done in the 113^th Congress.

As soon as we get new House and Senate bill numbers for this year, we’ll issue an  Action Alert here so you can begin lobbying your congressional representatives.

What this means for patients:

• If you have private insurance, have a routine screening colonoscopy (not ordered to check out symptoms, or as a result of a positive stool blood test); and have precancerous polyps removed, your insurer cannot charge a copayment. (The HHS has ruled that removing precancerous polyps is an “integral part of a colonoscopy.” Under the Affordable Care Act, no copays can be charged for approved screening tests.)
• If you have private insurance, and your doctor determines that you are in a high-risk category (e.g., you have a family history of colorectal cancer) that is covered by screening guidelines, the same rules apply: No copayment for a screening colonoscopy that includes removal of precancerous polyps.
• If you have Medicare coverage, you may still be charged a copayment if a screening colonoscopy includes removal of a polyp.
• If you have either private or Medicare coverage, it appears that a followup colonoscopy ordered because of a positive FOBT (stool test for blood) is not considered a screening procedure, and is not covered by this rule change.

 Yes, it’s complicated. If you have questions or concerns, please call our Answer Line at 1-877-427-2111.

For more information:

* Click here for clarifications of Affordable Care Act coverage of screening, including colonoscopy:

* Read here about Fight Colorectal Cancer’s 2013 Legislative goals.

* For tools on making your voice heard, our 2012 Advocacy Handbook  is a great start. A 2013 version for this year’s Congress is in final production. Stay tuned.

February is Cancer Prevention Month, and colorectal cancer (CRC) is a poster child, as one of the few cancers that can be literally seen and removed before it becomes cancer, or can be caught early enough in regular screening to be literally cured.

Ponder these facts, based on 20 years of experience and summarized by Linda Rabeneck, MD, MPH of Cancer Care Ontario at the recent “GI-ASCO” (Gastrointestinal Cancers Symposium of the American Society of Clinica Oncology):

• Annual stool tests (fecal occult blood test, or FOBT) reduce deaths from colorectal cancer by 15 to 33 percent.
• The newer FIT stool test (fecal immunochemical test) appears to be even better than the FOBT stool test at detecting CRC and early adenomas.
• Flexible sigmoidoscopy (a scope exam of the lower colon) can reduce the cases of CRC by 21%, and deaths from CRC by 26%.
• So-called ‘virtual colonoscopy’ (a special screening CT scan) finds up to 90% of people having adenomas or cancers that are at least 1 cm in diameter.

Colonoscopy (examining the entire colon with an endoscope) is still considered by many to be the “gold standard” for detecting and removing precancerous lesions. Dr. Rabeneck noted, however, that colonoscopy continues to be much more effective in detecting lesions in the left (lower) colon than the upper (proximal) right colon, where hard-to-spot “flat” lesions are more likely to occur. (Evidence in the past few years shows that these flat “serrated sessile polyps” may develop differently and more quickly into CRC.)

Dr. Rabenick told the conference that updated national screening guidelines will be released in coming months; one likely change is removing barium enemas as a tool for CRC screening. Other research has raised the question about whether African Americans should start screening earlier (e.g. at age 50): Stay tuned.

We can do better; much better

Despite the remarkable ability to detect and even prevent CRC, about 40% of Americans still don’t get the recommended screening. A recent study of 4000-plus Utah residents showed that 37% didn’t have recommended screening, even if they had a family history of colorectal cancer. The numbers of unscreened were much higher in rural areas.

Although it can be harder for some people (especially rural residents or those without full insurance coverage) to get a screening colonoscopy, they have choices:

• A simple yearly stool test (high-sensitivity FOBT or FIT) that is done at home and mailed in;
• Flexible sigmoidoscopy done every 5 years (most doctor’s offices do this test) along with stool tests every 3 years
• A colonoscopy every 10 years or CT colonoscopy every 5 years.

People aged 76 to 85 without risk factors (such as a family history or certain number of polyps found over the years) usually don’t need routine screening (and those over age 85 can skip it because risks outweigh benefits).

Get more information and breaking CRC news

• See a chart here that describes each screening option.
• Stay tuned here for screening updates, and….

Learn more news with GI-ASCO Keynoter

Next Tuesday, Feb. 19, 2013, from 8 – 9:30 pm (EST), the ASCO-GI keynote speaker, internationally renowned CRC specialist (and member of our own Medical Advisory Board) Dr. Richard Goldberg will talk directly to and with you at our webinar “The Latest in Colorectal Cancer.” He’ll share a “Decade of Progress” plus also give us his take on the most interesting news to come out at ASCO-GI. You don’t get many chances to listen to a world-renowned expert: Register to join it live, or listen later to this and all archived webinars. 

Sources: “CRC Screening Tools–The Date and the Guidelines,” ASCO-GI Jan. 26 2013; “Screening for CRC: which Tool and How Often,” ASCO-GI Educational Summary  and “Rural vs. Urban Residence Affects Risk-Appropriate CRC Screening,” in press Clinical Gastroenterology and Hepatology.

Michelle and Brett Gallaway

“A cook-off saved my life.”

That’s what Brett Gallaway wrote on his Facebook page on October 3, 2012, after reality sank in. He’d just heard from his doctor that a precancerous polyp had been found during his screening colonoscopy.  A polyp that, if left in place, could have developed into full-blown colorectal cancer.

“I didn’t even know I had it,” Brett said.  “I didn’t have any symptoms.”

Thanks to a raffle he won at a barbecue cook-off, he was able to receive a free colonoscopy and find the cancer early.

Brett’s Facebook page filled with “Likes” and comments. A lot of them were testimonials from friends who had brushes with cancer or had also discovered precancerous polyps just in the nick of time.  A lot of them seemed to be like Brett, in their forties or close to 50, with kids, spouses and busy lives. Native Texans, they shared a love of grilling and barbecue.  

Some of them had been at the cook-off that day. They knew the organizer, Suzan Mayberry, and flocked to the 2^nd Annual Steve Mayberry Annual Cookoff, held in September in honor of her husband who died of colorectal cancer in 2010. Brett was part of the USA Cookteam, a group of buddies who grill for fun and enter competitions across the country. He volunteered to help with the cook-off and grilled all the food available to sell during the event.

Brett wasn’t thrilled when he found out his wife purchased 12 raffle tickets, where the winning prize was a free colonoscopy. “People have been telling me to get a colonoscopy and I didn’t take it seriously at that point,” he said. His family also didn’t have health insurance, so the screening wasn’t his most pressing concern. But when he won the raffle, he took it as a sign. “I figured if I won this, there’s a reason.”

A week and a half later, Brett went in for the screening at the Baylor Surgical Center of Lewisville. Three days afterward, he got the news. “I was actually at work in my office and I let my wife know and then called my dad and then called my wife to tell her again,” Brett said. “I realized had I not gotten a screening done when I did, I wouldn’t have been able to [afford] one.”

Dr. James Cox, the gastroenterologist who saw Brett, said his case was “one of the most satisfying things I have done professionally.” Dr. Cox teamed up with United Surgical Partners to provide the pro bono screening.  “Without insurance, he probably would not have come in until he had symptoms and that could have been at an incurable stage,” Dr. Cox said.

That’s why he encourages patients to seek medical advice if they have any symptoms, including abdominal pain, weight loss or bleeding.  He often meets patients who dismiss their symptoms and wait until they get worse. “People say I’m bleeding from my hemorrhoids and I say ‘Really, you’ve looked inside and confirmed that?’ When we get in and look, we find a big polyp sitting there.”

For Suzan Mayberry, Brett’s story is the icing on the cake. Twenty-three teams of grillers participated in the cook-off this year and every team donated their winnings to Fight Colorectal Cancer. The event raised $15,000.

“It’s the only thing I can do to stick it back to cancer,” Suzan said. She hopes to use the annual event to raise awareness about colorectal cancer, screenings and Lynch syndrome, an inherited genetic mutation that doctors suspect was the cause of her husband’s colorectal cancer. Lynch syndrome runs in families and increases their chances of developing colorectal cancer and other Lynch-related cancers.

Since the polyp was removed, Brett is a changed man. “When I saw the risk factors [for colorectal cancer] included eating a lot of red meat, I said ‘whoa that’s me.’” In 2011, he had been the champion in the steak category during the Mayberry cook-off. His USA Cookteam were the 2011 world champions in the World Ribeye Steak Cook-off in Magnolia, Arkansas. Now, he cooks for competition and eats a lot less.

“I feel like I’ve won the lottery,” he reflects. “There was someone else’s hand in it. I was given a second lease on life. I’ve just got to figure out how to use my time.”

Fight Colorectal Cancer thanks Bayer Healthcare for their support of the cook-off, as well as Suzan Mayberry and her fantastic planning committee for their leadership and boundless enthusiasm.

If you  have questions about the symptoms or risk factors of colorectal cancer, please call the Fight Colorectal Cancer Answer Line at 1-877-427-2111.