GetScreenedSD has expanded from six pilot clinics to more than 200 clinics across the state of South Dakota.

People age 50 and over are encouraged to be screened for this preventable cancer, either with a take-home test or a colonoscopy. Financial help is available for those who cannot afford it.

Go to the South Dakota Department of Health to find a testing site near you.

Norma Schmidt, Cancer Program Director for the Department of Health, said in an announcement of the expansion,

Colorectal cancer is preventable and treatable when it’s found early with the appropriate screening. We’re very pleased to have so many providers working with us to make this lifesaving screening available statewide.

The new guidelines will mean that insurance plan can no longer charge copayments or other fees for a number of preventive services including colorectal cancer screenings.  The regulation does not take effect until Sept. 23, and it only applies to plans that are new after that, meaning that people who stay on their existing plan won’t benefit from the change.

Colorectal Cancer Coalition President Carlea Bauman was invited to the event, which was attended by about 50 other health care leaders, doctors, and nurses.

During her remarks, Secretary Sebelius said that “[t]oo many Americans don’t get the preventive care they need to stay healthy.”  A conclusion the colorectal cancer community is well aware of with colorectal cancer continuing to be the third most commonly diagnosed cancer in men and women and the second most common cause of cancer death.

Interested in learning more about today’s guidelines and other provisions in the Affordable Care Act that will affect the colorectal cancer community?  Take a look at our webinar that provides an overview of the Affordable Care Act through a cancer lens.

If you were not able to join us for the live webinar, you can access a video of the webinar or download the slides from the presentation.

Still have questions about the Affordable Care Act, and how it changes access to colorectal cancer screening and impacts the cost of cancer care?  Email us at Advocacy@FightCRC.org.

In a study of  1,000 ethnically and racially diverse people, the lowest percentage had a colonoscopy when that was the only test offered.  More completed fecal occult blood testing if it was the single choice. Overall 65 percent of the 1,000 patients studied were screened after their doctor recommended testing.

Primary care providers randomly recommended patients be screened for colorectal cancer by:

• Colonoscopy alone
• FOBT alone
• Their choice of colonoscopy or FOBT

In order to make colonoscopy easier, barriers to having the exam were reduced by:

• Reducing or eliminating the patient’s cost for colonoscopy.
• Providing information about the test and preparation for it in the language the patient preferred.
• Providing rides to and from the exam.
• Having an open access system with no more than 2 weeks between test recommendation and the scheduled procedure date.

While two out of three participants in the study had a recommended test:

• 38.4 percent had a colonoscopy when it was the only recommendation.
• 67.1 percent completed an FOBT when only FOBT was recommended.
• 70.0 percent completed screening when they were given a choice between FOBT or colonoscopy.

During a follow-up survey, health beliefs that interfered with having a colonoscopy included

• Fear of test results.
• Fear of cancer treatment.
• Concern that they wouldn’t be able to do the necessary prep.

John M. Inadomi and colleagues in the GI Health Outcomes, Policy and Economics (HOPE) Research Program at the University of California,San Francisco concluded:

Recommendation of colonoscopy alone results in lower adherence to any colorectal cancer screening test compared with recommendation for fecal occult blood test alone or choice of FOBT or colonoscopy.

SOURCE: Inadomi et al., Digestive Disease Week Abstract #124.

After following 170,000 people for more than 11 years, deaths from colorectal cancer were 43 percent lower among those who had a flexible sigmoidoscopy screening.  Diagnosis of colorectal cancer was reduced by 33 percent.

This is the first prospective clinical trial that actually proved that examining the rectum and colon with a scope could reduce colorectal cancer deaths.

Participants in the trial had indicated their willingness to be part of a randomized trial and were assigned either to a control group or to receive a single flexible sigmoidoscopy exam.  Twice as many people were in the control group as in the sigmoidoscopy group.

Participants were only people of average risk.  Those with previous colorectal cancer, polyps, inflammatory bowel disease, or family history were not included.

Enrollment in the trial began in 1996 with a goal of following patients for 15 years.

During the a median 11 years of followup, there were 1,818 cases of colon or rectal cancer in the control group compared to 706 in the sigmoidoscopy group.  Among those who didn’t have sigmoidoscopy, 538 people died of colorectal cancer and 189 died who did have the exam.

There was some selection bias — patients chose to enter the trial themselves but not whether they would get a sigmoidoscopy.  After researchers adjusted for that bias, incidence of cancer was about a third less (33 percent) for those who got sigmoidoscopy and deaths were reduced by 43 percent.

In choosing sigmoidoscopy and age 55 to focus on screening, Dr. Wendy Atkins, who led the trial, pointed out that most people develop polyps in their 50′s and cancer later in life.  About two-thirds of colon cancers are found in the distal colon, the part of the colon that can be reached by the sigmoidoscope.

The exams did not require sedation.  Preparation was a single phosphate enema which participants administered at home about an hour before leaving for their appointment.

Dr. Atkins and her colleagues concluded,

Flexible sigmoidoscopy is a safe and practical test and, when offered only once between ages 55 and 64 years, confers a substantial and longlasting benefit.

In the United States, both the US Preventive Services Task Force and the American Cancer Society in collaboration with the Multi-Society Task Force on Colorectal Cancer and the American College of Radiology  include flexible sigmoidoscopy in their colorectal cancer screening guidelines for people of average risk.  For people with increased or high risk, only colonoscopy is recommended by both groups.

US guidelines call for flexible sigmoidoscopy to be done every five years.

In an earlier article in The Lancet that looked at patient acceptance, safety, and costs of the UK sigmoidoscopy screening trial, Dr. David Ransohoff, found that:

• 80 percent of patients experienced no more than mild pain during the test.
• Three months after the test, 98 percent were glad they had it and 97 percent would encourage a friend to have the exam.
• There was only 1 perforation in over 40,000 sigmoidoscopies, including 19,000 polyp removals.
• Among the 2,377 people referred for an additional colonoscopy, there were 4 perforations.
• 12 patients needed to be admitted to the hospital for bleeding after a sigmoidoscopy with polyp removal.

Costs concerns in the trial centered on the need for colonoscopy follow-up when a polyp is found in the distal colon to be sure no further polyps are located in the proximal colon out of the reach of the sigmoidoscope.  In the UK trial only large adenomas were considered for colonoscopy follow-up.  They were found in about 5 percent of cases.  However, polyps of any size were discovered in 1 in 4 participants (25 percent) which, if followed by colonoscopy, would be more expensive.

Dr. Ransohoff suggests that it might be wise to tailor colorectal cancer screening strategies to individual risk.  He writes,

Implementation of a tailored approach, by adjusting intensity of screening or surveillance to a person’s risk, requires consideration of three points: the individual’s absolute risk of colorectal cancer; the degree to which each screening or surveillance strategy reduces that risk; and quantitative definition of the goals of screening—ie, what level of absolute risk is high enough to justify the effort of reduction. By contrast, a one-size-fits-all approach to screening and surveillance may be easier to implement but less efficient. And in some cases—for example, when people with very low risk of subsequent colorectal cancer undergo potentially hazardous surveillance procedures such as colonoscopy—such an approach may even be harmful.  A tailored approach, based on a quantitative definition of the goals of screening and surveillance, deserves increased consideration.

SOURCES:  Atkins et al., The Lancet, Early Online Publication, April 28, 2010.

Ransohoff, The Lancet, Volume 359, Number 9314, April 2002

Atkins et al., The Lancet, Volume 359, Number 9314, April 2002.

Interviews with Dr. Atkins and Jane Wardle, PhD from the trial and Dr. Jennifer Obel, speaking for the American Society of Clinical Oncology, done by MedPage Today are below:

Nearly half of the cancers found during screening were stage I (Dukes A), while previously only 1 in 10 were diagnosed at that earliest stage.

However, in another analysis of the pilot NHS NBCSP efforts, a significant percentage of patients who had cancer found on screening, believed to be without symptoms of colon or rectal cancer, recognized and reported symptoms when asked before their follow-up colonoscopies.

As part of the national bowel cancer screening program that began in England in 2006, the Wolverhampton Bowel Cancer Screening Centre sent over 108,000 fecal occult blood test (FOBT) kits to everyone in their target area between ages 60 and 69.  About half (51.6 percent) were returned .

As a result 1,039 colonoscopies were performed and 106 cancers discovered.

A research team compared the cancers found during screening to a control group of 256 colorectal cancers diagnosed without screening.  They found:

• Stage 1 (Dukes A): 45.6 percent with screening, 10.1 percent in control group before screening
• Stage II (Dukes B): 29.7 percent with screening, 50 percent in controls
• Stage III (Dukes C): 29.2 percent with screening, 36.3 percent in controls
• Stage IV (Dukes D): 3.8 percent with screening, 3.5 percent in controls

P. Ellu and the team from the Wolverhampton screening program concluded,

The 2-year data from the first English centre to start bowel cancer screening demonstrates significant downstaging of cancer, consistent with both the random controlled trial and pilot data.

Although initial results of the National Health Service National Bowel Cancer Screening Programme showed success in finding cancer earlier, an analysis of the NHS NBSCP pilot projects found that as many as 8 in 10 patients diagnosed with colorectal cancer through the screening program were already experiencing symptoms.

The pilot screening found 200 cancers:  28.5% were stage I,  35% stage II, 36.5 stage III.

Given a questionnaire about potential symptoms of colorectal cancer before their colonoscopies, some 81.5% reported experiencing gastrointestinal problems including:

• rectal bleeding in 47.7 percent
• change in bowel habits in 24 percent
• a feeling of difficulty during bowel movements in 36.5 percent
• peri-anal discomfort in 15.5 percent
• urgency in 25 percent,
• abdominal pain in 20,5 percent
• upper GI symptoms in 29 percent

In discussing the results  C. Harmston and the team wrote,

This data suggests a high prevalence of significant symptoms amongst patients with screening-detected CRC. It is possible that these patients would have presented via routine colorectal services if the awareness of symptoms of colorectal cancer were increased.

SOURCES:

Ellu et al., Colorectal Disease, Volume 12, Issue 5, pages 420-422, May 2010.

Harmston et al.,Colorectal Disease, Volume 12, Issue 5, pages 416-419, May 2010.

Whether this is because of different biology or lack of access to high-quality medical care has long been debated.

In a new study, blacks had very similar rates of polyps found during a screening flexible sigmoidoscopy.  But they were less likely to get a recommended follow-up colonoscopy.

While about 1 in 4 people had polyps discovered during their sigmoidoscopy, nearly identical percentages for blacks and whites, blacks got colonoscopy follow-up about 12 percent less often than whites.

For those who did get a colonoscopy, adenomas and advanced adenomas were just as likely in whites and blacks, as was the rate of cancers discovered.

The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial screened 60,572 people for colorectal cancer using flexible sigmoidoscopy.  Doctors recommended those who had abnormalities discovered during the screening test have a colonoscopy.  However, the trial did not pay for the follow-up exam.

Analysis of the PLCO trial found,

• 23.9 percent of whites had abnormalities found during flexible sigmoidoscopy compared to 25.5 percent of blacks, which was an insignificant difference.
• 72.4 percent of whites got a diagnostic colonoscopy compared to 62.6 percent of blacks
• During colonoscopy, 23.1 percent of blacks and 22.5 percent of whites had an advanced adenoma found.
• Nearly identical percentages had cancer discovered (2.1 percent of blacks and 1.5 percent of whites).
• Advanced adenomas were more frequently found on the right side of the colon in blacks (8.5 percent) than in whites (5.5 percent) suggesting that full colonoscopy that reaches the right side of the colon may be particularly important in screening African Americans.

Lead author Adeyinka O. Laiyemo, MD, MPH, from Howard University School of Medicine, and colleagues concluded,

We observed a lower follow-up for screen-detected abnormalities among blacks when compared with whites but little difference in the yield of colorectal neoplasia. Health-care utilization may be playing more of a role in colorectal cancer racial disparity than biology.

The study did not look at reasons that African Americans were less likely to get follow-up colonoscopies.  However, in an editorial accompanying the study results in the Journal of the National Cancer Institute, John Z. Ayanian, MD, MPP, from the Department of Health Care Policy discussed some potential barriers to follow-up care.

He pointed out that other research has shown:

• Blacks are less likely to have a primary care physician.
• They live more often in low-income communities with limited access to gastroenterologists.
• They may lack insurance that covers colonoscopy.
• They may not be able to afford out-of-pocket costs for colonoscopy not covered by insurance.

The barriers concerned Dr. Ayanian, who wrote,

These gaps in follow-up care were particularly concerning because up to one-quarter of participants who did not undergo colonoscopy were likely to have advanced adenomas that were neither detected nor removed. Valuable opportunities to prevent colorectal cancer were thus lost in these patients.

He called for programs like that in New York City which increased colonoscopy screening rates for black adults from 35 percent to 64 percent in four years to be expanded to other communities.  The program in New York uses public education, improved tracking systems, and patient navigators to get low-income people to screening.  He also cited the expanded Centers for Disease Control and Prevention program that will promote colorectal cancer screening for low-income Americans in 22 states and four tribal organizations.

He said,

Colorectal cancer is one important disease in which racial and socioeconomic disparities in outcomes can most readily be eliminated by ensuring that all eligible adults are effectively screened and abnormal findings are fully treated.

SOURCES:

Laiyemo et al., Journal of the National Cancer Institute, Advance Access, March 31, 2010.

John Z. Ayanian, Racial Disparities in Outcomes of Colorectal Cancer Screening: Biology or Barriers to Optimal Care?, Journal of the National Cancer Institute, Advance Access, March 31, 2010.

Click on Peter's face to hear the song.

Listen to folk singer Peter Yarrow, of Peter, Paul & Mary, sing the Colonoscopy Song.

Yarrow and CBS teamed up to deliver the message that getting a regular colonoscopy saves lives.

Although they “found a polyp hiding, they caught it just in time.”

CSI:NY actor Hill Harper urges screening for colorectal cancer in a new PSA from the American Society for Gastrointestinal Endoscopy (ASGE).

Guidelines suggest that those at average risk begin screening at age 50, however, some studies have shown that African-Americans are more frequently diagnosed with colon cancer at a younger age, leading some experts to suggest that African-Americans should begin screening at age 45.

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.