Seniors’ access to a screening colonoscopy is at risk and YOU can help!

We need you to continue to add your voice and urge your Representative to support H.R. 4120! Simply submit an Action Alert.

H.R. 4120, the Removing Barriers to Colorectal Cancer Screening Act of 2012, will fix a regulation that requires Medicare beneficiaries to pay coinsurance when their screening colonoscopy involves the removal of a polyp. The current policy can cost patients $100 to $300 and serve as a deterrent to screening.

We need cosponsors for this legislation if it is to pass into law & YOU can help!

 Time to catch up on some colorectal cancer news that we might have missed.

In Nutshell News: Virtual colonoscopy works just as well for over 65′s, over-the-counter and prescription stomach acid is connected to c. difficile diarrhea, and the recession cut into colorectal cancer screening among people with health insurance.

Older adults benefit from CT Colonography

CT colonography, so-called virtual colonoscopy, uses x-ray images to look into the colon. In the National CT Colonoscopy trial it was was as good at finding large polyps and cancers as optical colonoscopy.  However, the Centers for Medicare and Medicaid Services (CMS) doesn’t cover the test, citing lack of evidence that it works for older adults.

Analyzing people 65 and older enrolled in the National Trial, researchers at the Mayo Clinic in Arizona found no significant differences between Medicare-aged people and younger participants.  CT colonoscopy was able to find large adenomas and cancers at nearly the same rate in  older and younger trial enrollees. There was also a very small difference between intermediate size polyps over 6 mm.

As might be expected, older adults had more polyps. About 7 out of 100 (6.9%) had large polyps or cancer compared to 4  out of 100 (3.7%) younger people.

C. Daniel Johnson and his team concluded,

For most measures of diagnostic performance and in most subsets, the difference between senior-aged participants and those younger than 65 years was not statistically significant.

FDA Warning: Stomach Acid Drugs Linked to C. Diff Infections

The FDA has warned proton pump inhibitors (PPIs) are associated with Clostridium difficile (C. difficile) diarrhea (CDAD). The warning includes both prescription and over-the-counter medicines to treat frequent heartburn and medical conditions including as gastroesophageal reflux disease (GERD), stomach and small intestine ulcers, and inflammation of the esophagus.

The FDA recommends that patients who are taking a PPI and develop diarrhea that doesn’t improve contact their healthcare professional.

Healthcare professionals are told:

• A diagnosis of CDAD should be considered for PPI users with diarrhea that does not improve.
• Advise patients to seek immediate care from a healthcare professional if they experience watery stool that does not go away, abdominal pain, and fever while taking PPIs.
• Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated.

Over-the-counter PPIs include Prevacid (lansoprazole), Prevacid 24hr, Prilosec (omeprazole), and Zegerid.

Additional prescription medicines are AcipHex (rabeprazole), Dexilant (dexlansoprazole), Nexium (esomeprazole), and Vimovo (esomeprazole and naproxen).

Recession Reduced Screening Colonoscopies for Insured

During the recent economic recession in the US, there were half a million fewer screening colonoscopies for patients with health insurance aged 50 to 64.  The need to share costs through deductibles and copays appears to be part of the reason.

From December 2007 through November 2009, 500,000 fewer screening colonoscopies were done for patients with commercial insurance compared to the previous two years. Health plans with out-of-pocket costs over $300 had lower screening rates both before and during the recession. The recession had a smaller impact on plans with the lowest out-of-pocket requirements.

Reporting their analysis of reports from 106 health plans, Spencer Dorn, MD, MPH, and his team at the University of North Carolina wrote,

Policies to reduce cost sharing could increase adherence to recommended preventive services such as colonoscopy examinations.

Fight Colorectal Cancer is supporting the Removing Barriers to Colorectal Cancer Screening Act of 2012 (H.R. 4120) which would change Medicare law so that seniors wouldn’t face additional copayments when polyps were removed during a screening colonoscopy.

Representative Charlie Dent

Legislation was introduced in Congress today that will correct an oversight to the Affordable Care Act (ACA) that requires Medicare beneficiaries to pay coinsurance when their screening colonoscopy also involves the removal of a polyp or cancer. When a screening colonoscopy turns therapeutic, the cost to the Medicare patient is significant – $100 to $300 – and it could serve as a deterrent to screening.

The legislation, Removing Barriers to Colorectal Cancer Screening Act of 2012 (H.R. 4120), was introduced by Rep. Charlie Dent of Pennsylvania.

The ACA waived the coinsurance and deductible for covered preventive services that have an “A” or “B” rating from the U.S. Preventive Services Task Force (USPSTF), effective 2011. Colonoscopy, sigmoidoscopy, and fecal occult blood testing (FOBT) all have “A” ratings for adults aged 50 to 75. Unfortunately, the ACA did not waive Medicare beneficiary coinsurance when a colonoscopy turns therapeutic; an oversight that requires legislative correction.

“Fight Colorectal Cancer applauds Rep. Dent for introducing this legislation,” stated Carlea Bauman, Fight Colorectal Cancer’s President. “It is appropriate that this bill is introduced today, the first day of Colorectal Cancer Awareness Month. It is our belief that closing this gap in Medicare benefits will help save lives by keeping colonoscopies affordable and accessible for seniors.”

The median age for diagnosis of colorectal cancer is 71, and the risk for getting the disease increases with age.

In a nutshell:

A brief look this week at

• Blood sugar and colorectal cancer risk
• Outcomes for people with defective mismatch repair on oxaliplatin
• Medicare’s preventive services

High blood sugar readings increase colon cancer risk

Scientists at Albert Einstein College of Medicine, analyzed blood samples from 4,902 postmenopausal women in the NIH Women’s Health Initiative study. Both blood glucose and blood insulin levels were measured when women entered the study.

After 12 years, 81 women had been diagnosed with colorectal cancer. Women who had the highest levels of glucose in their blood at the beginning of the study were twice as likely to have colon or rectal cancer than those with the lowest readings.  Surprisely, initial circulating insulin levels made no difference.

In a news release from Albert Einstein College of Medicine, study author Geoffrey Kabat, Ph.D., a senior epidemiologist at Einstein, said,

The next challenge is to find the mechanism by which chronically elevated blood glucose levels may lead to colorectal cancer. It’s possible that elevated glucose levels are linked to increased blood levels of growth factors and inflammatory factors that spur the growth of intestinal polyps, some of which later develop into cancer.

SOURCE:  Kabat et al., British Journal of Cancer, advance online publication, November 29 2011.

Disease-free survival significantly higher for patients with defective mismatch repair (dMMR) on FOLFOX

Scientists reviewed clinical and tissue information from 303 stage III colon cancer patients who were treated with FOLFOX after surgery in 9 French hospitals over a 5 year period.

About 1 in 10 (11.2%) had tumors with defective mismatch repair (dMMR) discovered either by analyzing markers for microsatellite instability or immunohistochemistry for missing proteins involved in dMMR.

Three years after surgery 90.5% of dMMR patients were alive and cancer-free compared to 73.8% of patients with proficient mismatch repair.

Aziz Zaanan and his colleagues concluded,

Mismatch repair status is an independent prognostic biomarker for disease-free survival in patients with stage III colon cancer receiving adjuvant FOLFOX chemotherapy.

SOURCE: Zaanan et al, Clinical Cancer Research, Volume 17, Number 23, December 1, 2011.

Are you are Medicare?  Preventive services are now free.

Medicare now covers a whole list of preventive services, including colorectal cancer screening and an annual Wellness Visit to your doctor without deductibles or co-payments.

Here’s a helpful booklet from Medicare that explains your benefits: Your Guide to Medicare’s Preventive Services.

Obese people on Medicare  now have the opportunity to have regular weight loss counseling paid for when offered by a primary care provider.  Since this is considered prevention, there is no co-pay.

On November 29, the Centers for Medicare and Medicaid Services announced that there was enough evidence that intensive behavioral counseling was reasonable and necessary to prevent disease or disability and that Medicare beneficiaries were entitled to coverage as a preventive service.

This is particularly good news for people trying to prevent colon or rectal cancer since studies have consistently found a link between body mass index (fatness) and colorectal cancer, including the World  Cancer Research Foundation which included BMI and colorectal cancer in their 2007 comprehensive analysis reported in  Food, Nutrition, Physical Activity and the Prevention of Cancer.

This year the WCRF updated their analysis for colorectal cancer looking at new studies published since 2007 as part of the Continuous Update Project.  They wrote,

The CUP Panel agreed that the recent evidence was consistent with the conclusion of the Second Expert Report; the evidence that greater body fatness is a cause of colorectal cancer is convincing.

With the latest CMS coverage decision, Medicare patients with a BMI of 30 or over  can get:

• One face-to-face visit every week for the first month
• One face-to-face visit every other week for months 2-6
• One face-to-face visit every month for months 7-12, if the individual has lost at least 6.6 pounds.

The benefit is limited to counseling delivered in primary care settings by primary care doctors or primary care nurse practitioners, clinical nurse specialists, or physician assistants.

Benefits are also provided for screening to determine BMI and nutritional assessment.

CMS defines intensive behavioral counseling as providing the 5-As:

• Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
• Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
• Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
• Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
• Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

CMS estimates that 1 in 3 people receiving Medicare are obese.

Patrick Conway, MD, MSc, CMS Chief Medical Officer and Director of the Agency’s Office of Clinical Standards and Quality said,

This decision is an important step in aligning Medicare’s portfolio of preventive services with evidence and addressing risk factors for disease. We at CMS are carefully and systematically reviewing the best available medical evidence to identify those preventive services that can keep Medicare beneficiaries as healthy as possible for as long as possible.

Body Mass Index (BMI) is calculated using weight and height. It doesn’t measure “fatness” directly but correlates well to overall amount of body fat. You can use this CDC calculator to find out your own BMI.

After a normal colonoscopy when no polyps are found, guidelines call for a repeat test in 10 years.

However, almost half of Medicare patients with a negative colonoscopy got another exam within 7 years, and for one in four there was no clear evidence that they needed one.

Because colonoscopies have real risks and are expensive, over-testing can be both dangerous and costly. Given limited numbers of physicians who do colonoscopies, unecessary procedures add to long waiting lists for screening and for necessary follow-up exams.

Although Medicare regulations call for reimbursement only after 10 years in cases where the first procedure didn’t find a problem, payments are being made for earlier exams.  In fact, Medicare denied payment for only 2 percent of colonoscopies for which there was no clear indication of need.

Researchers at the University of Texas in Galveston reviewed a representative sample of Medicare claims for a  colonoscopy between 2001 and 2003.  Since they were looking for average risk patients who had a negative screening colonoscopy, they filtered out any tests that included removing a polyp or a biopsy or other procedure done during the exam.  They also removed any colonoscopies that included a diagnosis such as bleeding or pain and any that were done for patients who had a Medicare claim in the previous 3 months that included a diagnosis or symptoms of colorectal disease that might have indicated need for a  diagnostic colonoscopy.

In their sample of 5% of the Medicare population:

• 236,145 Medicare patients 66 and older had a colonoscopy in 2001-2003.
• 114,468 had an negative exam with no polyps removed, no biopsies or other procedure.
• 24,071 had a negative screening colonoscopy after all possible medical reasons for doing the test were eliminated.

The research team then looked for repeated colonoscopies within 5 and 7 years of the first test.  Again they eliminated any exams for which a diagnosis or other Medicare claims indicated a good reason to repeat the test.  If they couldn’t find a reason, they classified the colonoscopy as repeated with no clear indication.

In their sample of 24,071 who had a completely negative screening colonoscopy between 2001 and 2003,  8,608 had another colonoscopy within 7 years, and for 3,656 no reason other than routine screening could be found for doing the test.

However, only 86 patients (2 percent) actually had payment denied by Medicare.

Although the US Preventive Services Task Force recommends against routine screening for people between age 75 and 84 and against any screening for those over 85, one third of patients who were 80 or older at their initial negative screening colonoscopy had another exam within 7 years.

The study authors pointed out,

This is of special concern, given the increased potential for complications and decreased benefit of this examination in the very old.

Repeating a colonoscopy early after a negative exam was more likely to occur when:

• Endoscopist doing the first colonoscopy did more than 1,200 procedures a year.
• Exam took place in a doctor’s office rather than hospital or ambulatory surgical center.
• Patients were male.
• Exam took place in the Middle Atlantic or North Central regions of the United States.
• Patients had less than a high school education.

For average risk patients without a family history of inherited colorectal cancer, the natural development of cancer from even quite large polyps is slow.  Before the era of colonoscopy, doctors at the Mayo Clinic followed 226 patients who had barium enemas with advanced adenomas (over 1 cm) for 5, 10, and even 20 years.  During that time only 2.5% became cancer at 5 years and 8% at 10 years.  Seven out of ten cancers were found at an early stage before spreading to lymph nodes or distant sites.

After analyzing their results, James Goodwin, MD, and his colleagues at the University of Texas concluded,

A large proportion of Medicare patients who undergo screening colonoscopy do so more frequently than recommended. Current Medicare regulations intending to limit reimbursement for screening colonoscopy to every 10 years would not appear to be effective.

SOURCE:  Goodman et al., Archives of Internal Medicine, online first May 9, 2011.

What This Means for Patients

Although the research was done in Medicare patients over 65, there is no reason to believe that younger patients are not also being screened more often than guidelines call for for.

• After your screening colonoscopy, be sure that you have a copy of the the results that describe if adenomas (polyps) were found and what their size and description was. If you don’t understand the report, ask your doctor to explain it.
• Check to see if the recommendation for the next screening exam fits within the guidelines for colorectal cancer screening.  If the return recommendation is sooner that guidelines call for, ask why!

For people at average risk of colorectal cancer, colonoscopy screening is recommended beginning at age 50 and then every 10 years unless adenomas or cancer are found.

The US Preventive Services Task Force says that elderly people between 75 and 84 should not be routinely screened for colorectal cancer and those over 85 should not be screened at all.  If your older relative is getting colonoscopy recommendation that don’t fit the guidelines, ask why. They are at higher risk for complications from the procedure and may well not benefit from screening.

But remember:

• Symptoms of colorectal cancer at any time – even after a negative screening colonoscopy — and at any age call for diagnostic colonoscopy.
• People with a family history of colorectal cancer or a personal medical history of cancer, adenomas, or inflammatory bowel disease (ulcerative colitis or Crohn’s disease) are not at average risk. They should follow screening and surveillance programs for increased and high risk, including beginning earlier than 50 and being screened more often.

Colorectal cancer screening programs targeted at the pre-Medicare population (ages 54-64) could pay for themselves in avoided future Medicare expenditures, according to a study released last week at the American College of Gastroenterology’s annual meeting.

Using a computer simulation program, researchers estimated the total lifetime costs for screening and any subsequent treatment of colorectal cancer in people over age 50, using three different kinds of testing (fecal occult blood test, or FOBT; a mix of FOBT and colonoscopy; or colonoscopy alone).

“With rising chemotherapy costs and aging of the population, the Medicare program will face increased costs” in caring for colorectal cancer, said researcher Luuk Goede, MD. His study was aimed at predicting the cost impact of different types of screening in the pre-Medicare population.

The results predicted that total screening costs for the pre-Medicare age group would increase (about 8 percent for FOBT testing; 12.6 percent for the FOBT/colonoscopy program; and almost 14 percent for colonoscopy screening). But if total screening and treatment costs were tracked after the population aged into Medicare, “treatment savings in the older age group fully offset the increased costs in the younger group” for all types of screening, according to Dr. Goede.

What This Means for Patients:

This type of population-based estimate of future costs helps focus public expenditures for screening. But the message for individuals remains the same: Don’t wait until you go on Medicare. Start routine screening for colorectal cancer by age 50 for those with average risk. Legislation in Congress would create a National Colorectal Cancer Screening Program. Urge your Members of Congress to support this lifesaving program.

Source: Medical News Today, Oct 19, 2010

Previously: Colorectal Cancer Screening Before 65 Could Save Medicare Dollars, October 6, 2008

This week the federal government began mailing $250 checks to Medicare Part D enrollees who have reached the doughnut hole where Part D no longer covers prescription drugs.

These checks are sent automatically to seniors when 2010 prescription costs reach the coverage gap.

It is not necessary to apply for the check!

But scam artists are already at work, contacting  seniors and other Medicare beneficiaries asking for social security numbers, bank accounts, and pretending to help them apply for the $250 rebates.

The Centers for Medicare and Medicaid Services has begun a national education campaign to help consumers protect themselves against rebate check fraud.  It includes radio, television, and print advertising along with outreach efforts.

CMS Acting Administrator Marilynn Tavenner told the press,

Since early April, we have learned of seniors across the country who are being asked for personal information to help them get a rebate check,” Beneficiaries who reach the donut hole will get a check mailed to the same address Medicare uses to send them information now without doing anything special. Seniors should be on the look-out for scams where people they don’t know ask them for their personal information in order to get their checks. This is not how the process will work. Checks will come directly to beneficiaries who qualify for this benefit under the Affordable Care Act. Seniors or family members should contact us at 1-800-MEDICARE to report any of these types of calls or go to www.stopmedicarefraud.gov to learn more about efforts to fight scams like these.

Rebate checks are part of the Affordable Care Act which will continue to provide discounts for prescription drugs until the coverage gap is finally closed in 2020.

If someone acts you for personal information over the phone, especially if they ask for social security numbers or bank accounts, HANG UP.

And then let Medicare know.

Although Medicare pays for colorectal cancer screening, not all older people enrolled in Medicare are screened.

Reviewing published medical literature, a task group from the National Colorectal Cancer Roundtable found research identifying both barriers to screening and factors that made it easier.

The most frequently mentioned barrier related to healthcare providers was lack of a doctor’s recommendation.  Having a usual source of health care facilitated getting screened.

Other barriers included:

• Low level of education
• African American race
• Hispanic ethnicity
• female gender

Being married or living with a partner was the most frequent personal faciliator.

Lack of health insurance or dual coverage with Medicare and Medicaid were most frequently reported insurance barriers to getting screened, while Medicare coverage was consistently reported as facilitating it.

Idris Guessous led the study team from the National Colorectal Cancer Roundtable Screening Among the 65 Plus Task Group.

SOURCE: Guessous et al., Preventive Medicine, Volume 50, Issues 1-2, pages 3-10, January-February 2010.

Briefly

• The Colorectal Cancer Association of Canada is sponsoring a contest for print and video ads that raise awareness of colorectal cancer.
• Clinical trials at the NIH Clinical Center in Bethesda, MD are an option for cutting-edge treatment at no cost.
• When co-pays are raised for Medicare, the elderly make fewer outpatient visits but are hospitalized more often and stay in the hospital longer.

Raise CRC awareness with an ad or video and win!

Your print or video public service announcement to raise awareness of colorectal cancer and its prevention could be a winner.

The Colorectal Cancer Association of Canada will award $2,500 for the best video and $1,000 for the best print ad that reduces colorectal cancer by encouraging:

• Prevention= health lifestyles, diet and exercise, screening
• Awareness= signs, symptoms, stats
• Education= knowledge about treatments
• Support= cancer coaching and psychosocial aspects
• Advocacy = access to diagnostics and medicine

Entries must be submitted online and be received by March 31, 2010.

Cancer clinical trials at the National Institutes of Health in Bethesda

The National Cancer Institute Center for Cancer Research in Bethesda, MD, just outside of Washington D.C., conducts cancer clinical trials, including trials for colon and rectal cancer.

There is no cost to participate in a clinical trial at the NIH Clinical Center.  In addition, transportation expenses are paid and there is a per diem to cover meals and lodging for outpatients.

Higher co-pays for Medicare end up costing more

When Medicare co-pays are raised for ambulatory visits, plan members make fewer out-patient visits, but are hospitalized more often and for more days.

In plans that raised co-pays, there were 20 fewer out-patient visits per 100 enrollees each year, but 2 more hospitalizations and 13 more days in the hospital compared to plans that kept co-pays stable.

For every 100 patients in plans that raised co-pays, the plan got $5,950 in extra money from co-pays and saved $1,200 from fewer outpatient visits for a net savings to the insurance plan of $7,150.  However, with an average cost of $11,o65 for each hospitalization of a patient 65 to 84, the increase in hospitalization cost $24,000 for each 100 plan enrollees.

Increased co-pays hit low-income, black, and less-educated patients particularly hard, decreasing numbers of visits and increasing hospitalizations.

Writing in the January 28, 2010 issue of the New England Journal of Medicine, lead author Amal N. Trivedi, MD, MPH and team concluded,

Increasing copayments for ambulatory care reduced the use of outpatient care among elderly enrollees in managed-care plans, but this decline was offset by an increase in hospitalizations, particularly among enrollees with low socioeconomic status and those with chronic disease. Increasing copayments for ambulatory care among elderly patients may have adverse health consequences and may increase spending for health care