Implementing COLORECTAL CANCER Screening

WORKSHOP SUMMARY

Margie Patlak, Christine Micheel, and Robert German, Rapporteurs

National Cancer Policy Forum

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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Implementing COLORECTAL CANCER Screening WORKSHOP SUMMARY Margie Patlak, Christine Micheel, and Robert German, Rapporteurs National Cancer Policy Forum

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Gov- erning Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engi- neering, and the Institute of Medicine. This study was supported by Contract Nos. HHSN261200611002C, 200-2005- 13434 TO #1, HHSP233200700373P, and 223-01-2460 TO #27, between the National Academy of Sciences and the National Cancer Institute, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, and the Food and Drug Administration, respectively. This study was also supported by the American Cancer Society, the American Society for Clinical Oncology, C-Change, and the Association of American Cancer Institutes. Any opinions, find- ings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agen- cies that provided support for this project. International Standard Book Number-13: 978-0-309-12139-2 International Standard Book Number-10: 0-309-12139-6 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: http://www.iom.edu. Copyright 2008 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2008. Implementing colorectal cancer screening: Workshop summary. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal govern- ment on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its mem- bers, sharing with the National Academy of Sciences the responsibility for advis- ing the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in pro- viding services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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WORKSHOP PLANNING COMMITTEE1 RALPH COATES, Ph.D. (Chair), Associate Director for Science in the National Office of Public Health Genomics at the Centers for Disease Control and Prevention MARY BARTON, M.D., M.P.P., Scientific Director of the United States Preventive Services Task Force, Agency for Healthcare Research and Quality TOM KEAN, M.P.H., Executive Director, C-Change WILLIAM LAWRENCE, M.D., M.S., Senior Service Fellow in Outcomes Research, Center for Outcomes and Evidence, Agency for Healthcare Research and Quality SCOTT RAMSEY, M.D., Ph.D., Full Member, Fred Hutchinson Cancer Research Center LAURA SEEFF, M.D., Associate Director for the Office of Colorectal Cancer Programs in the Centers for Disease Control and Prevention’s Division of Cancer Prevention and Control ED WAGNER, M.D., M.P.H., Director, MacColl Institute and Senior Investigator, Group Health Center for Health Studies Project Staff ROGER HERDMAN, M.D., Study Director and Director, National Cancer Policy Forum and Board on Health Care Services LAURA LEvIT, J.D., Senior Program Associate CHRISTINE MICHEEL, Ph.D., Program Officer MICHAEL PARK, Senior Program Assistant 1 Institute of Medicine planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. 

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NATIONAL CANCER POLICY FORUM1 HAL MOSES, M.D. (Chair), Director Emeritus, Vanderbilt-Ingram Cancer Center PETER B. BACH, M.D., M.A.P.P., Associate Attending Physician, Memorial Sloan-Kettering Cancer Center EDWARD BENZ, Jr., M.D., President, Dana Farber Cancer Institute and Director, Harvard Cancer Center, Harvard School of Medicine THOMAS G. BURISH, Ph.D., Past-Chair, American Cancer Society Board of Directors and Provost, Notre Dame University BETTY R. FERRELL, Ph.D., R.N., F.A.A.N., Research Scientist, City of Hope National Medical Center JOSEPH F. FRAUMENI, Jr., M.D., Director, Division of Cancer Epidemiology and Genetics, National Cancer Institute STEPHEN H. FRIEND, M.D., Ph.D., Executive Vice President, Oncology, Merck & Co., Inc. PATRICIA A. GANZ, M.D., Professor, University of California, Los Angeles Schools of Medicine and Public Health, Division of Cancer Prevention & Control Research, Jonnson Comprehensive Cancer Center ROBERT R. GERMAN, Dr.P.H., M.P.H., Associate Director for Science (Acting), Division of Cancer Prevention and Control, Centers for Disease Control and Prevention ROY S. HERBST, M.D., Ph.D., Chief, Thoracic/Head and Neck, Medical Oncology, M.D. Anderson Cancer Center THOMAS J. KEAN, M.P.H., Executive Director, C-Change WILLIAM LAWRENCE, M.D., M.S., Senior Service Fellow in Outcomes Research, Agency for Healthcare Research and Quality LYNN M. MATRISIAN, Ph.D., Chair, Department of Cancer Biology, Vanderbilt University Medical Center JOHN E. NIEDERHUBER, M.D., Director, National Cancer Institute DAvID R. PARKINSON, M.D., President and CEO, Nodality, Inc. EDITH A. PEREZ, M.D., Director, Clinical Investigation and Breast Cancer Program, Mayo Clinic SCOTT RAMSEY, M.D., Ph.D., Full Member, Cancer Prevention Program, Fred Hutchinson Cancer Research Center MARGARET R. SPITZ, M.D., Chair, Epidemiology, M.D. Anderson Cancer Center 1 Institute of Medicine forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the work- shop rapporteurs and the institution. i

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ELLEN STOvALL, President and CEO, National Coalition for Cancer Survivorship JANET WOODCOCK, M.D., Deputy Commissioner and Chief Medical Officer, Food and Drug Administration Staff ROGER HERDMAN, M.D., Director, National Cancer Policy Forum and Board on Health Care Services SHARYL NASS, Ph.D., Senior Program Officer CHRISTINE MICHEEL, Ph.D., Program Officer LAURA LEvIT, J.D., Senior Program Associate ERIN BALOGH, M.P.H., Research Associate MICHAEL PARK, Senior Program Assistant ASHLEY McWILLIAMS, Senior Program Assistant ADAM SCHICKEDANZ, Intern SHARON MURPHY, M.D., Scholar in Residence ii

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its pub- lished report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: George Isham, HealthPartners, Inc. Thomas J. Kean, C-Change Laura Seeff, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention Robert A. Smith, American Cancer Society Judith L. Wagner, Independent Consultant, Bethesda, Maryland Although the reviewers listed above have provided many construc- tive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was over- seen by Dr. Melvin Worth. Appointed by the Institute of Medicine, they ix

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x REVIEWERS were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authors and the institution.

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Contents Introduction 1 Moving Evidence-Based Recommendations into Practice 2 Natural History and Epidemiology 5 Effectiveness of Colorectal Cancer Screening 10 Screening Strategies 15 Effectiveness of Community- and Office-Based Interventions 19 Overcoming Barriers to Screening 26 Public and Patient Interventions to Implement Screening 31 Primary Care Practice Interventions to Implement Screening 36 Gastrointestinal Specialty Practice Concerns 40 State and Federal Initiatives to Boost Colorectal Cancer Screening 44 Colorado Screening Initiatives 44 Nebraska Screening Initiatives 47 Population-Based Federal Screening Initiatives 50 Employer-Based Initiatives to Increase Screening 53 Strategies to Monitor Performance 56 Interventions to Address Costs of Developing and Maintaining Screening Programs 59 Colorectal Cancer Screening in Primary Care 59 Cost Considerations in Medical Practice 62 Costs of Developing and Maintaining Public Health Colorectal Cancer Screening Programs 66 xi

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xii CONTENTS General Discussion and Wrap-up 69 Screening Implementation 71 Communications 73 Costs and Coverage 75 Primary Care System 76 Final Words 78 Acronyms 79 Glossary 81 References 86 Appendix A Workshop Agenda 97 Appendix B Workshop Speakers 100 Appendix C Epidemiology of Colorectal Cancer and Colorectal Cancer Screening: A Background Paper 101 Appendix D The Medical Home 111