Implementing Colorectal Cancer Screening Workshop Summary (2008) / Chapter Skim
Currently Skimming:
Implementing Colorectal Cancer Screening: Workshop Summary
Implementing Colorectal Cancer Screening: Workshop Summary
Pages 1-78
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 1... ...
To maximize the impact of such a discussion, the NCPF chose to focus on colorectal cancer screening. Despite the strong evidence that screening is effective in preventing deaths and that there are effective health systems and community interventions to increase screening, use of colorectal cancer screening remains low.
|
From page 2... ...
Yet colorectal cancer screening rates remain relatively low in the United States. Encouraged by the Centers for Disease Control and Prevention (CDC) to recognize the need to make colorectal cancer screening more widespread, the NCPF convened the workshop "Implementing Colorectal Cancer Screening," which was held February 25 and 26, 2008, in Washington, DC.
|
From page 3... ...
and the CDC added later, both agencies recently prioritized clinical preventive services. Colorectal cancer screening was ranked number four on the list of all preventive services, and number two for the screening services, mainly because of the preventable disease burden linked to such screening, and the fact that optimal colon cancer prevention is not being achieved with current levels of screening (Maciosek et al., 2006)
|
From page 4... ...
Coates said. This seems to be especially true for colorectal cancer screening, Dr.
|
From page 5... ...
Coates noted. But recognizing that the health care delivery system does not operate in isolation, the workshop planners also aimed to gather expert advice on ways that other sectors of society, such as employers, health insurers, and state and federal public health agencies, have fostered successful implementation of colorectal cancer screening.
|
From page 6... ...
As he noted, it is now well known that colorectal cancers begin as adenomas that may progress to invasive cancer over 5 to 15 years (Rozen et al., 2002)
|
From page 7... ...
. Consequently, colon cancer screening strategies cannot be directed solely to high-risk patients, Dr.
|
From page 8... ...
TABLE 1 Stage at Diagnosis Improving Over Time 1975–1979 1985–1989 1996–2003 All White Black All White Black All White Black Percent localized 33% 33% 30% 38% 38% 33% 40% 40% 35% Percent regional 37% 37% 35% 37% 37% 36% 37% 37% 35% Percent distant 22% 22% 26% 19% 19% 24% 19% 18% 24% Percent unstaged 8% 8% 9% 6% 6% 7% 4% 4% 6% SOURCE: Levin presentation (February 25, 2008)
|
From page 9... ...
Dr. Pignone stressed that there is nearly a 30 percentage point difference in colorectal cancer screening rates between those who are insured and those who lack insurance, recent data show (Meissner et al., 2006)
|
From page 10... ...
Whitlock and her colleagues conducted focused on assessing the following factors: • ortality impact of colorectal cancer screening; M • ffectiveness of optical colonoscopy and flexible sigmoidoscopy in E community practice; • fficacy of newer screening technologies such as high-sensitivity E FOBTs (Hemoccult SENSA) , fecal immunochemical tests (FITs)
|
From page 11... ...
One review published after 2002 found that biennial FOBT was linked to a 15 percent reduction in colorectal cancer mortality in four randomized controlled trials (Kerr et al., 2007) , but there was no additional evidence since the previous recommendation on the effects of other fecal screening tests, flexible sigmoidoscopy, optical colonoscopy, or CT colonography on mortality, Dr.
|
From page 12... ...
Both the Hemoccult SENSA FOBT (Beckman Coulter, Fullerton, CA) and the PreGen Plus fecal DNA test (EXACT Sciences, Marlborough, MA)
|
From page 13... ...
PreGen Plus (Reference) N 13,945 2,507 Sensitivity for CRC 64.3a–79.4% 37.1% 51.6% 12.9% Specificity for CRC 86.7–90.1a% 97.7% 92.4b% 95.2b% Test positives 10.1a–13.6% 2.5% 8.2% 5.8% NOTES: CRC = colorectal cancer, FOBT = fecal occult blood test, Hemoccult II = Hemoccult II FOBT from Beckman Coulter (Fullerton, CA; see http://www.hemoccultfobt.com/)
|
From page 14... ...
FlexSure MonoHaem OC–Hemodia N 26,335 37,330 5,841 7,976 35,351 Sensitivity for CRC 25–38% 61–85% 82%a 56–91% 67–88% Specificity for CRC 98% 94–98% 97% 94–97% 83–95% Test positives 2% 2–6% 3.2% 4.7% 5–9% FDA approved Yes No Yes Yes No U.S. market Yes No Yes No No NOTES: CRC = colorectal cancer, FlexSure = FlexSure fecal immunochemical test, now sold as Hemoccult ICT (Beckman Coulter, Fullerton, CA; see http://www.beckman.com/products/RapidTestKits/hemoccult_ict.asp; Allison et al., 2007)
|
From page 15... ...
. Screening strategies The most efficient strategies for colorectal cancer screening were explored by the next speaker, Dr.
|
From page 16... ...
This analysis will be used by the USPSTF to decide whether to change its current recommendations on screening, which are that colorectal cancer screening should begin at age 50, and that the screening interval should be every year for stool FOBT, every 5 years for flexible sigmoidoscopy, and every 10 years for colonoscopy. Current recommendations do not give an age when screening may be discontinued.
|
From page 17... ...
TABLE 4 Test Characteristics Base Case Assumptions Used for the Simulations Test Hemoccult Characteristics Hemoccult II SENSA FIT Sigmoidoscopya Colonoscopy Specificity 98% 92.5% 95% 100% 100% Sensitivity within Sensitivity reach: Adenomas ≤0.5 mm 2% 7.5% 5% 75% 75% 0.6 mm–0.9 mm 5% 12% 10% 85% 85% ≥1.0 12% 24% 22% 95% 95% Cancers 40% 70% 70% 95% 95% 80% reach the Reach Whole colorectum Whole colorectum Whole colorectum sigmoid–descending 95% reach cecum colon junctionb aThe assumed sensitivity for colorectal cancer screening by sigmoidoscopy for the whole colon was comparable to the evidence review. bIt was assumed that 80 percent of the flexible sigmoidoscopies would reach the junction of the sigmoid and descending colon and that 40 percent of the flexible sigmoidoscopies would reach to the beginning of the splenic flexure.
|
From page 18... ...
"Maybe as a society," she said, "if we could at least get people to do the first colonoscopy, the burden to society both in terms of incidence of colon cancer and mortality would be greatly reduced, and the additional gains obviously would be very important." Dr. Ganz then suggested modeling to look at which fraction of the population benefits most from the subsequent colonoscopies, to see whether genetic predisposition to adenomas could be determined, effectively simplifying colorectal cancer screening to one-time colonoscopy.
|
From page 19... ...
But, as Dr. Mercer pointed out, a study of client reminders for breast and cervical cancer screening "did suggest there is broad applicability of these data." There were no qualifying studies on the use of patient reminders to boost adherence to other colorectal cancer screening tests or procedures.
|
From page 20... ...
(per 1,000) MISCAN Model Colonoscopy 2,250 140 3,193 184 4,136 230 Ages 50–75, 10-year interval FOBT -- Hemoccult SENSA 1,752 149 2,427 177 3,350 230 Ages 50–75, 1-year interval Fecal immunochemical test 1,510 145 2,116 173 2,949 227 Ages 50–75, 1-year interval FOBT -- Hemoccult II 962 113 1,395 145 1,982 194 Ages 50–75, 1-year interval Flexible sigmoidoscopy 1,150 128 1,373 155 1,911 203 Ages 50–75, 5-year interval Flexible sigmoidoscopy plus 1,553 147 2,063 178 2,870 230 FOBT -- Hemoccult SENSA Ages 50–75, 5-year flexible sigmoidoscopy, 3-year FOBT interval
|
From page 21... ...
, Sim-CRC = a microsimulation model designed to evaluate colorectal cancer screening. SOURCE: Zauber presentation (February 25, 2008)
|
From page 22... ...
NOTE: FIT = fecal immunochemical test, FOBT = fecal occult blood test, Hemoccult II = Hemoccult II FOBT test from Beckman Coulter (Ful lerton, CA; see http://www.hemoccultfobt.com/) , MISCAN = a micro simulation model designed to3,evaluate colorectal cancer screening, SENSA Figure R01298.
|
From page 23... ...
The TFCPS review team assessed whether various measures aimed at reducing structural barriers to community access to colorectal cancer screening interventions were effective, based on seven studies (Church et al., 2004; Freedman and Mitchell, 1994; King et al., 1992; Mant et al., 1992; M
|
From page 24... ...
Based on the evidence the Community Guide provided, the Task Force on Community Preventive Services (TFCPS) recommended: • Patient reminders for increasing fecal occult blood testing; • mall media campaigns directed at patients to increase their use of S FOBT; • Interventions to reduce structural access barriers; and • Provider reminders on cancer screening measures.
|
From page 25... ...
Dr. George Isham of HealthPartners added that in his health system in Minnesota, repeat testing adherence is assessed with a single metric -- whether patients are up to date on their preventive services.
|
From page 26... ...
study reviewed claims data to determine whether screening was up to date on any of four tests: colonoscopy once every 10 years, flexible sigmoidoscopy once every 5 years, FOBT every year, or double contrast barium enema once every 5 years. It was found that colon cancer screening of the recommended population participating in commercial plans increased from 47.4 percent in 2003 to 54.5 percent in 2006 (NCQA, 2007)
|
From page 27... ...
. "The standardization of measures and the encouragement of reporting by health plans has been a significant factor in health plans encouraging their networks to improve their colon cancer screening rates," Dr.
|
From page 28... ...
Isham noted several ways that health plans show their commitment to increasing colorectal cancer screening by providing various incentives. In addition to providing coverage for screening, many health plans do outreach to members and communities with educational initiatives, health fairs, and public service campaigns on the importance of getting screened.
|
From page 29... ...
In addition to extending insurance coverage of colorectal cancer screening to all patients, he suggested requiring all health insurance plans to eliminate copayments and coinsurance for covered preventive services. He also suggested requiring all health plans and providers to publicly report their screening rates for colorectal cancer screening because such transparency and accountability for results can improve rates.
|
From page 30... ...
Richard Wender of Thomas Jefferson University raised the question of whether federal or state laws requiring insurers to cover all colorectal cancer screening options may not make much of an impact on improving screening rates, based on the evidence Dr. Isham presented.
|
From page 31... ...
Dr. Vernon pointed out that evidence from systematic reviews, including the Community Guide, shows that client reminders and reducing nonfinancial structural barriers are effective at increasing colorectal cancer screening with FOBT.
|
From page 32... ...
(2000) Clinical Trial FIGURE 5 Results of FOBT clinic interventions, such as one-on-one education, mailed client reminders, small media, and multicomponent interventions.
|
From page 33... ...
Vernon showed data from the 2005 NHIS indicating that lack of awareness of the importance of colorectal cancer screening was the reason most often given by
|
From page 34... ...
(2004) did not have a control group -- both groups received invitations in the mail to get colorectal cancer screening from either their general Figure 8, R01298.
|
From page 35... ...
During the discussion, several challenges of data collection were pointed out, including overreporting by patients about their own colorectal cancer screening, underreporting by providers in the medical record, and the incomplete claims data held by insurance programs.
|
From page 36... ...
He noted that such screening is currently constituted as a primary care activity, in that it is initiated and tracked by primary care physicians. But several factors affect the ability of these doctors to carry out such screening in their patients, including a shortage of time, the complexity of colorectal cancer screening algorithms, other competing preventive care measures, and broader societal influences.
|
From page 37... ...
Fletcher said. Despite the competing responsibilities, limited time, and insurance barriers that hamper primary care physicians from fostering colorectal cancer screening among their patients, studies indicate that physicians committed to such screening are able to achieve high screening rates.
|
From page 38... ...
, PRIMARY CARE SEPARATE OFFICE PREVENTION CLINICS • Doctor recommendation • Patient/doctor reminders • Office policy • Distributed tasks Periodic preventive • Communication health examinations COLORECTAL – Stage of change CANCER SCREENING – Shared BY decision COLONOSCOPISTS making • Decision tools FIGURE 10 Opportunities for improvement inside and outside the current office paradigm. Several factors can be improved within primary care offices to improve colorectal cancer screening rates.
|
From page 39... ...
. He also suggested that primary care physicians consider innovative ways to improve their patients' colorectal cancer screening rates, including partnering with colonoscopists and separate prevention clinics.
|
From page 40... ...
Dr. Fletcher ended his talk by noting that interventions to increase colorectal cancer screening rates should support other preventive care.
|
From page 41... ...
This has changed the goals of screening from early cancer detection, first recommended by the American Cancer Society14 in 1980, to colon cancer prevention. The increase in the number of colonoscopies performed challenges gastroenterologists to document and improve the quality of the procedure and meet the rising need for colonoscopies with the limited resources at hand.
|
From page 42... ...
. The CORI study found that the complication rates ranged widely from site to site, depending on the thoroughness of reporting at each site.
|
From page 43... ...
Dr. Lieberman ended his talk by saying, "There is great evidence today that screening can prevent colon cancer, but only if it is done well.
|
From page 44... ...
Providing better service in a more timely fashion is going to be important for any program to be successful." State and federal initiatives to boost colorectal cancer screening Colorado Screening Initiatives Dr. Tim Byers, professor in the Department of Preventive Medicine and Biometrics at the University of Colorado Denver School of Medicine and deputy director of the University of Colorado Cancer Center, made the first of three presentations on state or federal initiatives to boost colorectal cancer screening by describing a series of programs he and his colleagues at the University of Colorado instituted to foster more screening within the state.
|
From page 45... ...
Between 2003 and 2006, brochures were mailed to 75 percent of all households in Colorado that had a Medicare beneficiary, with the same promotional messages given in the pilot project brochures, and accompanied by a Colorado-specific endorsement from television news journalist Katie Couric, who has been active in promoting screening since her husband died of colorectal cancer when he was 42 years old. An evaluation based on telephone calls suggests the widespread mailing boosted colorectal cancer screening rates by 5 percentage points.
|
From page 46... ...
For some people with colon cancer, that amount is not sufficient, but it is usually enough to carry them over until they can receive funding from Medicaid or another source.
|
From page 47... ...
The program has focused on FOBT because it provides low-cost, effective screening that can fit within most communities' budgets, but the educational component includes the entire spectrum of testing recommended by American Cancer Society guidelines. The main reasons for starting this program was Nebraska's low colorectal cancer screening rate -- one of the lowest in the nation -- and the haphazard way colon cancer screening was being conducted in Omaha, in part because of competition among various health systems and hospitals.
|
From page 48... ...
"We thought it would make a much better statement to the community if we said that colorectal cancer screening is such an important issue that we are going to rise above the competitive instinct and develop a collaborative program, and that is exactly what we did." Dr. Thorson compared the guiding principles that informed the creation of the screening program with those developed by ACS "for communities to utilize in developing colorectal screening programs utilizing FOBT," he said.
|
From page 49... ...
The health care provider outreach offers information on colorectal cancer screening through presentations by physicians to the lay public as well as to nurses and physician assistants at their professional meetings. Physicians and their office staff are also given information kits and the opportunity to participate in fax quiz competitions.
|
From page 50... ...
Laura Seeff, associate director for the Office of Colorectal Cancer Programs in the CDC's Division of Cancer Prevention and Control, spoke about the CDC's colorectal demonstration screening program, which is aimed at increasing colorectal cancer screening in underserved populations. Several bills have been introduced in Congress to fund a nationally based colorectal cancer screening program akin to the national breast and cervical cancer early detection program run by the CDC.19 But no such program exists, so the demonstration project Dr.
|
From page 51... ...
The CDC evaluated each program's start-up phase -- the time between when a program is funded and when it initiates screening -- and implementation phase -- the time between the start of screening and the present. These analyses found that 80 percent of those screened were women, perhaps because many of the programs build on their already established breast and cervical cancer screening programs, and because men are traditionally harder to reach for preventive health measures, according to Dr.
|
From page 52... ...
We explored the breast and cervical model as one model because it is out there, but there is no certainty that this is the way we would go." Dr. Ferrell suggested adding colorectal cancer screening programs onto successful screening programs for prostate cancer.
|
From page 53... ...
Ms. Skye described the company's efforts to develop strategies to promote colorectal cancer screening among its employees, via participation in groups such as the CEO Roundtable on Cancer and its CEO Cancer Gold Standard™, and via implementation and analysis of the Quintiles wellness program.
|
From page 54... ...
and http://www.ceoroundtable oncancer.org. BOX 5 CEO Cancer Gold Standard™ Five areas of focus: The five "Pillars" • Tobacco use • Diet and nutrition • Physical activity • Screening and early detection • Access to quality care and clinical trials NOTE: CEO = Chief Executive Officer.
|
From page 55... ...
Skye's presentation focused on what could help employers at mid- to large-sized companies promote colorectal cancer screening to their employees. "If employers like us just get a little bit of help, we can make a huge impact on screening rates because there are a lot of employed people in this country." Ms.
|
From page 56... ...
Ms. Skye also made a few suggestions on what would help smallsized companies boost colorectal cancer screening rates of their employees.
|
From page 57... ...
(HEDIS) found that about half the people in both commercial and Medicare plans have adequate colorectal cancer screening coverage.
|
From page 58... ...
. NCQA will reassess colorectal cancer screening every 3 years, Mr.
|
From page 59... ...
We have tried to enable some regional collaboration and data aggregation efforts, and the plans have been very uncomfortable with sharing or pooling data." Interventions to address costs of developing and maintaining screening programs Colorectal Cancer Screening in Primary Care The next speaker, Dr. Carrie Klabunde, epidemiologist in the Health Services and Economics Branch of NCI's Division of Cancer Control and Population Sciences, addressed colorectal cancer screening practices in primary care and what elements encourage such screening.
|
From page 60... ...
The systems the survey explored were the use of EMRs, reminder systems, nurse practitioners or physician assistants, and feedback reports on screening rates. EMRs can make it easier to systematically institute patient and provider reminders of needed colorectal cancer screening, assuming the EMR system can easily integrate with other health systems databases, such as those of the specialists providing colonoscopies, Dr.
|
From page 61... ...
. It is also possible to generate feedback reports to providers on colorectal cancer screening rates without an EMR system, at the cost of about $47,000, one study found (Wolf et al., 2005)
|
From page 62... ...
Dr. Wender addressed the costs of colorectal cancer screening in primary care practices.
|
From page 63... ...
Prevention activities in general are perceived as not reimbursable or, at best, partially reimbursable, Dr. Wender said, and the greater complexity of colorectal cancer screening compared to other prevention screening, such as the simple blood test for prostate-specific antigen (PSA)
|
From page 64... ...
Dr. Wender added that the focus to date in patient-centered medical homes has been much greater on management of chronic diseases, such as diabetes and asthma, than on cancer screening.
|
From page 65... ...
Wender added that although most primary care physicians may be recommending colorectal cancer screening, they do not provide patients with any explicit instructions about how to carry out that screening. "So the patients don't follow up because they are waiting for someone to call them or are thinking maybe they will talk about it next time," he said.
|
From page 66... ...
Their cost data collection approach can be seen in Figure 13. When the funding sources were averaged for all five awardees in the demonstration program, CDC funds made up 52 percent and in-kind contributions, including labor and supplies, made up 43 percent, with the remaining funds coming from other sources in two of the sites, Dr.
|
From page 67... ...
. NOTE: CRCSDP = Colorectal Cancer Screening Demonstration Program.
|
From page 68... ...
. CRCSDP = Colorectal Cancer Screening Demonstration Program.
|
From page 69... ...
You do this and get high-quality data or you end up with estimates. If we are going to be using this for any expanded effort on colorectal cancer screening, we must try to get as close as possible to the real costs of running this program." She added, in response to another question, that much of this detailed cost information was lacking when the CDC's National Breast and Cervical Cancer Early Detection Program31 started, although it has been collected for the past 3 years.
|
From page 70... ...
Financial stability of the practices and incentives for preventive care in primary care practices are also important considerations. • orkforce capacity: It is unclear whether the capacity to fully W implement colorectal cancer screening is currently available.
|
From page 71... ...
Kean reviewed the themes that arose from the workshop presentations, he opened the discussion to everyone by posing the question, what are the main ideas that conference particpants had that would help to improve colorectal cancer screening in the United States? Four main topics were discussed: screening implementation, communications, costs and coverage, and the primary care system.
|
From page 72... ...
Mr. Kean then pointed out the fair amount of agreement on the importance of boosting the awareness effort aimed at the public that encourages a demand for certain preventive health services, including colorectal cancer screening.
|
From page 73... ...
Dr. Coates commented on the conflicting messages about which colorectal cancer screening practices to recommend to the public.
|
From page 74... ...
"There's a clear message in saying you need a mammogram -- the public and the professional get it. I'm not sure we have a clear message for colorectal cancer screening, and we have all learned over the last 30 years that without the clear message, everything else is not going to work.
|
From page 75... ...
Dr. Byers agreed with the suggestion to provide funding for colorectal cancer screening among the underinsured, and added that when funding a CDC program to address that, such funding should be adequate and not done "in a small token way that takes the heat off the problem but doesn't solve it.
|
From page 76... ...
"If there were a single payer, then all the screening tests have more or less the same costeffectiveness from society's perspective," he said. Primary Care System In addition to the discussion of a national colorectal cancer screening program and the potential benefits of universal health care, there were discussions of changes to the current primary care system that could help improve colorectal cancer screening.
|
From page 77... ...
Dr. Lieberman advocated for increasing colorectal cancer screening rates by fostering better connections between primary care physicians and gastrointestinal specialists, including more communications and electronic interoperability between the two groups, and improved patient access and navigation so that a primary care physician's recommendation for screening is more likely to be carried out.
|
From page 78... ...
He ended his summary by noting the concern of many for more standardized information about interventions reported in a consistent manner, and more cost data collected and considered in cost-effectiveness analyses. Final Words Many workshop presenters and participants believe the implementation of colorectal cancer screening faces several challenges that need to be addressed: awareness of the need for screening, the messages received by patients and providers, costs and coverage of screening, and facilitation of screening within the primary care system.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.