The United States has made significant strides in cancer treatment options, diagnostic tools, and prevention strategies to drive down cancer rates over the past two decades. Among cancer types, colorectal cancer is the third most common and second leading cause of cancer deaths in America. Approximately 1 in 23 men (4.4%) and 1 in 25 women (4.1%) will be diagnosed with colon cancer in their lifetime. Colon cancer incidence and mortality are highest among non-Hispanic Blacks and lowest in Asian/Pacific Islanders. Death rates for Black patients are almost 40% higher than those for non-Hispanic White patients. Thus, it is critical to screen all patients early and often to prevent colon cancer and to address inequities in care and outcomes.
The good news is that colon cancer screening saves lives through early identification of polyps and non-cancerous growths. When the disease is detected at early stages, treatment is more successful. Screening reduces colorectal cancer mortality both by decreasing incidence and increasing survival rates. Routine screening and early detection can occur through a variety of modalities: colonoscopy, sigmoidoscopy, fecal occult blood test, and DNA stool test (such as Fecal Immunochemical Test or “FIT”). If a positive fecal occult blood test or FIT result is found, it is recommended by the U.S. Preventive Services Task Force to follow up with a subsequent colonoscopy.
In July 2022, the US Centers for Medicare and Medicaid (CMS) announced expansion for colorectal cancer screening that, effective as of 2023, includes a follow-up colonoscopy after a Medicare-covered non-invasive stool test returned positive. Prior to this directive, the colonoscopy had been deemed diagnostic following a positive stool test and thus subject to beneficiary cost sharing, meaning a charge to the patient. This new change means that both the initial non-invasive test and subsequent follow-up colonoscopy are covered with no co-payments.
This year, 45 is the new 50 as the colorectal screening age guideline has been lowered (screening includes ages 45-75). Health insurance will continue to cover the costs for tests for all adults in this age group. The recommended age change comes from a rise in colorectal cancer cases among young and middle-aged people. Deaths of people under the age of 55 have increased 1% each year from 2008 to 2019, even though overall colorectal cancer rates have dropped.
Amidst these strides in overall cancer survival, many factors still prevent Americans from reaching health goals or receiving optimal care, such as unhealthy diet, sedentary lifestyle, high alcohol consumption and smoking, to limited access to risk reducing behavior such as preventative screening. More non-modifiable factors for high risk of colon cancer include personal or family history as well as long-term irritable bowel syndrome. Colorectal cancer outcomes have also been shown to demonstrate a socioeconomic pattern. Socioeconomic status is one of the strongest and most consistent predictors of health, overall disease burden and premature death. Social Drivers of Health (SDOH) include low-income status, lack of insurance and being part of racial or ethnic minority groups. These barriers may make it difficult for patients to access healthcare and get screened in a timely manner. Thus, SDOH influences rates of colorectal cancer incidence, care received and survival rates.
It is well documented that cancer screening rates are lowest in people without health insurance. It is reported that 40% of Americans aged 50-75 have not received the recommended screening for colon cancer, and 80% of those Americans are uninsured. As colorectal cancer mortality has decreased considerably following the recommendation and adoption of national screening programs, within at-risk subgroups, there are still significantly measurable differences in clinical outcomes.
40% of Americans aged 50-75 have not received the recommended screening for colon cancer.
To add fire to the flames, after a 16% drop in colorectal cancer screenings from 2018-2020 for men and women nationally, in March and April of 2020, screenings dropped by close to 80 percent, due to the COVID-19 pandemic. The pandemic altered many usual structures through which patients and clinicians conducted primary care. Preventive care visits were postponed, more telemedicine visits conducted, and even the ability to obtain a colonoscopy procedure in a timely manner was hampered. The steep decline in screenings was seen even more sharply in underserved communities, leading to more deaths and ultimately, worsening cancer disparities.
This decrease, however, was offset by a 7% increase in at home stool testing throughout the COVID-19 pandemic. Because the pandemic had such a dampening effect on preventive screenings, many patients have been lost to follow-up or disengaged in their care overall. With colorectal cancer, it is critical to get patients in and screened to avoid disease progression and possible death. Many American's cite fear or worry, financial, and logistical challenges as barriers to getting a colonoscopy and are unaware of the other screening options available. Lack of childcare, transportation, stress, and housing insecurity leave little room for a patient to be able to successfully complete a colonoscopy. Barriers such as time, cost, and transportation logistics can be overcome using at-home testing such as FIT or Cologuard.
Home testing presents a highly attractive option for patients reluctant to bowel prep and eliminates barriers of taking time off work or finding childcare during the procedure. Home tests are more convenient, non-invasive, come in multiple options, and are effective for cancer screening. Home tests used in screening programs have been shown to increase screening uptake and improve colorectal cancer screening outcomes. Proper utilization of FIT or Cologuard involves multiple steps beyond provider recommendation of the test, such as identifying patients with open FIT lab orders and reminding them to complete the test.
Shared decision making between the provider and patient can help assist in these decisions about preventive health and which screening will be best. Evidence suggests that patients who are offered more than one reasonable option are more likely to go through with the screening. This provides the opportunity to align patient care more closely with preventive guidelines and patient preferences. As the clinician describes options and benefits with each option, patients can share back values and preferences. This dynamic allows for collaboration in reaching the final decision—truly the embodiment of patient centered care.
With an understanding that there are many factors which influence whether a patient is screened or not, Azara DRVS is here to help you better understand the impact of your efforts surrounding home-testing to increase screening rates. In part 2 of this blog series, I will highlight some simple ways to use Azara DRVS to assist in engaging your patients for colorectal cancer screening and follow-up.