BETHESDA, MD. — Efforts to improve colorectal cancer screening should rely on evidence-based interventions to target underscreened populations and should include a full range of screening options, according to findings from a panel convened by the National Institutes of Health.
In a draft “state-of-the-science” statement issued Feb. 4, the 13-member panel also recommended investing in a variety of quality monitoring methods to ensure that colorectal cancer screening is accompanied by high rates of cancer detection and prevention.
Efforts will need to address financial and geographic barriers to screening as well as appropriate follow-up, the panel advised. In the target population of adults aged 50 and older, screening rates were 55% in 2008.
“We are convinced by evidence in the literature that efforts … to tailor strategies will be very important to test. In different communities and in different population subgroups, there need to be different strategies tested in order to get high [screening] rates,” panel chairperson Donald M. Steinwachs, Ph.D., said in a press telebriefing that followed the release of the draft statement.
Systems that remind patients to get screened and one-on-one interactions with providers, educators, or patient navigators could help to increase screening, the panel noted. Systems of care that employ these techniques have much higher screening rates than the national average, such as Kaiser Permanente (75% in the Medicare population) and the Veterans Affairs health care system (80%), according to the statement.
The panel also found that a physician's recommendation is the only consistent physician-related factor that has been shown to predict screening.
“The decision on which approach to use is driven by factors like insurance and patient preferences,” said panelist Dr. Leonard E. Egede, a professor in the division of general internal medicine and geriatrics at the Medical University of South Carolina, Charleston.
He noted that when patients have no preference for a particular screening method, most primary care physicians provide fecal occult blood test (FOBT)–based screening (followed by colonoscopy if needed) or direct access to colonoscopy.
A wide variety of methods with varying screening intervals are available for screening adults aged 50 and older, including annual FOBT (guaiac or immunochemical), flexible sigmoidoscopy, or double-contrast barium enema every 5 years, and colonoscopy every 10 years. The panel noted that CT colonography is a potentially viable screening option that could be expanded, but it is not currently covered by Medicare. Any positive results from noncolonoscopic screenings need to be followed with a colonoscopy.
When colonoscopy overtook FOBT and flexible sigmoidoscopy in 2001 as the most widely used screening method, there was a subsequent decline in the use of flexible sigmoidoscopy.
In that same time, double-barium contrast enema fell out of favor and the overall use of FOBT declined more gradually, although these stool tests are still widely used in the Veterans Affairs health care system and some managed care systems.
To provide colorectal cancer screening to low-income, uninsured, and underinsured populations, the panel noted that the Centers for Disease Control and Prevention recently began the Colorectal Cancer Control Program in 22 states. T
The program is modeled after the agency's successful breast and cervical cancer screening program, but “its reach so far has been limited,” Dr. Egede said.
Most of the current sources of information about screening rates do not provide enough detail on the use and quality of colorectal cancer screening, according to the statement.
“Monitoring systems exists in some communities, but overall, we don't have systems that monitor whether or not people are receiving screening services appropriately and whether or not the quality of the services being rendered are the highest,” said Dr. Steinwachs, director of the Health Services Research and Development Center at Johns Hopkins University, Baltimore.
The panel suggested that a colorectal cancer screening registry analogous to the existing Breast Cancer Surveillance Consortium should be established to monitor the rates of colorectal cancer screening, overuse, quality, and complications.
The panel based its statement on a report commissioned by the Agency for Healthcare Research and Quality, data presented at an NIH conference, and input from attendees of the conference. The statement is available at http://consensus.nih.gov
“In different communities and in different population subgroups, there need to be different strategies tested in order to get high [screening] rates,” said panel chair Donald M. Steinwachs, Ph.D.
Source Courtesy NIH.gov
This Month's Talk Back Question
What strategy for colorectal cancer screening does your practice use?
My Take
Focus on Screening—By Any Method
We must get more patients screened for colon cancer—the second most common cause of cancer-related deaths in the United States—and the primary care physician is the key to successful screening of average-risk patients.