NIH panel concludes insurance, access most important
factors in decision to get screened.
Removing financial obstacles to
colorectal cancer screening and providing regular access to
health care providers are crucial factors in increasing the rate of colorectal
cancer screening, a council of experts concluded after a three-day
state-of-the-science conference in Bethesda, Md.
Colorectal cancer is the second-leading cause of
cancer-related deaths in the United States. During the
NIH State-of-the-Science Conference: Enhancing Use and
Quality of Colorectal Cancer Screening, an independent panel considered the
results of a systematic literature review, expert presentations and audience
input to produce
statement regarding ways to increase screening, the factors that influence
the decision to get screened and the most effective screening modalities.
Donald M. Steinwachs, PhD, panel chair and
director of the Health Services Research and Development Center at Johns
Hopkins University, said rates of screening have improved in the past decade
but still lag behind.
“When you look at rates of which individuals have
been screened for purposes of prevention and early detection of colorectal
cancer, those rates have gone up substantially,” Steinwachs said.
“They were in the 20% to 30% range in 1997. In 2008, the rate was up to
55%, yet this is lower than what we’d all expect. Looking at other cancer
prevention efforts, screening rates sometimes go into the 70% or even 80%
Screening rates for colorectal cancer have already
exceeded the 50% target established by Healthy People, a set of national health
objectives managed by the Office of Disease Prevention and Health Promotion.
The NIH panel did not set a formal target for screening, but Steinwachs said he
would like to see rates increase to 80% to 85% in adults older than 50 years.
In addition, the panel said targeted initiatives to
improve screening rates and reduce disparities in under-screened communities
could further reduce colorectal cancer morbidity and mortality.
“We looked at what associations there are between
characteristics of the patient, provider and system of care and whether or not
the individual got screened. We were looking to identify those things that
might help shape opportunities for implementation,” Steinwachs said.
“One of the most striking findings, one of the greatest barriers for
getting screened was financial — not having health insurance or having
insurance that does not fully cover the cost of screening.”
Improving screening rates
The panel issued five recommendations for
implementation and research opportunities that would improve the use and
quality of colorectal screening:
- Widely implement interventions that have proved effective at
increasing colorectal cancer screening, including patient reminder systems and
one-on-one interactions with providers, educators or navigators.
- Tailor specific approaches to match characteristics and preferences
of target population groups to increase colorectal cancer screening.
- Implement systems to ensure appropriate follow-up of positive
colorectal cancer screening results.
- Eliminate financial barriers to colorectal cancer screening and
- Develop systems to assure high quality of colorectal cancer screening
Panelists noted that since 2001, use of screening
modalities such as fecal occult blood testing, flexible sigmoidoscopy and
double-contrast barium enema have decreased, whereas use of colonoscopy has
steadily increased. Paula Kim, a panel member and chief executive officer of
Translating Research Across Communities, said use of colonoscopy increased from
19.2% of all screens to 47.5% from 2000 to 2008.
However, Kaiser Permanente has achieved a screening rate
of 75% and the Department of Veterans Affairs has achieved a rate of 80%
relying on the fecal immunochemical test and fecal occult blood testing and
confirming any positive results with colonoscopy.
“It is important to know more about the factors
that lead physicians to recommend, or patients to choose, one test over
another. Financial considerations, such as differential reimbursement rates for
different tests, may affect physicians’ decisions to recommend
endoscopy,” the panelists wrote in their conference statement. “A
likely factor affecting patient choices is copayments. Another factor affecting
both groups is a perception that colonoscopy is the gold standard, despite the
absence of randomized clinical trial evidence supporting the test’s
relationship to morbidity and mortality.”
Because there are different rates of screening depending
on insurance status, socioeconomic status, race and ethnicity, and geography,
panelists said each demographic will require a strategy tailored to their
particular concerns. Toward that end, panelists called for more research to
understand the specific factors influencing the decision-making in a particular
“We are convinced by evidence in the literature
that efforts to tailor strategies will be very important to test. In different
communities, different population subgroups, there need to be different
strategies tested to get high rates,” Steinwachs said. “If you look
at what are really disparities — geographically or socioeconomic status,
etc. — it leads one to think tailoring could be a very important way to