BETHESDA, MD—The medical community needs to explore ways to increase the use of screening techniques in order to decrease colorectal cancer rates, according to a panel of medical experts. The panel met for a two-day state-of-the-science conference on the campuses of NIH.

“We recognize that some may find colorectal cancer screening tests to be unpleasant and time-consuming. However, we also know that recommended screening strategies reduce colorectal cancer deaths,” said Dr Donald Steinwachs, panel chair, and professor and director of the Health Services Research and Development Center at the Johns Hopkins University. “We need to find ways to encourage more people to get these important tests.”

Removing Barriers to Screening

Colorectal cancer is the third most common cancer, and the second leading cause of cancer deaths, in the United States. Each year, nearly 150,000 people are newly diagnosed with colorectal cancer, and 50,000 die. An effective way to reduce mortality from colorectal cancer is to screen for it and its precursor, the adenomatous polyp. “Although screening methods have been available for decades and new methods continue to develop, screening rates remain low,” noted the panel in its draft report. “The purpose of this conference was to analyze national screening rates for colorectal cancer, identify the barriers to screening, and propose solutions to increase screening rates.”

One of the most consistent barriers to people being screened are financial ones, Steinwachs explained in a telebriefing following the conference. “One of the greatest barriers preventing many people from being screened is financial … not having health insurance or having insurance that doesn’t fully cover the cost of screening,” he noted. The panel’s recommendations highlighted the need to remove out-of-pocket costs for screening tests.

The panel also recommended implementing systems that would issue both reminders to get screened and for appropriate follow-up in the event of positive results. “We found that there were interventions that were working, interventions that have been proven. Some of them are very simple: patient reminders to both get screened and, when the results are positive, to have follow-up; one-onone interventions with individuals, which increase appropriate use of colorectal screening; and organizations that put together services that can include outreach and reminders,” explained Steinwachs.

“There is a serious lack of monitoring systems within communities and within many health care organizations, to track whether or not patients are receiving screening services, and whether or not the quality of the services being rendered are the highest,” he added. “These are issues that need to be addressed.”

Using Different Screening Tools

Given the variety of available tests, the panel emphasized that informed decisions incorporating personal preferences may help reluctant individuals determine which test’s combined attributes—invasiveness, frequency, and required preparation—are preferable to them. For example, an individual may choose a more invasive test requiring less frequent follow-up or a less invasive test requiring more frequent follow-up. However, this would mean using some screening techniques that have fallen out of favor over recent years, including fecal occult blood testing (FOBT), use of which has decreased proportionately to the increase in colonoscopy use.

“The reason people in the United States have gravitated towards colonoscopy is it’s one-stop shopping,” explained Dr Lawrence Friedman, a Harvard Medical School and panel member. “You get screened and can get treated with one intervention, so that if polyps are found or colon cancer is found, you have your answer. And in many cases, the polyps can be removed. In fact, colonoscopy is not only a cancer detection test, but it’s a cancer prevention test because by removing the polyps, you prevent future colon cancer.”

However, in many countries and in some health systems, including theVA, screening is based primarily on FOBT, with a follow-up colonoscopy upon a positive result. “The thing to know about fecal occult blood testing is that it’s the only screening technique for which there are randomized control trials showing a decreased mortality from colon cancer,” Friedman explained. “If you have fecal occult blood testing on a regular basis, ultimately, the yield of detecting early colon cancer is fairly high. So it’s a reasonable approach to colorectal cancer screening at much less expense than colonoscopy.”

The tradeoff is that an FOBT is needed every year, whereas if a patient has a negative colonoscopy screening, they will not need another for as much as 10 years. “But we should point out there are other options, and one of the conclusions of this panel is that people have different preferences,” Friedman said. “They weigh the pros and cons of different options. And what is good for one person may not be as desirable for another based on personal preferences.”

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