Capt. John Bassett (middle), a gastroenterologist at Naval Hospital Jacksonville, along with Hospitalman Wesley Ward (left) and Robert Hauser (right), an endoscopy technician, perform a colonoscopy on a patient in 2018. U.S. Navy photo by Jacob Sippel
ROCKVILLE, MD — In recent years, the protocols for colorectal cancer screening have undergone some significant changes.
One reason is the growing issue of early-onset colorectal cancer in patients 50 and younger. That prompted the U.S. Preventive Services Task Force to lower the age for which screening is recommended from 50 to 45.1
“Colorectal cancer is most frequently diagnosed among persons aged 65 to 74 years,” the panel wrote. “It is estimated that 10.5% of new colorectal cancer cases occur in persons younger than 50 years. Incidence of colorectal cancer (specifically adenocarcinoma) in adults aged 40 to 49 years has increased by almost 15% from 2000-2002 to 2014-2016. In 2016, 25.6% of eligible adults in the U.S. had never been screened for colorectal cancer and in 2018, 31.2% were not up-to-date with screening.”
That meant about 21 million Americans became eligible for screening. In the Military Health System, the estimated effect of the lower age recommendation means more than 200,000 additional beneficiaries will need to be screened for CRC, according to Chin Hee Kim, MD, deputy chief of specialty care support of the Defense Health Agency Directorate of Medical Affairs.
The new DHA guidelines offer a range of CRC screening options, including expanding the use of a stool-based test, the fecal immunochemical test (FIT) as an alternative to a colonoscopy.
A recent VA study discussed the challenges of screening during the height of the COVID-19 pandemic and how backlogs in high-volume gastrointestinal endoscopic procedures, such as colonoscopy, occurred.2
The recent report in the journal Gastroenterology pointed out that the inability to perform that screening is projected to lead to a rise in avoidable colorectal cancers. “Almost one-third of colonoscopies performed in Veterans Health Administration (VHA), the largest integrated health system in the United States, are for screening,” according to the authors from the VA Ann Arbor, MI, Healthcare System and the University of Michigan Health System.1
The article advised, however, that colonoscopy is not the only option for colorectal cancer (CRC) screening. It explained that the USPSTF recommends several different testing modalities, including annual FIT as alternatives to colonoscopy for average-risk screening.
“Future work should focus on developing multilevel implementation strategies to provide facilities with effective tools to enhance uptake and sustainability of stool-based CRC screening to reduce colonoscopy demand and improve overall endoscopy access for high-need patients, particularly in integrated healthcare systems and other settings with limited endoscopy access,” the authors emphasized.
Their recommendations were based on a recent simulation study that projected how increased FIT-based screening during COVID-19 could mitigate the consequences of reduced screening rates on CRC outcomes during the pandemic.
The study found that, systemwide, a 9.3% decrease (95% confidence interval [CI], -10.5% to -8.1%) in the mean (adjusted) facility-level proportion of screening procedures pre-COVID and COVID occurred. “Most facilities modestly decreased screening colonoscopy use in the COVID period, with wide variation across facilities (interquartile range, -14.8% to -4.6%),” the authors wrote. “At the same time, average monthly FIT volume increased by 7.9% before and after COVID-19 (pre-COVID, 31,604 FIT per month; COVID, 34,109 FIT per month).”
“Although we found a modest (9.3%) decrease in the overall proportion of screening procedures by the fourth quarter of 2020, VHA facilities clearly did not maximize the opportunity to accomplish a marked, systemwide reduction in screening colonoscopy demand by shifting to an underused, evidence-based alternative screening modality (FIT),” the authors concluded. “This occurred despite a national VHA policy directive strongly encouraging widespread adoption of a stool-based CRC screening strategy to enhance overall endoscopy access.”
VA has been recognized for achieving CRC screening rates that surpass the national benchmark of 80%. It also has been found to be free of many of the racial/ethnic CRC screening disparities that occur in healthcare settings throughout the United States. In the VA healthcare system, Hispanic and Black veterans have similar or higher CRC screening rates than whites.
- US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(19):1965–1977. doi:10.1001/jama.2021.6238
- Adams MA, Kurlander JE, Gao Y, Yankey N, Saini SD. Impact of Coronavirus Disease 2019 on Screening Colonoscopy Utilization in a Large Integrated Health System. Gastroenterology. 2022 Jun;162(7):2098-2100.e2. doi: 10.1053/j.gastro.2022.02.034. Epub 2022 Feb 24. PMID: 35219698; PMCID: PMC8867975.
