In past years, the rate of colorectal cancer (CRC) has become a serious public health problem in Mississippi. A study conducted in 2020 showed that Mississippi had one of the highest mortality rates from CRC as well as one of the CRC lowest screening rates between 2015 and 2019. The state also leads the nation in cardiovascular disease mortality rates as well as diabetes mortality. These are both known comorbidities for many types of cancers, including CRC. 

One theory as to why the screening rates are so low in Mississippi is that about 55% of the state’s population resides in rural locations, which may make it hard for some individuals to access regular medical care. The rural population in Mississippi has a high rate of uninsured individuals making it hard for this population to afford regular screenings. In 2016, 14% of the population under 65 were uninsured. 

Another theory as to why CRC rates are so prevalent in Mississippi is that the diet of many of the residents is high in red meat and low in fiber. This is in part due to a culture that relies on red meat and processed foods. This diet is also more prevalent in areas that have a low socioeconomic background, as it can be difficult to obtain healthy food if one lives in a food desert. 

Colorectal cancer-related mortality in those over 50 (2014-2018).
Data source: https://statecancerprofiles.cancer.gov/map/map.noimage.php.

Fortunately, the Mississippi government recognized the issue and has developed a plan to help increase the screening rate of residents in Mississippi and decrease mortality rates 70X2020 was initiated in 2014. Since the start of the program, there has been an increase in individuals who got screened, specifically in minority communities. So far, screening rates have improved from 55% in 2014 to 69.9% in 2020. For white individuals there was a compliance rate of just under 70% and for black individuals there was a compliance rate of just above 70% in 2020. 

From this case study, we are able to theorize that screening and diet play a crucial role in the development of CRC. We are also able to see that there is a strong correlation between screening rates and CRC mortality rates. 

A recent article published in the New England Journal of Medicine stressed the need to make health equity our national priority. The researchers identified significant differences in the screening rates between black and white Americans. Additionally, they found that improvements in screening rates, more timely treatments, as well as earlier detection of cancer significantly improved cancer outcomes. 

The researchers evaluated the association between rates of colorectal cancer screening as well as age-standardized incidence rates between 2000 to 2019 among non-Hispanic black (hereafter black) and non-Hispanic white (hereafter white) persons 50 to 75 years of age who were members of the Kaiser Permanente Northern California (KPNC) health plan. The researchers then conducted follow-ups with participants until the age of 79 years to investigate screening patterns as well as incidence rates.

Between the years 2006 and 2008, KPNC began a population-based colorectal cancer screening program that utilized proactive mail-in fecal tests and colonoscopies upon request. The study found that screening rates for black individuals increased from 42% in 2000 to 80% in 2019 and those for white individuals increased from 40% in 2000 to 83% in 2019. The study also investigated colorectal cancer-specific mortality in both groups. Among black populations, there were 54 deaths per 100,000 in 2007, which dropped to 21 cases per 100,000 in 2019. Among white populations, colorectal cancer-specific mortality decreased from 33 per 100,00 in 2007 to 20 per 100,000 in 2019. 

After evaluating the yearly trends, the researchers were able to hypothesize that one of the major reasons for this drop in incidence as well as mortality from colorectal cancer in both black and white individuals was the sustained delivery strategies across the care continuum, including advancements in prevention methods, earlier detection of treatable cancers, and more timely treatments. Overall, the results of this study showed that it is possible to increase screening and decrease the incidence and mortality of colorectal cancer when the correct methods are implemented. 

Abigail Parker is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

Image source: anarosadebastiani (Pixaby) 

Colorectal cancer and breast cancer screening programs, when implemented properly, have led to significant reduction in death. However, screening uptake varies greatly across the U.S. Rural communities, specifically in Appalachia, the Mississippi delta, frontier lands, and prairie lands face issues with access that are accentuated by poor health behaviors.

A 2021 cross-sectional study by Shete et al, which was recently published in JAMA found that urban women were significantly more likely to be adherent to colorectal cancer screening as compared to women residing in rural areas (82% vs 78%, respectively; P=.01). When they conducted a multi-variable mixed effects analysis, they found that rural women had 19% lower odds of being adherent to colorectal cancer screening guidelines. 

Along with a difference in screening adherence, there was a significant difference in beliefs and understanding of cancer, health, and screening. When comparing the thoughts of women dwelling in rural vs. urban areas regarding cancer and cancer screening:

  • 62% vs 52% believed “It seems like everything causes cancer”
  • 24% vs 17% believed “There’s not much you can do to lower your chances of getting cancer”
  • 76% vs 67% believed “There are so many different recommendations about preventing cancer, it’s hard to know which ones to follow”

Despite the differences in beliefs and perception of cancer screening overall, rural and urban women were similarly adherent (81% vs 81%) to breast cancer screening. Here the authors hypothesize that the difference in colorectal cancer screening is likely due to the difference in screening diffusion in the rural areas.

Newer colorectal screening technologies like fecal immunochemical tests (FIT) may work better in a rural setting because rural women are 69% more likely to skip going to a doctor due to cost. Taking away the face to face component can reduce cost for insurance companies and by effect patients, which could increase screening uptake. 

FIT tests can also be useful for working women. Among women over the age of 65, the adherence rate to colorectal cancer screening recommendations was significantly higher than among women ages 50-64 years. This difference in uptake due to age is likely because older/retired women do not have to take time off of work for screening tests such as a colonoscopy or a sigmoidoscopy.  

Furthermore, patients with insurance were 2 to 3 times more likely to get screened, so changes in insurance care coverage—particularly, the removal of a copayment for a preventive service—through the Affordable Care Act would increase screening uptake. In order to increase rural colorectal cancer screening uptake, programs that identify and act on access issues are needed as are policies that can improve access at the local level.

A study published in the Journal of Medical Economics simulating a cohort of one million Medicare patientsUS adults aged 65 years and olderwith average risk of colorectal cancer, investigated the cost-effectiveness of non-invasive fecal tests (fecal immunochemical test (FIT), fecal occult blood test (FOBT), and multi target stool DNA test (mt-sDNA)). The researchers used the Colorectal Cancer and Adenoma Incidence and Mortality Microsimulation Model (CRC-AIM) with test-specific adherence data to estimate the cost-effectiveness of the various options.

Assuming 100% adherence follow-up colonoscopies and using real-world screening adherence data, the researchers found that mt-sDNA was cost-effective when compared to FOBT but not FIT. Cost-effectiveness was defined at the $100,000/quality adjusted life-year (QALY) threshold. 

  •     $62, 814/QALY when compared to FIT
  •   $39,171/QALY when compared to FOBT

The assumption of100% adherence to follow-up colonoscopies is not a significant limitation to this study because this is just one scenario and also because follow-up colonoscopies are covered under Medicare. Since follow-up colonoscopies are covered under Medicare there is not a financial disincentive to get a colonoscopy and therefore most people under Medicare do get the colonoscopy.  Moreover, when the authors ran the model using real-world follow up-colonoscopy and screening adherence rates, they found that mt-sDNA was even more cost-effective:

  •   $31,725/QALY when compared to FIT
  •   $28,465/QALY when compared to FOBT

Generally an incremental cost-effectiveness ratio (ICER) of less than $100,000 is considered good value, and those under $61,000/QALY is considered cost-effective. Therefore, when real-world adherence rates were considered, mt-sDNA was the more cost-effective option compared to both FIT and FOBT and resulted in greater reductions in CRC incidence and mortality.

Cost-effectiveness analyses are important for determining which screening test performs better than the others, and where to relocate resources to achieve the best health outcomes for the lowest possible cost. These types of studies on Medicare populations are important because they help policy makers make informed decisions on resource allocation.

 

Gargi Patel is a Colon Cancer Prevention Intern with the Colon Cancer Foundation.

“This is a problem with a solution. The solution is awareness of the colorectal cancer problem and getting screened.”
– Dr. Thomas K. Weber, Founder, Colon Cancer Foundation

My late father Dr. Thomas Weber founded the Colon Cancer Foundation (CCF) because he recognized the power of preventing colorectal cancer and diagnosing it early through screenings. The screenings identify precancerous polyps and early stage growths that doctors can remove.

The CCF has now led the mission of raising awareness and increasing screenings for 19 years.

As we enter Colorectal Cancer Awareness Month in March, you can take direct action today to solve the colorectal cancer problem and save lives:

Talk to your doctor about getting a colonoscopy if you are 45 years or older. If you are younger than 45 but have one or more family members that were diagnosed with colorectal cancer, ask your doctor if you should start screening earlier.

Participate and help increase visibility for CCF’s awareness campaigns and fund colorectal cancer screenings.

Donate Now: The funds collected through your fundraising efforts enable us to reach more people with life saving public awareness, prevention, and research programs.

Two Reasons to Show Your Support

Reason #1: Screenings were down due to COVID-19 but are beginning to pick up again. That’s great news, but it is critical that colonoscopy rates grow past pre-pandemic levels to save lives.

Reason #2:  Deaths from colorectal cancer in people ages 0-49 are increasing. Educating our friends and family with high risk factors can help identify and treat the disease in young people.

CCF’s March Awareness events, tools, and resources are designed to maximize the impact of your donations.

Thank you for taking action!

Sincerely,

Nick Weber

P.S. Your support, plus our ongoing work to mobilize the medical community to address colorectal cancer in young people with the Early-Age Onset Colorectal Cancer Summit, will make a difference!

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The new year brought news of two success stories in our fight to increase accessibility to colorectal cancer (CRC) screening. The first, is a change in private insurance coverage requirements for colonoscopies. The second is from Kentucky, where a pharmacy protocol was passed to allow at-home fecal tests to be taken care of like a regular prescription. More details below.

Coverage for Screening Colonoscopy Without Cost Sharing

A document jointly released by the Departments of Labor, Health and Human Services, and Treasury on January 10th 2022 categorically states that private insurance plans are required to cover a follow-up colonoscopy after a positive non-invasive stool-based test or a direct visualization screening test, without any cost-sharing with respect to the colonoscopy for the health plan beneficiary. This coverage requirement will go into effect on May 31, 2022, one year after the updated recommendation on CRC screening was issued by the US Preventive Services Task Force

The Affordable Care Act requires health insurers to fully cover preventive screening. However, colonoscopies done after a stool-based test (such as FIT, gFOBT, or MT-sDNA/sDNA-FIT) were considered diagnostic and were not covered in the same way as decennial colonoscopies. This policy change however, is only applicable to private insurance holders; it does not apply to those who are enrolled in traditional Medicaid and Medicare plans.

Kentucky: Easy Access to Stool-Based Testing

On September 28, 2021, a new pharmacy protocol passed in the state of Kentucky will allow fecal immunochemical test (FIT) or stool DNA test (sDNA-FIT) to be taken care of at the pharmacy like a flu shot or regular prescription.

With the screening age for average-risk adults lowered to 45 years, it is important to eliminate the barriers for those who actually want and need screening. As we have seen over the last couple of years though, the COVID-19 pandemic has prevented many from getting the care that they need, including preventive care services. This bill has truly come at the right time. 

“Kentucky is the first state in the nation to have this type of protocol passed, and why not here?” said Dr. Whitney Jones, founder of the Colon Cancer Prevention Project, which is based out of Kentucky. “Colorectal cancer is treatable and preventable when caught early, and this new protocol will allow the general population more avenues to get screened on time.”

 

Gargi Patel is a Colon Cancer Prevention Intern with the Colon Cancer Foundation.

The COVID-19 pandemic has affected nearly every aspect of life from schools to offices and, most importantly, healthcare. While certain things may have gone back to normal, the healthcare space continues to struggle. During a discussion at the National Colorectal Cancer Roundtable (NCCRT) Annual Meeting, panelists shared how their respective organizations  adapted to the pandemic to ensure continued delivery of colorectal cancer (CRC) screening.

Rachel Issaka from the Fred Hutchinson Cancer Research Center kicked off the discussion with the history of the COVID-19 pandemic in the U.S., starting with when the SARS-CoV-2 virus reached the U.S and the government declared a national emergency on March 13th, 2020, due to the rapid spread of the virus. A day later, on March 14th, the office of the U.S. Surgeon General advised hospitals to reschedule all elective procedures. Subsequently, the Gastroenterology Society released a statement that recommended all endoscopies and clinical practices be rescheduled along with other non-urgent procedures and the Centers for Disease Control & Prevention (CDC) recommended that healthcare systems prioritize urgent visits and delay elective care. The American Cancer Society (ACS) advised patients to postpone elective care, including cancer screenings, if they are at average risk for cancer and did not have any signs or symptoms. 

Following these recommendations, many adults delayed or avoided medical care. A study conducted in June 2020 by the CDC found that:

  • 41% of U.S. adults had delayed or avoided treatment
  • 12% had avoided urgent and emergency care 
  • 32% avoided routine care

Another study conducted in April 2020 found that cancer diagnoses decreased by 46% as compared to the year before, and CRC diagnoses dropped by 49%. The primary cause for this drop in diagnoses was delayed screenings for individuals who had symptoms but did not want to use the healthcare system during the pandemic. CRC screenings were down 25% between March of 2020 and March of 2021. It is estimated that these delays in screening and diagnoses will be responsible for an additional 4,500 deaths from CRC by the year 2030. 

Fortunately, organizations such as the Lincoln Community Health System in Newport, Oregon, recognized this growing gap in screening and diagnosis of CRC and came up with solutions. Jaraka Carver, LPN, from Lincoln Community Health Center, who was planning on running a CRC awareness campaign in March 2020, witnessed the project being derailed by the pandemic. Instead, after seeing the growing gap in CRC diagnosis she and her team implemented a bi-annual FIT mailing program to reach out to individuals and remind them that they were overdue for a CRC screening, and then sent them an at-home FIT test. Of the kits that were sent out:

  • 33.5% came back for testing, of which 15 came back as abnormal 
  • 30 individuals were referred for colonoscopies, 20 of whom completed the colonoscopy and 1 was diagnosed with cancer 

Virginia Mason Franciscan Health in the Pacific Northwest was also looking to increase CRC screenings among their constituents. Their divisional vice president, Michael Anderson, had partnered with ACS on a program to increase CRC screenings to 70%. However, once the pandemic hit, they had to change directions. With the goal of scheduling annual wellness visits during the pandemic, they specifically focused on vulnerable populations and clearly communicated Medicare’s new rule that a patient could complete a visit in person, online, or by phone. 

The organization also began reaching out to patients who were overdue for an annual visit and implemented a digital tool that helped prioritize patients by their likelihood of completing a CRC screening test. The program had a 40% success rate: they scheduled 5,300 annual wellness visits, completed 1,325 cancer screenings, and saved nearly 8.16 years of life. On a population level, this program allowed 41 more men and women to spend an extra year of life with their friends and family because they were screened for CRC. 

The panel concluded with a question and answer session where participants were able to ask the presenters questions regarding the effects of SARS-CoV-2 on CRC screenings. This meeting stressed the importance of annual screenings as well as the importance of adapting to different situations and needs, with a focus on ensuring that patients are able to achieve the best health outcome possible. 

 

*Additional Information on the NCCRT annual meeting can be found at 2021 80% in Every Community Conference & NCCRT Annual Meeting – National Colorectal Cancer Roundtable  

Presenters slides can be downloaded using this link https://nccrt.org/download/101349/ 

 

Abigail Parker is a Colon Cancer Prevention Intern with the Colon Cancer Foundation.