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How Can We Improve Access to Blood-Based Colorectal Cancer Screening?

In a recent blog post, Parker Lynch discussed the accuracy of blood-based colon screenings that are becoming increasingly popular in colorectal cancer (CRC) prevention efforts. The non-invasive nature of these tests has the potential to improve CRC screening rates in the general population, which is becoming increasingly necessary with the rise in early-onset CRC rates. 

While these tests have high specificity and sensitivity, their newer status on the market raises questions about whether they will be covered by insurance plans for most Americans. 

At the recent American Society of Clinical Oncology meeting, researchers presented their findings on a new multi-cancer detection test that utilizes only a blood sample for cancer screening. This test is groundbreaking in its ability to quickly and accurately provide positive test results for a broad spectrum of cancers. It will be essential to cancer prevention movements in the colorectal sphere and across the board. 

While these new tests are groundbreaking for prevention efforts, ensuring that the population has equitable access to these tests will establish their validity as a public health tool. The much heralded Galleri multi-cancer detection test has a list price on the company website of $949 and states that most insurance plans do not cover it. Considering that a significant portion of Americans (40%) cannot afford to cover a $400 emergency bill, the Galleri test’s pricing and lack of coverage will create access barriers to the general American public. 

Blood-based biomarker tests specifically for detecting CRC will be more easily accessible to the public, but still can be challenging to obtain. The Centers for Medicare & Medicaid Services, for example, will cover a blood-based biomarker test every three years, for an individual who is between 45 and 85 years old, asymptomatic, and at an average risk for developing CRC. This leaves out the early-onset population (<45 years), many of whom are diagnosed at an advanced stage and may benefit from a blood-based testing approach.

To advance health equity in CRC prevention and care, these innovative new tests must become more accessible through pricing and insurance coverage. When all individuals can access high-quality cancer prevention, regardless of income or socioeconomic status, we can protect the most vulnerable members of our population. 

 

Emma Edwards is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

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Serving the Underserved: Transportation, Physician Access for CRC Prevention

By Deepthi Nishi Velamuri

Colorectal cancer (CRC) remains a serious health issue in the U.S. It is the second most common cause of cancer-related deaths in both men and women, and it is the third most frequently diagnosed cancer. An average of 50,000 Americans die from CRC each year. However, CRC is quite treatable if diagnosed early through routine screenings for average- and high-risk adults. The incidence and mortality rates associated with this disease are being reduced through public health initiatives, such as awareness campaigns and improving access to screenings. To prevent and identify CRC in its earliest stages, people must fully comprehend the risk factors, symptoms, and significance of regular screening.

The studies in the infographic below were presented at Digestive Disease Week 2023 and were focused on understanding the factors that impact screening rates for CRC in the U.S. The researchers delved into various aspects such as patient education, healthcare policies, socioeconomic disparities, and the effectiveness of screening methods and aimed to enhance screening efforts, raise awareness, and develop targeted interventions to increase screening rates.

 

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Connections & Comorbidities: The Link between Colorectal Cancer and Cardiovascular Disease

Welcome back to our ongoing series exploring the intricate relationship between colorectal cancer (CRC) and various health conditions. Our previous post uncovered the association between CRC and diabetes mellitus. Today, we embark on a new journey as we unravel the intriguing connection between cardiovascular disease and CRC. Through uncovering the latest research, we aim to shed light on shared risk factors and significant findings that emphasize the importance of addressing both these conditions. 

Shared Risk Factors Identified

A meta-analysis of 84 studies involving over 52 million participants has unveiled a clear association between cardiovascular disease and CRC. The analysis confirmed that individuals harboring risk factors for cardiovascular diseases, such as obesity, high body-mass index, diabetes, and smoking, face an increased likelihood of developing CRC. These shared risk factors act as crucial indicators of potential health complications. 

Intriguingly, the same study revealed a compelling insight: individuals who are obese and exhibit at least one metabolic abnormality, such as hyperglycemia, dyslipidemia, or hypertension, face a 31% higher risk of being diagnosed with CRC. This underscores the significance of managing weight and addressing metabolic health concerns as part of a comprehensive approach to reducing the risk of developing both cardiovascular disease and CRC. 

A study conducted in Taiwan involving a substantial cohort of over 94,000 patients delved into the relationship between cardiovascular disease and CRC prognosis. The findings demonstrated that individuals diagnosed with CRC are more prone to developing cardiovascular disease, particularly coronary heart disease, within the first three years following their CRC diagnosis. This highlights the need for comprehensive health management strategies encompassing cancer treatment and cardiovascular health for CRC patients. 

Uninsured and the Risk of CRC, Cardiovascular Disease 

In a noteworthy cohort study published in June 2022, researchers examined over 197,000 cases of CRC from the SEER database to study the prognosis of CRC patients. They assessed mortality trends due to cardiovascular disease and identified risk factors to develop a predictive model for cardiovascular disease outcomes in this population. The study unveiled a significant risk factor: lack of insurance coverage. It was found that CRC patients without insurance faced a higher likelihood of cardiovascular death than those with health coverage. These findings emphasize the need for further exploration of the link between social determinants of health and health outcomes. 

As we conclude our exploration of the connection between cardiovascular disease and CRC, it becomes increasingly evident that these two conditions share risk factors and impact each other’s prognosis. This knowledge encourages a holistic approach to

healthcare that prioritizes overall well-being and seeks to achieve optimal health outcomes for individuals facing these conditions. By addressing common risk factors, focusing on metabolic health, and implementing comprehensive healthcare strategies, we can strive to minimize the impact of both cardiovascular disease and CRC.

 

Emma Edwards is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

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UnitedHealthcare to Implement Prior Authorization for Certain Colonoscopies

Update on June 2nd, 2023: Following an outcry from physician groups and patient advocacy groups, UnitedHealthcare (UHC) has slightly modified their policy. Gastroenterologists will now be required to submit an advance notification to UHC before conducting diagnostic or surveillance colonoscopy procedures. Under the revised policy, care will not be denied, so patients will not face out-of-pocket costs. However, physician groups remain skeptical.

 

Individuals who are covered under UnitedHealthcare’s commercial insurance will now require prior authorization for a colonoscopy. This policy, which goes live on June 1, 2023, does not apply to screening colonoscopy, which is conducted in individuals (45-74 years) at average risk who are healthy and do not display any gastrointestinal symptoms.

To understand the prior authorization process, read more here.

Procedures that will require prior authorization include:

  • Diagnostic colonoscopies: conducted in those who have a greater risk of colorectal cancer. This would include individuals with abnormal gastrointestinal symptoms, polyps in the colon, or a positive screening test.
  • Surveillance colonoscopies: conducted in those who have a personal history of colorectal polyps or cancer.

Will This Create Access Barriers for Patients?

Physicians are concerned that this procedural change will impact both patients and healthcare staff. Prior authorization adds a layer of administrative burden for clinics and hospitals. More importantly, gastroenterologists and oncologists are concerned that patients may face unnecessary delays in diagnostic procedures, which can potentially affect disease outcome.

Folasade May, M.D., Ph.D., M.Phil., expressed her concerns with long wait times—maybe even weeks or months—for the approval to come through. For patients with aggressive disease, being left undiagnosed while waiting for insurance approval could mean advanced stage cancer, which is usually difficult to treat.

Colonoscopy procedures can be expensive if paid for out of pocket. The procedure alone can cost on average $2,125; this can increase to an average of $2,543 with the added costs of anesthesia, pathology, and bowel preparation.

 

Surabhi Dangi-Garimella, Ph.D. is a Scientific Consultant with the Colon Cancer Foundation.

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Adults Aged 45-49 Risk Losing Free Colon Cancer Screening Services

Millions of Americans risk losing free preventive care after a Texas judge ruled against the Affordable Care Act’s (ACA) preventive services requirement. This could potentially derail the gradual uptick in screening rates among 45-49-year-old Americans–the age group that was recently asked to start screening for colorectal cancer (CRC).

ACA requires insurers to offer full coverage of preventive services upon recommendation of the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices, or the Health Resources and Services Administration. This means that enrollees do not have to pay anything out of pocket for those preventive services. However, Texas federal judge Reed O’Connor ruled that the USPSTF is an independent panel of volunteers who are not officers of the U.S. government, and therefore, they are not qualified to determine which preventive services should be free. 

The ruling applies explicitly to new and updated recommendations by the USPSTF since the ACA was established in March 2010. If it stands, additions and revisions to USPSTF recommendations made after March 2010 may be subject to out-of-pocket costs. These could include lung cancer screenings, medications to lower the risk of breast cancer for high-risk women, preexposure prophylaxis (PrEP) for HIV prevention, and statin use for heart disease prevention, among other recommendations. 

screening coverage

 

ACA and Colorectal Cancer Screening

CRC is a leading cause of cancer-related deaths in the U.S., and its incidence among individuals younger than 50 is rising. For the longest time, average-risk adults were asked to start preventive screening for CRC at 50 years and continue till 74 years. In 2021, the USPSTF expanded its recommendation and lowered the screening age to include adults ages 45 to 49. It is this 45-49 age group that may potentially begin to face cost barriers to CRC screening if Judge O’Connor’s ruling stands.

The ruling does not immediately invalidate the complete coverage of preventive services under the ACA; however, millions will soon be required to pay for certain preventative care services, which could impact screening rates. Medically underserved communities that experience significant healthcare inequities, including access to preventive screening for CRC, could face additional barriers to CRC screening and disparities in CRC healthcare outcomes.

 

Sahar Alam is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

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CDC Report: Why Do Certain Populations Never Screen for Colorectal Cancer?

Cancer screening remains a powerful tool. Even limited screening has long-term benefits compared to no screening  and can lower the risk of cancer and related deaths. A recent study by researchers at the CDC compared data on adults who reported they had not received a colorectal cancer (CRC) screening test between 2012 and 2020 using information from the Behavioral Risk Factor Surveillance System (BRFSS). The study identified various trends, most notably that 22 states did not meet the CDC’s Healthy People 2020 goal of 70.5% adults screened for CRC.

The sample was limited to adults aged 50 to 75 years, with up to date screenings defined as one of the following:

  • Home stool-blood test within the past year
  • Sigmoidoscopy within five years with fecal occult blood test or within one year with fecal immunochemical test
  • Colonoscopy within ten years

The ‘never screened’ numbers were a composite of those who answered no to being screened or those who were not up to date. Those who declined to answer or reported uncertainty were excluded. Overall, the study identified:

  • A 5.8% decrease in unscreened adults between 2012 and 2020 
  • States with the largest improvements were also those with the largest unscreened population in 2012 

 

Despite these improvements, CRC screening goals have yet to be met and may be difficult to meet with the new Healthy People 2030 standards. The target of 74.4% screened may have been a challenge to meet, possibly further exacerbated by the COVID-19 pandemic.

Researchers noted that including just two more questions on the BRFSS in 2020, the percentage of up to date screenings increased to 71.6%. These two questions enquired about:

  • Stool DNA testing
  • Computerized tomographic colonography

It is important to note that the National Colorectal Cancer Roundtable—a membership organization established by the CDC and the American Cancer Society—has set its goal to 80% screening rates across the country.

Study authors recognized recall bias and an inability to distinguish between screening versus diagnostic tests as major study limitations. Additionally, social desirability bias and a low response rate may have also affected the results. However, financial factors and health disparities may also describe the differences between states.

Following implementation of the Affordable Care Act, researchers at the American Cancer Society found that CRC screening among low-income adults across the U.S. increased by up to 8%, with the greatest increases observed in early Medicaid expansion states. They also noted that a majority of those who were never screened also lived in a state without expansion (South Dakota). 

Nonfinancial factors such as health disparities were studied in a mixed-methods analysis conducted at the Virginia Commonwealth University’s School of Medicine. Here, researchers noted that participants of gender-specific and race-specific focus groups brought forth nuanced concerns regarding screening. This included lack of awareness of both the disease and the screening, lack of physician recommendation that is clear and rational, and fear of being diagnosed and complications associated with testing. These concerns, if unaddressed, may limit others from seeking out CRC screening.

To read more about the Healthy People 2030 CRC screening standards and the current progress, visit Healthy People 2030.

 

Kaylinn Escobar is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation. 

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Medicaid Expansion May Have Improved Diagnosis of Early-Stage CRC

Health insurance coverage is an important determinant of access to health care. Most people in the U.S. receive health insurance through their employers and many others qualify for government insurance programs like Medicare (generally for those >65 years) or Medicaid (for low-income families/individuals). The 2010 Affordable Care Act mandated preventive screening coverage for those who are enrolled in Medicaid and provided support to participating states. A cross-sectional cohort study has now revealed that after Medicaid expansion in 2014, the proportion of patients diagnosed and treated at Commission on Cancer–accredited facilities increased within expansion states and decreased in non-expansion states. 

This study evaluated whether the proportion of patients diagnosed with early-stage colorectal cancer (CRC) changed over time within states that expanded Medicaid, compared with non-expansion states. The authors queried the multicenter registry data from the National Cancer Database (2006-2016) and identified a total of 10,289 patients in expansion states and 15,173 patients in non-expansion states. They found:

  • A 0.9% annual increase in the number of individuals diagnosed with early-stage CRC in expansion states after 2014 
  • A 0.8% annual reduction in the number of individuals diagnosed with with early-stage CRC in non-expansion states after 2014 
  • By 2016, the absolute difference in the propensity-adjusted proportion of early-stage CRC was 8.8% 

Similarly, a study published in the Journal of American Surgeons also found that Medicaid expansion has had a notable impact on the diagnoses of early-stage CRC compared to non-expansion states. 

Improved insurance coverage following Medicaid expansion may have facilitated access to screenings and earlier diagnoses. 

For more information on insurance coverage for CRC screening, please visit: Insurance Coverage for Colorectal Cancer Screening. 

 

Kitty Chiu is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

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