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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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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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Patient Preference Key to Success of Colorectal Cancer Screening Programs

Colorectal cancer (CRC) screening is a vital preventative method to detect and remove a polyp and to diagnose cancer before it advances to an incurable stage. CRC screening options include endoscopy and stool-based testing. Now a new study that surveyed unscreened individuals at average risk for CRC has found that people have a preference for the stool-based screening option. 

The third most diagnosed cancer in the U.S., over 5 million people worldwide currently live with CRC. One method of CRC screening is a colonoscopy, which detects swollen, abnormal tissues, polyps, or cancer in the large intestine (colon) and rectum. Another form of CRC screening is the fecal immunochemical test (FIT). FIT is one of the most widely used CRC screening methods globally and is an affordable screening tool for studying large populations. FIT detects hidden blood in stool, a potential early sign of cancer, and it has an overall 95% diagnostic accuracy for CRC. 

It is estimated that 106,180 new colon cancer cases and 44,850 new rectal cancer cases will be diagnosed in the U.S. in 2022. With the screening age for CRC for average-risk adults lowered to 45 years, we need a better understanding of what the various age groups may prefer as a screening option to improve compliance and screening rates. 

The new study that was published has found that individuals in the 40-49 age group and those ≥50 years prioritized test modality above effectiveness when choosing their screening test. The findings of this study demonstrate that:

  • Both 40-49-years-old and ≥50-year-old age groups preferred FIT-fecal DNA every three years
  • The second preferred test for both age groups was a colon video capsule, or capsule endoscopy, every five years 
  • Regarding only the USPSTF tier 1 tests, both age groups preferred an annual FIT over a colonoscopy every ten years
    • 68.9% of 40-49-year-olds and 77.4% of ≥50-year-old participants preferred an annual FIT

These results conflict with current CRC screening approaches in the U.S., where colonoscopy is the screening test customarily used. Furthermore, these findings prompt the modification of current CRC screening guidelines and suggest that healthcare providers consider sequential-based screening procedures where FIT is offered before colonoscopy. The results, however, are consistent with a 2007 study, which supports the effectiveness of providing FIT before colonoscopy—the percentage of patients that were up-to-date with screening increased by almost 50% between 2000 and 2015 when they were offered direct-to-patient annual FIT outreach with colonoscopy. 

Scheduling delays and longer waiting times for colonoscopies have increased as millions of newly eligible individuals need a colonoscopy, all of which can strain resources and delay access and early screening for patients, especially for those at greater risk for CRC. Sequential approaches for CRC screening, such as those that offer FIT before colonoscopy, can help acknowledge and adjust to the increased need for screening and the lack of resources and help prioritize access to colonoscopy for those at greater risk for CRC.

 

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

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NCCN Policy Summit: Supporting Workplace Needs of Cancer Patients, Survivors

On June 17, 2022, the National Comprehensive Cancer Network (NCCN) held a policy summit to discuss cancer care in the workplace and building a 21st century workplace for patients, survivors, and caretakers.

One of the distinct portions of this summit was a panel on Patients, Survivors, and Caregivers in the Workplace: Contemporary Barriers and Solutions to Achieving Inclusive Workplaces. Panel moderator John Sweetenham, MD, FRCP, FACP, FASCO, Chair, NCCN Board of Directors, and Professor of Medicine, Associate Director of Clinical Affairs, UT Southwestern Simmons Comprehensive Cancer Center, noted that the disproportionate distribution of accommodations due to socioeconomic differences leads to inadequate care and suboptimal outcomes for certain populations.

Rebecca V. Nellis, MPP, Executive Director, Cancer and Careers, shared results from a 2021 Cancer and Careers/Harris Poll Survey, which found that for three-fourths of responders, work helped them cope and aided in their recovery. These statistics show us that we can work towards a healthier workplace environment for cancer patients  and subsequently influence their health outcomes. Lynn Zonakis, BA, BSN, Principal, Zonakis Consulting, former Managing Director of Health Strategy and Resources for Delta Air Lines, shared the strategies employed by Delta for combating the difficulties associated with a cancer diagnosis. “At all levels, I would say that people were very open to disclosure, and that was the vast norm, because in each work unit, at every level, there were multiple cancer survivors or survivorship in family members, so they understood that it was to their benefit to disclose.”

She did elaborate on the associated risks,  citing the example of pilots at risk of losing their jobs when disclosing mental health risks. This can be applied to a cancer diagnosis as well. “At a lot of organizations it can put you at risk. Some people will feel that their job could be vulnerable, and they won’t disclose it, so there’s no one size fits all,” she noted.

Workplace Flexibility for Patients and for Caregivers

Angela Mysliwiec, MD, Senior Medical Director, WellMed, touched on an important aspect of the support process: the caregivers. She spoke about a program at WellMed dedicated to assisting caregivers, who she explained are experiencing the same challenges as the person they’re caring for. “When it comes to work they need flexibility, they need to take care of themselves, they need their mental health cared for, and the organizations themselves who are often ill equipped to manage a person on staff with cancer can often be even more ill equipped to manage the caregiver,” Mysliwiec said.

Randy A. Jones, PhD, RN, FAAN, Professor, Associate Dean for Partner Development and Engagement, and Assistant Director of Community Outreach and Engagement at the University of Virginia, concurred with Mysliwiec. “Caregivers share the anxiety, they share the fatigue, along with some of the patients with cancer that they’re dealing with.” He also made a point about institutions having the resources to empower patients, especially since “people are more aware of these issues, you know people understand that there is an issue between how patients are getting benefits as well as how they may be navigating the system.”

Sweetenham and Nellis closed the panel by highlighting the importance of proactive planning instead of reactive planning. They recommended that organizations should implement workplace flexibility that should be communicated upfront to new employees, and then practice it on a regular basis instead of making adjustments and assumptions as events occur.

Employer Policies Play a Big Role 

Joanna Fawzy Morales, Esq., Chief Executive Officer, Triage Cancer, spoke to the audience about The Policy Landscape to Support Patients, Survivors, and Caregivers at Work. Morales pointed out that employment can be a contributor to financial toxicity in the form of lost wages, employee benefits, and more. She further elaborated on a point that Nellis had made about battling assumptions, saying that “Employers have assumptions about their employees who’ve been diagnosed with cancer and their ability to do their jobs. Health care professionals make a whole lot of assumptions about their patients and whether or not they want to work or they can work.”

Explaining the current and suggested employment rights and accommodations, Morales said that they play a big role in helping patients make educated decisions on next actions. While there is a significant lack of awareness of protections available through the law, there are several gaps that need to be bridged. “There are many opportunities to close those gaps to improve the quality of life of patients and their families and mitigate the financial toxicity of a cancer diagnosis,” she added. She concluded her talk by emphasizing the need to educate employers, health care professionals, and the cancer community.

From informing the employer to the employee to equitable care for patients and their caregivers, this policy summit discussed various aspects of cancer in the workplace, and how we can improve the experience for those involved.

Juhi Patel is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

Image credit: Mohamed Hassan, Pixabay

 

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COVID-19 Testing Prior to Endoscopy Heightened CRC Screening Disparities

Medically underserved communities experience significant health care inequities, including preventive screening for colorectal cancer (CRC) and CRC-related morbidity and mortality. Multilevel barriers to CRC screening and subsequent follow-up create disparities and inequities in individual outcomes. Pandemic-related pre-procedure COVID-19 testing has been shown to cause higher rates of endoscopy cancellations among patients from marginalized populations. This, in addition to financial concerns, patient mistrust, lack of access to specialists and colonoscopy services are just some of the barriers to completion of CRC screening and follow-up procedures. 

CRC Screening Disparities: What’s the Solution?

The fecal immunochemical test (FIT) is one of the most widely used CRC screening methods globally and is an affordable screening tool for studying large populations. FIT detects hidden blood in stool, which can potentially be an early sign of cancer, and is an affordable home-health test with an overall 95% diagnostic accuracy for CRC. However, to be an effective screening tool, each step of the multi-step screening process must be completed: a diagnostic colonoscopy must follow a positive FIT test. Failure to complete the screening process is associated with higher rates of CRC mortality. 

While patient navigation helps with follow-up after a positive FIT test, only one-third of patients complete colonoscopy. Proactive, organized CRC screening involving centralized tracking, reminders, alerts for providers, and culturally competent and tailored messaging for patients are more effective for improving screening rates for White and African American patients. Such tactics have also reduced the differences in screening rates and cancer-specific mortality between White and African American patients. 

The COVID-19 pandemic has disproportionately impacted medically-underserved communities. African American, American Indian/Alaska Natives, and Hispanic populations have been particularly hard hit. COVID-19 testing requirements prior to endoscopy have disproportionately affected medically-underserved communities. 

While COVID-19 testing was a requirement earlier in the pandemic, the American Gastroenterological Association updated its guidelines as our understanding of viral transmission improved, vaccines became available, and viral transmission during endoscopy was found to be minimal. However, multiple institutions have continued to require pre-procedure COVID-19 testing prior to medical procedure—including endoscopy—which has led to high rates of endoscopy cancellations among individuals from marginalized populations. Pre-procedure testing may have introduced an additional barrier to care and increased existing disparities in health care and health outcomes. 

Recommendations for Eliminating Screening Barriers

Researchers have recommended the following strategies to reduce the impact of disparities due to COVID-19 testing:

  • Mailing SARS-CoV2 testing kits to endoscopy patients several weeks pre-procedure
  • Offering rapid testing to patients on the day of the procedure
  • Offering an opt-out option for testing due to hardships, such as the inability to schedule testing due to work schedules, difficulties finding transportation, or the need for childcare

Multilevel barriers to CRC screening and appropriate follow-up after screening create disparities and inequities in health care outcomes. Healthcare systems must collaborate with healthcare providers, community leaders, and social service representatives to improve access to care and guarantee equitable health care for all.  

 

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

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AGA: Concerted National Approach Needed to Reduce CRC Burden

The American Gastroenterological Association (AGA) has developed 8 position statements—solutions to eliminate colorectal cancer (CRC) screening barriers and reduce CRC burden. Evidence supports the existence of disparities in CRC screening: individuals with low income and lack of access to insurance coverage are disproportionately affected. Cost-sharing for preventive screening, in the form of deductibles and copayments, can be a financial barrier for some individuals. CRC screening programs and policies should cover all the steps following screening because each element is essential to the effectiveness of a screening program. Furthermore, these factors should not be subject to cost-sharing. Uniform, equitable delivery of screening programs will not only improve adherence and participation in CRC screening but also eliminate health disparities and reduce the burden of CRC in the United States. 

The following infographic details AGA’s approach:

The position statements have been published in Gastroenterology.

 

Photo credit: Clarissa Watson on Unsplash

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

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Researchers Focus on Equity to Improve Colorectal Cancer Screening 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.

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The Urban-Rural Divide in Colorectal Cancer Screening

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.

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Colorectal Cancer Advocates Celebrate Screening Policy Reforms

patient consultation

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. 

Medicare covers a follow-up colonoscopy after a positive stool-based screening test result. Medicaid coverage policies vary based on the state.

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.

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