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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.

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 Canceraccredited 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.

A friendly bet resulted in a potentially life-saving procedure for actors Ryan Reynolds and Rob McElhenney. Reynolds bet McElhenney that if he learned to speak Welsh, Reynolds would let a camera crew document him as he underwent a colonoscopy. In partnership with Lead from Behind, Reynolds documented and shared his experience on YouTube

Both Reynolds and McElhenney turned 45-years-old this year. In May 2021, the US Preventive Services Task Force (USPSTF) revised the colorectal cancer (CRC) screening age for average-risk adults to 45 years instead of 50. Reynolds noted in his video description, “I made a bet. I lost. But it still paid off.” Reynolds’ colonoscopy, conducted by Jonathan LaPook, MD, a gastroenterologist with NYU Langone’s Colon Cancer Screening and Prevention Program, resulted in the detection and removal of an “extremely subtle polyp” on the right side of his colon. McElhenney also decided to undergo a colonoscopy, which resulted in the identification of three polyps. Dr. LaPook emphasized, “This [colonoscopy] saves lives. Pure and simple.”

Importance of Colorectal Cancer Screening

Colorectal cancer (CRC) is the third most diagnosed cancer and over 5 million people worldwide currently live with CRC. According to the American Cancer Society, the lifetime risk of developing CRC is 1 in 23 for men and 1 in 25 for women, and recent research indicates an increased incidence of CRC among individuals younger than 50 years of age. There will be an estimated 106,180 new colon cancer cases and 44,850 new rectal cancer cases in the United States in 2022. While CRC screening rates have significantly improved over the past 20 years, only 65%-70% of age-eligible individuals achieve screening nationally. Screening is a significantly effective and preventive method to detect CRC before it advances to an incurable stage. 

When to Schedule a Colonoscopy

The American Cancer Society and USPSTF recommend screening should begin at 45 years for average-risk adults. Individuals who are at a higher risk of developing CRC may need to be screened earlier.

What to Expect During a Colonoscopy

A colonoscopy detects swollen, abnormal tissues, polyps, or cancer in the large intestine (colon) and rectum. Before a colonoscopy, patients are required to empty their colon by following a specific diet recommended by their doctor, taking a prescribed laxative, and adjusting any daily medications as instructed by their doctor. On the day of the procedure, a long, flexible tube (colonoscope) is inserted into the patient’s rectum under anesthesia. A tiny camera at the tip of the tube allows the doctor to view the colon. If polyps and abnormal tissues are detected, they can be removed during the colonoscopy itself, just like in Reynolds’ and McElhenney’s procedures. According to the American Society for Gastrointestinal Endoscopy, more than 40% of adults over the age of 50 years have precancerous polyps in the colon.  

What Are Colorectal Cancer Symptoms?

CRC may not cause symptoms immediately. Screening is the most effective method to detect and remove polyps before they advance into malignant disease. Speak to your doctor if you are 45 or older, have a family history of CRC, or notice any abnormal symptoms.

Remember: CRC survival is 90% if detected at an early stage when the cancer is localized and has not spread to other sites or organs.

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

Colorectal cancer (CRC) is the third most common cancer diagnosis and the second most common cause of cancer death globally. The American Cancer Society estimates that there will be 106,180 new colon cancer cases and 44,850 new rectal cancer cases in the United States in 2022. Early detection and consistent screening reduce CRC incidence and mortality. A recent randomized controlled trial that analyzed the feasibility, adherence, yield, and related costs of various screening modalities found that a risk-adapted approach is feasible and cost-favorable for population-based screening. 

Current guidelines recommend standardized screening plans for specific age groups, with colonoscopy recommended every 10 years and a fecal immunochemical test (FIT) between 1-3 years. Implementation of risk-stratified screening can potentially allow for more frequent screening and earlier detection of CRC at a population level. This would especially be beneficial for individuals who are at higher risk of CRC. Additionally, risk-stratified screening can help health practitioners detect and introduce plans for CRC treatment at earlier stages.

The National Health Service Breast Screening Programme (NHSBSP) recently investigated the potential benefits, costs, and effectiveness of risk-stratified breast cancer screening with BC-Predict, a platform that collects self-reported risk factor information for breast cancer, analyzes the self-reported information, and invites high-risk or moderate-risk women to a conversation about prevention and early detection options. BC-Predict was found to have the potential to reduce breast cancer mortality due to early screening. It also reduced screening in women who are at lower risk, minimizing the number of false positive test results in lower-risk women. The results from this analysis are pertinent to risk-stratified screening for CRC and support the implementation of a risk-adapted approach in CRC screening.

What Did the Study Find?

More than 19,000 participants in the TARGET-C trial conducted in six cities in China were placed into one of the screening arms in a 1:2:2 ratio: 

  • One-time colonoscopy (n=3,883)
  • Annual fecal immunochemical test (FIT) (n=7,793)
  • Annual risk-adapted screening (n=7,697).

The detection rate of advanced colorectal neoplasia, CRC, and advanced precancerous lesions were the main outcomes that were monitored. The follow-up to trace the rate of advanced colorectal neoplasia for all participants was conducted over a 3-year study period. 

Over three screening rounds, the participation rates for colonoscopy, FIT, and risk-adapted screening arms were 42.4%, 99.3%, and 89.2%, respectively. The costs to the for detecting one advanced neoplasm, presented as both Chinese Yuan (CNY) and US dollar, using a package payment format were:

  • CNY6,928 ($1,004) for one-time colonoscopy
  • CNY5,821 ($844) for annual fecal immunochemical test (FIT)
  • CNY6,694 ($970) for annual risk-adapted screening.

These findings underscore the value of a risk-adapted approach for CRC screening for feasibility and cost-effectiveness, as well as for allowing for more frequent screening and earlier detection of CRC for individuals with a high or moderate risk for CRC.

 

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

In May 2021, the US Preventive Services Task Force (USPSTF) revised the colorectal cancer (CRC) screening age for average-risk adults to 45 years. However, stakeholders are concerned about the lack of awareness, access, and motivation among the younger age group to get screened. Now, a new research study has found that the prevalence of CRC screening remained lowest for individuals ages 50 to 54 years old and young adults (age<50) experienced smaller increases in screening prevalence over time, regardless of race, ethnicity, education, income, and insurance coverage. 

An investigation using population-based data from the National Health Interview Survey (NHIS), an annual, cross-sectional survey of the U.S. population conducted by the National Center for Health Statistics at the U.S. Centers for Disease Control and Prevention, studied CRC screening participation using surveys from multiple years. A sample of 80,220 participants ages 50 to 75 years old was analyzed for CRC screening participation. For each survey year, the prevalence of CRC screening was estimated for age, race, ethnicity, educational attainment, family income, and health insurance.

Racial, ethnic, and socioeconomic disparities influence screening rates. Despite the prevalence of CRC screening increasing from 36.7% in 2000 to 66.1% in 2018, screening prevalence was observed to be the lowest for:

  • Participants ages 50 to 54 years old
  • Hispanic populations (56.5%)
  • Asian populations (57.1%)
  • Participants with less than a high school degree (53.6%)
  • Participants from low-income families (56.6%)
  • Participants without insurance (39.7%) 

This may be the result of a lack of concern for cancer and cancer screening among younger adults and their healthcare providers, limited access to healthcare, absence of or limited insurance coverage, and other priorities for young adults, such as work and family. Disparities in screening rates can potentially extend to adults ages 45 to 49 as the new USPSTF recommendations are implemented. Multilevel barriers, such as patient-, provider-, and system-level factors, impact the completion of CRC screening for young adults (age<50), creating disparities and inequities in CRC screening. The administration of new CRC screening guidelines must acknowledge and account for multilevel disparities in screening programs to ensure all populations have equal access to CRC screening and benefit from CRC screening, especially newly eligible adults ages 45 to 49 years old. 

The benefits and outcomes of the updated USPSTF guidelines to extend CRC screening to ages 45 to 49 years old have been debated by clinicians and researchers. Concerns about the updated guidelines include redirecting endoscopic resources away from higher-risk and older patients, resulting in a more significant exacerbation of health disparities. Another criticism is that adults ages 45 to 49 years old who participate in screening may be less likely to belong to groups at higher CRC risk. 

One benefit of expanding CRC screening to the 45-49 age group is to increase the screening participation rate among older populations. Awareness of CRC screening may also increase, resulting in newly eligible adults having more time to schedule their first screening test. However, the impact of screening among those in the 45-49 age group on disparities, benefits, and participation of older adults may take several years to be fully recognized and understood, as the USPSTF’s effect on insurance coverage only occur in mid-2022.

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

The American Gastroenterological Association (AGA) has developed 8 position statementssolutions 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.

Colonoscopy is the most effective test for colorectal cancer (CRC) screening and prevention. This procedure minimizes the incidence and mortality of colorectal cancer through early detection. During a colonoscopy, a physician inserts, and threads a flexible tube with a tiny camera called a colonoscope into the rectum and through the entire colon, or large intestine. This helps identify abnormal growths and excise any polyps which can then be sent for diagnosis.

However, research has shown that despite being the gold-standard for CRC screening, 23-30% of adenomas are overlooked and missed during a traditional colonoscopy, the success of which can vary depending on operator skills.

“Colorectal cancer is the second leading cause of cancer-related deaths in the United States and it is one of the few cancers that can be prevented if caught early,” said Aasma Shaukat, MD, MPH at NYU Grossman School of Medicine and the Robert M. and Mary H. Glickman Professor of Medicine and Gastroenterology and Director of Outcomes Research for the Division of Gastroenterology and Hepatology. “Our mission remains to improve and enhance the quality and efficacy of the colonoscopy across the board to provide the best care for patients.”  

In order to improve the efficiency and efficacy of colonoscopies, Dr. Shaukat and her team have developed an artificial intelligence (AI) platform to assist endoscopists. The findings of their  prospective, randomized, multicenter collaborative study to test the AI platform were recently published in the journal Gastroenterology. Between January and September 2021, twenty-two skilled, board-certified gastroenterologists performed colonoscopies on 1,440 patients. The patients were randomized to receive a traditional colonoscopy or a colonoscopy with computer-aided detection software —the software detects colorectal polyps during high-definition white-light colonoscopy procedures. This device can identify potential polyps and identify areas of concern, refining the results of the procedure in real-time. 

The researchers found that using AI during a screening colonoscopy increased the adenoma per colonoscopy rate by 22%: from 0.82 to 1.05. This evidence indicates that AI can be an effective and efficient tool for gastroenterologists and endoscopists to reduce the number of overlooked polyps left behind in the colon, many of which can be precancerous. 

Dr. Shaukat states, “Our findings add to the growing amount of literature that shows using computer-aided technology during an endoscopy procedure can improve the quality of exams performed and improve outcomes for our patients. Several software technologies are currently available for clinicians and incorporating the use of these resources will only enhance the care we provide our patients and improve the quality of exams we as physicians are able to perform.”

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