The National Colorectal Roundtable is heading the push for the "80 by 2018" initiative, which aims to raise the national colorectal cancer screening rate to 80 percent by 2018. Three gastroenterologists and three colorectal surgeons discuss what physicians in the GI field can do to help boost screening rates and patient awareness.
Ask a Gastroenterologist is a weekly series of questions posed to GI physicians around the country on business and clinical issues affecting the field of gastroenterology. We invite all gastroenterologists to submit responses. Next week's question: What are a few of the best GI practice marketing ideas?
Alan Yahanda, MD, FACS, Chief of Surgery, Cancer Treatment Centers of America at Southeastern Regional Medical Center (Newnan, Ga.): Efforts to increase colorectal cancer screening rates need to be initiated more by the primary care physician than the gastroenterologist. There are a number of studies that demonstrate that the rates of referral for colonoscopy are significantly better if the primary care physician believes in the utility and importance of colonoscopic screening and spends the time to counsel the patient about that. If the referral is not made, then the gastroenterologist would have little ability to screen the patient.
The more widespread use of electronic health records may also be helpful in increasing colorectal cancer screening rates. The system can be designed to issue warning or reminder notices for patients who are candidates for screening and keep track of when their next examination might be due. Furthermore, the EHR can be programmed to modify those notifications based on the patient's past history of colorectal polyps or cancer and for any significant family history of colorectal cancer.
The use of nurse navigators in counseling patients about the importance of colonoscopic screening and in helping facilitate the scheduling and preparation for the examination has also been shown to improve compliance. Perhaps one of the most important things that they can do is to allay the patient's fear and debunk some of the misconceptions about the procedure. These navigators could be involved at either the level of the primary care physician or the gastroenterologist.
As for the gastroenterologist, it will be important that they continue to develop and test new, less invasive or disruptive means of cancer screening. Examples of such testing now being evaluated include fecal DNA testing, CT colonography or capsule colonoscopy.
Lastly, it is the responsibility of the primary care physician, gastroenterologist and the entire medical community to educate the public about the need for screening and that colon cancer can largely be prevented with regular colonoscopic examinations.
Maxwell Chait, MD, FACP, FACG, FASGE, AGAF, ColumbiaDoctors Medical Group (Hartsdale, N.Y.): Colorectal cancer develops slowly over many years as a noncancerous adenoma or polyp. Polyps can be removed to significantly reduce cancer risk. CRC is the third-leading cause of death from cancer in the United States for men and women. More than 140,000 people in the United States are diagnosed with colorectal cancer each year and more than 50,000 die because of it annually. The majority of CRC can be prevented with proper screening, early detection and removal of adenomatous polyps. Screening helps prevent CRC by finding precancerous polyps so they can be removed before they turn into cancer. The five-year survival rate for people with CRC discovered early is greater than 90 percent. But only 39 percent of CRCs are found at that early stage. Five-year survival rapidly declines when the cancer has spread to nearby organs or lymph nodes.
CRC risk factors should be ascertained. They are family history of CRC or polyps, a known family history of inherited CRC syndromes, a personal history of CRC, a personal history of chronic inflammatory bowel disease, such as ulcerative colitis or Crohn's Disease or individuals or who have other types of cancers. They are at increased risk for developing the disease and need to undergo more aggressive screening starting at a younger age. CRC can occur with or without symptoms, family history or any predisposing conditions. Evaluate for red flag symptoms of CRC such as blood in the stool, narrower than normal stools, abdominal pain, change in bowel habits and anemia.
Screening should begin at age 50 in both men and women at average risk for developing CRC, since the risk of developing CRC increases with age, with more than 90 percent of cases occurring in persons aged 50 or older. Men and women should begin screening earlier and more often if they have any of the CRC risk factors noted above. There are several screening methods which have different abilities to detect or prevent CRC: stool blood test known as fecal occult blood test or fecal immunochemical test, flexible sigmoidoscopy, colonoscopy, CT colonography, barium enema with air contrast and stool DNA testing. Tests that mainly detect cancer include FOBT and stool DNA. Tests that mainly detect polyps or cancer include colonoscopy, flexible sigmoidoscopy, CT colonography and barium enema. Colonoscopy is considered the gold standard of CRC screening methods for its ability to view the entire colon and both detect and remove polyps during the same procedure. Patients should be offered one of the alternate methods if they refuse colonoscopy screening.
Studies of different populations have identified associations that may affect the risk of developing colorectal cancer. Smoking clearly increases the risk of CRC and other cancers. Studies have shown an increased risk of CRC among individuals with higher red meat or non-dairy, meat-associated, fat intake. Adequate amount of calcium and vitamin D in the diet or from supplements can reduce the risk of polyps and cancer. Use of aspirin and NSAIDs, such as celecoxib, sulindac and aspirin has been proven to decrease the risk of colorectal polyps. Probiotics, vitamins and other natural products have been examined for their role in CRC prevention. Few studies have been able to show that modifying lifestyle reduces the risk of colorectal polyps or cancer. Regardless of dietary and lifestyle habits, screening for colorectal polyps is the key in preventing CRC.
Although all men and women are at risk for CRC, certain populations are at higher risk for the disease because of age, lifestyle or personal and family medical history. Hispanic Americans are less likely to get screened for the disease than either Caucasians or African-Americans. African-Americans are at a higher risk for the disease than other populations. The incidence and death rate of CRC is higher among African-Americans and Hispanic Americans than other population groups in the United States. Research shows that African-Americans are being diagnosed at a younger average age than other people. They are less likely than Caucasians to get screening tests for CRC and are less likely than Caucasians to have colorectal polyps detected at a time when they can easily be removed. They are more likely to be diagnosed with CRC in advanced stages when there are fewer treatment options available and are less likely to live five or more years after being diagnosed with CRC than other populations. African-American women have the same chance of getting CRC as men, and are more likely to die of CRC than are women of any other ethnic or racial group. Also, African-American patients are more likely to have polyps deeper on the right side of the colon. Therefore, some experts suggest that African-Americans should begin their screening at age 45.merican
Ana Garza, MD, Colorectal Institute, Dignity Health Glendale (Calif.) Memorial Hospital and Health Center: Routine colorectal cancer screening with a colonoscopy undeniably saves lives. All colorectal cancers are believed to originate from a polyp, and those polyps can be readily removed colonoscopically, thus stopping the progression to cancer. No other screening tool simultaneously allows therapeutic intervention with the removal of pre-cancer lesions. If patients are routinely screened, we can decrease the number of colon cancers and deaths from colon cancers.
Many patients are afraid to undergo a colonoscopy. They are often embarrassed, or misinformed about the discomfort associated with colonoscopies. The reality is that the colonoscopy is done with sedation and patients usually wake up wondering when the procedure will actually start. Other patients may believe they are not at risk, or simply are not aware of the national recommendations to undergo a colonoscopy at the age of 50, and sometimes even earlier.
Most people over 50 years old have seen a doctor, but too often are not referred for a screening colonoscopy. It is imperative that physicians who treat patients for acute or chronic problems also educate their patients about screening colonoscopies. Gastroenterologists and colorectal surgeons must make patient and physician education a priority. We, at the Colorectal Surgery Institute at Glendale Memorial Hospital, help improve the rate of colorectal cancer screening in our community by participating in media coverage of this preventable disease, organizing regular lectures and seminars to our colleagues and nursing staff and sharing informative literature on prevention with physicians in our area. We educate our own patients and their family members about risk factors and encourage high risk family members to get screened. Prevention is the easiest way to cure colorectal cancer.
Gary H. Hoffman, MD, Los Angeles Colon and Rectal Surgical Associates: While many people are aware of the need to screen for colon cancer and rectal cancer, many others are either afraid to reach out for help, or are unaware of the real risks of developing this preventable disease. Through our efforts to educate the public, colon and rectal surgeons have helped lower the rates of colon cancer. Each year, 150,000 people are newly diagnosed with colorectal cancer, and 50,000 die of it. Although large, these numbers represent a dramatic decrease from prior years. The key to this decrease has been patient and family education. In particular, we use our website as an educational tool to help patients understand that a visit to the Colon and Rectal specialist is an easy, painless and educational experience.
Through media awareness and persistence on the part of Colon and Rectal Surgeons and the medical community, colon and rectal cancer death rates have declined over the past 10 years. We are educating patients about the benefits of early screening methods such as colonoscopy, barium enema and virtual colonoscopy. These are used to find and remove polyps before they can become malignant. Additionally, colorectal cancers may be clustered in families, may have a hereditary component, and are preventable with early education and detection. We encourage all patients that have a family history of colon cancer to undergo genetic testing for hereditary colon cancer as early as possible.
We have brought colon cancer into the open, allowing patients and families to talk about this preventable illness and to talk about preventive strategies available to all family members. However, while we can educate, the final step of trust belongs to the patient. The colorectal surgeon can offer a gentle manner and a safe environment but it is the patient who must trust and move forward with life saving prevention strategies.
William Katkov, MD, Providence Saint John's Health Center, Santa Monica, Calif.:We have made great strides to achieve universal screening for colorectal cancer. However, far more than a fourth of adults aged 50 to 75 years have not been screened. Gastroenterolgists can play an active role in the effort to increase the rate of colorectal cancer screening in the U.S. The key is to facilitate access to colonoscopy screening and to take advantage of in a positive and ethically responsible manner the broad coverage for colon cancer screening under the Affordable Care Act. The traditional model of primary care referral for screening will remain intact, but there is great potential for direct and open access to screening too. Marketing and messaging are essential: colonoscopy is a highly effective cancer prevention tool. While colonoscopy is the optimal screening modality, physician and patient education is essential so that all available screening tools be made available including fecal occult blood testing. Any screening for colon cancer is better than no screening at all.
Patrick Takahashi, MD, CMIO and Chief of Gastroenterology Section of St. Vincent Medical Center, Los Angeles: Colorectal cancer screening continues to improve on an annual basis. With more awareness of colorectal cancer screening, it has become easier for physicians to approach this topic as the majority of patients have heard of the term "colonoscopy."
As gastroenterologists, we must continue to educate not only our patients, but also referring physicians as to the importance of colorectal cancer screening. Many primary care physicians are unaware of the fact that most commercial plans cover screening colonoscopy. On the contrary, insurance companies often report rates of screening for colorectal cancer by physician to the general public, therefore shedding a bad light on those physicians who are not screening their patients.
It behooves us as specialists to get the word out. I have found that sending a quick note or postcard about updated screening guidelines for colonoscopy is helpful for busy primary care physicians, especially as it pertains to familial risk factors, racial demographics and the like. Reminder systems through an electronic health record are critical for recalling patients for screening/surveillance colonoscopy purposes. Patients can also be reminded of testing via written communication or a simple telephone call from the office. For those patients who may be leery about having colonoscopy done, I at least offer screening the stool for occult blood. In this manner, it is a way to garner the patient's trust, with the ultimate goal of performing a screening test of some sort.
Patients often times have so many reservations about colonoscopy, mainly because they are unaware of all the potential risks, alternatives and expectations. Ultimately, it comes down to communication in regards to increasing colorectal cancer screening. By effectively discussing the issues at hand with patients while offering them acceptable alternatives, we can get them on board as well as save a few more lives along the way.
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