In response to growing early-onset colorectal cancer rates, the U.S. Preventive Services Task Force issued draft guidelines Oct. 27 to lower the CRC screening age to 45.
AMSURG, the ambulatory division of Nashville, Tenn.-based Envision Healthcare and a leading colonoscopy provider, made a similar recommendation at the start of this year. More recently, it published findings that nearly 200,000 Americans have missed their colonoscopies this year.
Jay Popp, MD, AMSURG’s medical staff lead, spoke to Becker's ASC Review about the proposed new guideline and the importance of early detection to CRC prevention.
Note: Responses were lightly edited for style and length.
Question: What is the significance of the U.S. Preventive Services Task Force's upcoming guidance that the CRC screening age be lowered to 45?
Dr. Jay Popp: The American Cancer Society made that recommendation in 2018, and it's very important to get this endorsement from the USPSTF. Even though it's a draft statement and people have a month to make comments, I think it's very likely to go into effect. The reason it's important is we've seen this dramatic increase in the incidence of colon cancer in people under 50. In fact, over about the last 25 years, there's been about a 50 percent increase in the incidence of colon cancer in people under 50. And of the people under 50, about half are in that 45-to-49 age category. As we've seen this incidence go up, we also know that younger people tend to get more advanced disease so it's harder to treat; I'm hopeful that this will become a cast-in-stone recommendation. I think everybody's very much in favor of it for public health reasons.
The puzzle about this young age onset cancer is we really don't know why it's happening. There are many things that can contribute to the development of colon cancer — family history is right up there — but then there are environmental factors, obesity, lack of exercise.
Q: How is AMSURG working to ensure the right patients are getting preventive screening?
JP: We're trying to get across that people under 50 who have digestive symptoms that may be something benign shouldn't just blow it off and say, 'I see a little blood in my stool, but it's probably a hemorrhoid. I'm too young to have colon cancer.' That's the kind of thinking we really want to change. If you look at rectal cancer and the time that younger people wait from the time they have symptoms till the time they're diagnosed, it's far more than for people over 50. People over 50 tend to say, 'This is a problem. I'm going to go see a doctor,' and those under 50 wait. So, we're trying to get that message across not only to patients, but to doctors as well. We all need education around this to take these symptoms seriously when they occur.
That's our major concern: making sure people understand all types of healthcare screening need to continue despite COVID-19, and reassuring patients, especially on the ASC side, that these things can be done very safely, in a very safe environment. A compilation put together by the ASC Quality Collaboration looked at over 700 centers. The incidence of COVID-19 in the two weeks following a procedure in an ASC was roughly two in 10,000. So, I think we as an industry have done a good job. AMSURG has gone to great lengths to make sure that our centers are safe, we have credible protocols set up. We need people to feel comfortable coming to get these necessary screenings done.
Q: What are some challenges for CRC screening, especially in light of the pandemic?
JP: There certainly can be anxiety on the part of our staff. What we do to reassure staff and patients is make sure we've got adequate PPE, protocols in place as to what we must do before a patient or staff member arrives at the facility. We have staff members monitored every day. They report any symptoms they have, their temperature is taken, and a log is kept. That gives people some peace of mind. Now, you have the flu season. We've been very diligent in encouraging all our providers, staff and patients to get the flu vaccine, and we know there is some resistance, that people are fearful of getting vaccines.
When we think about colonoscopies, there's certainly a financial barrier for some patients. Fortunately, people with insurance generally have coverage for screening colonoscopies; it's been a benefit now under Medicare and most commercial plans for a number of years. The other barriers may be being able to take off work or fear of the procedure. This is education that doesn't happen overnight. Every year, we develop new messaging tailored to what's most important to people. We are involved at AMSURG in a number of advocacy projects. We sponsor the National Colorectal Cancer Roundtable, we sit on some of their task forces. Fight CRC and Colorectal Cancer Alliance are two other advocacy organizations. We participate with all those organizations to try to help with advocacy. We're all about prevention. Coverage is a big issue, but I think we've made a lot of progress in getting the full continuum of colorectal screening paid for, and we're not going to quit — that's for sure.
Q: For GIs, what will the fallout of the pandemic look like over the next decade?
JP: GIs are still going to be necessary, and they may be doing some different things, like more telehealth, but procedures are here to stay. There was great interest in telehealth prior to the pandemic. That's been ramped up in a tremendous way and embraced by the GI profession. You just can't do some things over the phone or with a touch screen, but you can certainly do a lot. We'll certainly be relying on that more and more. Patients who've experienced telehealth by and large really like it. A lot of physicians like it; it's much more efficient.
Technology will continue to change when we think about colon cancer screening. We know colonoscopy is the best test because it gives you the opportunity to not only identify precancerous lesions but also to remove them. But there are many other modalities. There are non-invasive tests that are stool-based. There are being developed now blood-based tests not only to look for colon cancer but also many other cancers. So, we have to be prepared for change.