Colorectal cancer screening in 2015: Achievements to date & hurdles ahead

With accountable care organizations and population health on the rise, a premium is placed on preventative care. Colorectal cancer screening has been a central focus in healthcare and gastroenterology for years, with a significant pay off, but more remains to be done. Four gastroenterologists offer insight into the successful history of colorectal cancer screening and what the field looks like in 2015.

Question: Do you expect colorectal cancer screening rates to increase in 2015?

David LiebermanDavid A. Lieberman, MD, AGAF, AGA Institute Clinical Research Councillor, Professor of Medicine; Chief, Division of Gastroenterology and Hepatology, Oregon Health and Science University (Portland): Colorectal cancer screening rates have been increasing steadily over the past two decades. Over the past 10 years, there has been a 30 percent reduction in CRC mortality — an incredible success story. Currently, about 65 percent of individuals over age 50 years have had some form of CRC screening. I expect these rates to continue to increase. The American Cancer Society and the National Colorectal Cancer Roundtable, which includes the American Gastroenterological Association, have strongly endorsed the "80 percent by 2018" campaign. This will be a multi-pronged effort to reach the public and primary care providers. In addition, as accountable care organizations mature their products, I would anticipate a strong emphasis on preventive health measures, and chief among them will be CRC screening.

Harry E. Sarles Jr., MD, FACG, President of the American College of Gastroenterology: Screening rates will increase as the population ages. Family practice practitioners Dr. Sarlesare very gung-ho about referring people. There continue to be attempts, such as the effort to eliminate co-pays, to lower barriers.

The ACG is now signed on with HHS and the American Cancer Society to get to the "80 percent by 2018" goal. The push for screening is really related to the fact we have such a tremendous success rate with decreasing mortality. If we continue to boost screening, we will be able to decrease the rate even further. This could be one of the most unbelievable healthcare stories in the last decade.

C SchmittColleen M. Schmitt, MD, MHS, FASGE, president of the American Society for Gastrointestinal Endoscopy: I think screening rates will continue to increase. We are driving our efforts along with our sister GI societies. We are having conversations on the Hill, with the Department of Health and Human Services and we are working with the National Colorectal Cancer Roundtable (NCCRT) to improve CRC screening efforts.

Q: If CMS were to cut colonoscopy reimbursement, how could this affect CRC screening goals?

Xavier Llor, MD, PhD, chair, American Gastroenterological Institute International Committee, AGA representative, National Colorectal Cancer Roundtable: This would affect screening. Colonoscopy is one of the most effective ways to detect and prevent cancer. Cuts in GI have already been happening and our margins are becoming tighter and tighter.

DL: Colonoscopy is at the center of all CRC screening programs, either as an initial screening test, follow-up of another screening test or surveillance in higher-risk individuals. We have emphasized the need to perform and document high-quality exams. The impact of reduced reimbursement is difficult to predict. Some healthcare systems and providers may offer alternatives to colonoscopy as a primary screening strategy for CMS patients if there is a large reduction in reimbursement.  

CS: Frankly, I think that would be a tragic move. We are really seeing decreasing colorectal cancer rates and mortality. I think reimbursement cuts could potentially reduce access to screening colonoscopies for Medicare patients.

HS: This might turn the success story into a great American tragedy. Everything is related to access. Access for Medicare and Medicaid recipients would be adversely affected. There are physicians that ration exposure to those payers. Some physicians don't even work these payers. I think others would jump on this band wagon if these cuts were to take place.

Q: What do you think are some of the largest barriers to CRC screening in 2015?

DL: There are several important barriers. First, and foremost, is access to care. If patients do not have a medical home and a primary care provider, they are unlikely to receive or accept CRC screening. There are still concerns and reservations about undergoing testing, which involves collection of stool samples or colonoscopy. Research suggests that these barriers can be overcome, but requires the active participation of primary care providers. There are cultural barriers that can apply to any form of screening and prevention in healthy individuals. There is poor recognition of high-risk individuals with a family history of CRC. These individuals should have more intensive screening, which often begins at a younger age.  

XL: Coverage is the number one barrier. Number two, we have to do a better job of spreading the word. It is important that we are reaching out to underserved populations and ensuring they have the proper information and access.

CS: Education and awareness are obviously important. Patients are asking smart questions about physicians and procedures. I think these two issues are less of a barrier than they were before. The other barrier we are seeing is financial. ASGE has worked to eliminate co-pays for Medicare beneficiaries when a polyp is removed during a screening colonoscopy. It is also important that we educate patients about their financial responsibility. More and more offices are creating ways to work with patients to educate them on cost. Patients are bringing it up more than they used to, as well.

HS: There has been a bit of negative press surrounding colonoscopy. We need to be constantly aware of articles that show up in major publications. Our organization continues to work to convey the importance and value of screening colonoscopy. We are also working on eliminating co-pays and deductibles.

Q: What can individual GI physicians to help reach the "80 percent by 2018" goal?

HS: I honestly think to achieve this goal all GI physicians have to open their doors and improve access. We need to offer complimentary screenings for the underinsured and uninsured. HHS is working on clinics to improve access. There are a lot of people involved in this. Hopefully payers will see that access is a driving factor as well.

DL: I believe that GI physicians need to engage with primary care providers who are on the front lines of the screening effort to emphasize the remarkable benefits of screening. From 2000 to 2010, there has been a 30 percent reduction in CRC deaths, and some of this benefit is due to CRC screening. There is evidence that primary care providers play a crucial role in improving adherence to screening.

Healthcare systems should be keen to engage in screening if the effort will reduce the costly impact of CRC treatment by either preventing cancer or detecting it early. GI physicians can play an important role in working with accountable care organizations to ensure that they understand the health benefits of screening. Finally, GI physicians can work with primary providers and healthcare organizations to assure that high-risk patients with a family history of CRC are recognized and triaged appropriately for more intensive screening.

The AGA's colorectal cancer clinical service line provides information for healthcare professionals, including guidelines that provide recommendations on the screening of patients for colorectal cancer, as well as clinical care pathways that transform guideline recommendations into clinical steps for screening and surveillance. The CRC clinical service line can be found at

CS:  We need to focus our efforts on disparities in patient groups in lower socio-economic groups and rural areas. We need to address these challenges and work with underinsured and uninsured patients within our local communities. In our community, we work with Volunteers in Medicine and the Project Access to create opportunities for these patient populations. ASGE, a member of the NCCRT, is working on these issues as a partner in the new NCCRT program aimed at improving colorectal cancer screening rates and access to specialty care in community health centers.

XL: This goal is possible, but it will be a challenge. We need to set attainable, but aggressive goals. The "80 percent by 2018" goal is a great initiative. There are many stakeholders in the roundtable committed to making this happen. It is important that we get more patient organizations involved. The more organizations sitting at the table the better.

Q: Do you think gastroenterologists will use a greater number of CRC screening tests to help improve patient compliance?

DL: CRC screening includes several options, which begin at the primary care level. Currently, the primary tests are stool-based screening tests, which are non-invasive, and colonoscopy.  Patients may prefer one test over another, but every program leads to colonoscopy if the initial test is positive. Gastroenterologists are the experts who perform high-quality colonoscopy, either for primary screening or as a result of a positive stool test or imaging. It is unlikely that GI physicians will be using other primary CRC screening tests until new serum genomic tests are found to be effective. It is quite possible that some form of hybrid testing could emerge in which patients who have a colonoscopy, may have some interim test before their next scheduled colonoscopy. To date, no hybrid program has been studied.  

XL: We will have to be vigilant and watch for all of the studies coming out that assess the usefulness of new tests, such as the stool DNA test. Over the next several years we will be learning about these alternatives. The more options we have the better. We need to be aware of patient preference. It is important that people get screened.

HS: I think more and more of these tests will be utilized. I am not 100 percent sure where there will be maximum utilization yet, but it will most likely be at the primary care level. Once patients come to GI physicians, it will most likely be for a colonoscopy. We are also fighting to establish a continuum of care in the screening process. If there is a positive stool test, then colonoscopy follows.  

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