Colorectal Cancer Health Disparities and the Role of US Law and Health Policy

Why is early detection of colon cancer still not possible in 2023?

Colorectal cancer (CRC) screening is a fundamental tool in the prevention and early detection of one of the most prevalent and lethal cancers. Over the years, screening, particularly in those settings where it is well organized, has succeeded in reducing the incidence of colon and rectal cancer and improving the prognosis related to them. Despite considerable advancements in screening technologies and strategies, the effectiveness of CRC screening programs remains less than optimal. This paper examined the multifaceted reasons behind the persistent lack of effectiveness in CRC screening initiatives. Through a critical analysis of current methodologies, technological limitations, patient-related factors, and systemic challenges, we elucidated the complex interplay that hampers the successful reduction of CRC morbidity and mortality rates. While acknowledging the advancements that have improved aspects of screening, we emphasized the necessity of addressing the identified barriers comprehensively. This study aimed to raise awareness of how important CRC screening is in reducing costs for this disease. Screening and early diagnosis are not only important in improving the prognosis of patients with CRC but can lead to an important reduction in the cost of treating a disease that is often diagnosed at an advanced stage. Spending more sooner can mean saving money later.

A health equity framework to support the next generation of cancer population simulation models

Over the past 2 decades, population simulation modeling has evolved as an effective public health tool for surveillance of cancer trends and estimation of the impact of screening and treatment strategies on incidence and mortality, including documentation of persistent cancer inequities. The goal of this research was to provide a framework to support the next generation of cancer population simulation models to identify leverage points in the cancer control continuum to accelerate achievement of equity in cancer care for minoritized populations. In our framework, systemic racism is conceptualized as the root cause of inequity and an upstream influence acting on subsequent downstream events, which ultimately exert physiological effects on cancer incidence and mortality and competing comorbidities. To date, most simulation models investigating racial inequity have used individual-level race variables. Individual-level race is a proxy for exposure to systemic racism, not a biological construct. However, single-level race variables are suboptimal proxies for the multilevel systems, policies, and practices that perpetuate inequity. We recommend that future models designed to capture relationships between systemic racism and cancer outcomes replace or extend single-level race variables with multilevel measures that capture structural, interpersonal, and internalized racism. Models should investigate actionable levers, such as changes in health care, education, and economic structures and policies to increase equity and reductions in health-care-based interpersonal racism. This integrated approach could support novel research approaches, make explicit the effects of different structures and policies, highlight data gaps in interactions between model components mirroring how factors act in the real world, inform how we collect data to model cancer equity, and generate results that could inform policy.

Sociocultural Factors, Access to Healthcare, and Lifestyle: Multifactorial Indicators in Association with Colorectal Cancer Risk

Black Americans of low socioeconomic status (SES) have higher colorectal cancer incidence than other groups in the United States. However, much of the research that identifies colorectal cancer risk factors is conducted in cohorts of high SES and non-Hispanic White participants. Adult participants of the Southern Community Cohort Study (N = 75,182) were followed for a median of 12.25 years where 742 incident colorectal cancers were identified. The majority of the cohort are non-Hispanic White or Black and have low household income. Cox models were used to estimate HRs for colorectal cancer incidence associated with sociocultural factors, access to and use of healthcare, and healthy lifestyle scores to represent healthy eating, alcohol intake, smoking, and physical activity. The association between Black race and colorectal cancer was consistent and not diminished by accounting for SES, access to healthcare, or healthy lifestyle [HR = 1.34; 95% confidence interval (CI),1.10-1.63]. Colorectal cancer screening was a strong, risk reduction factor for colorectal cancer (HR = 0.65; 95% CI, 0.55-0.78), and among colorectal cancer-screened, Black race was not associated with risk. Participants with high school education were at lower colorectal cancer risk (HR = 0.81; 95% CI, 0.67-0.98). Income and neighborhood-level SES were not strongly associated with colorectal cancer risk. Whereas individual health behaviors were not associated with risk, participants that reported adhering to ≥3 health behaviors had a 19% (95% CI, 1-34) decreased colorectal cancer risk compared with participants that reported ≤1 behaviors. The association was consistent in fully-adjusted models, although HRs were no longer significant. Colorectal cancer screening, education, and a lifestyle that includes healthy behaviors lowers colorectal cancer risk. Racial disparities in colorectal cancer risk may be diminished by colorectal cancer screening.

PREVENTION RELEVANCE

Colorectal cancer risk may be reduced through screening, higher educational attainment and performing more health behaviors. Importantly, our data show that colorectal cancer screening is an important colorectal cancer prevention strategy to eliminate the racial disparity in colorectal cancer risk. See related Spotlight, p. 561.

Healthcare Disparities and Colorectal Cancer

Health care disparities are defined as health differences between groups that are avoidable, unnecessary, and unjust. Racial disparities in colorectal cancer mortality, particularly for Black patients, are well-described. Disparities in preventative measures, early detection, effective treatment, and posttreatment services contribute to these differences. Underlying these issues are patient, provider, health care system, and policy-level factors that lead to these disparities. Multilevel interventions designed to address each level of care can provide an effective means to mitigate these disparities.

Analysis of Post-Colonoscopy Colorectal Cancer and Its Subtypes in a Screening Programme

Using the algorithm of the World Endoscopy Organisation (WEO), we have studied retrospectively all colorectal cancers, both detected and non-detected by the Basque Country screening programme from 2009 to 2017. In the screening programme 61,335 colonoscopies were performed following a positive Faecal Immunochemical test (FIT) (≥20 µg Hb/g faeces) and the 128 cases of post-colonoscopy colorectal cancer (PCCRC) detected were analysed. Among them, 50 interval type PCCRCs were diagnosed (before the recommended surveillance), 0.8 cases per 1000 colonoscopies performed, and 78 non-interval type PCCRCs (in the surveillance carried out at the recommended time or delayed), 1.3 per 1000 colonoscopies. Among the non-interval type PCCRCs, 61 cases were detected in the surveillance carried out at the recommended time (type A) and 17 when the surveillance was delayed (type B), 1 case per 1000 colonoscopies performed and 0.28 cases per 1000 colonoscopies performed, respectively. Interval type PCCRC is less frequent than non-interval type PCCRC. In interval type PCCRCs, CRCs detected in advanced stages (stages III-IV) were significantly more frequent than those detected in early stages, compared to those of non-interval type PCCRCs (OR = 3.057; 95% CI, 1.410-6.625; p < 0.005). Non-interval type B PCCRCs are less frequent than non-interval type A PCCRCs, but the frequency of advanced stages is higher in interval type B PCCRCs.

Improved Survival Outcome and Access to Cancer Screening from Hemorrhoid in Patients with Rectal Cancer

Background

The interventions for hemorrhoid increase access to rectal cancer screening and thus might reduce cancer death. We aimed to examine the impact of hemorrhoid on survival outcomes in rectal cancer.

Methods

We identified 510 patients with stage I to III rectal cancer from a prospectively collected database. Patients were divided into hemorrhoid and non-hemorrhoid group. The primary endpoints were disease-free survival (DFS) and overall survival (OS).

Results

Hemorrhoid group had significantly more stage I-II diseases in comparison to nonhemorrhoid group (71.1% vs. 55.9%, P = 0.049). The hemorrhoid group had significantly better DFS and OS compared to nonhemorrhoid group, the hazard ratios (HRs) of which were 0.39 (95% CI 0.17-0.88, P = 0.018) and 0.33 (95% CI 0.12-0.92, P = 0.034), respectively. Multivariate analysis revealed that hemorrhoid was independently associated with DFS [adjusted HR 0.43 (95% CI 0.17-0.95, P = 0.045)]. A nomogram for predicting DFS outcome was generated based on hemorrhoid history, with a concordance index of 0.71 (95% CI 0.66-0.75, P < 0.001).

Conclusions

There may exist a screening effect and survival benefit from hemorrhoid in rectal cancer, which supports the significance of rectal cancer screening in lowering its mortality.

Framework and Strategies to Eliminate Disparities in Colorectal Cancer Screening Outcomes

Preventable differences in colorectal cancer (CRC) mortality across racial/ethnic, economic, geographic, and other groups can be eliminated by assuring equitable access and quality across the care continuum, but few interventions have been demonstrated to do so. Multicomponent strategies designed with a health equity framework may be effective. A health equity framework takes into account social determinants of health, multilevel influences (policy, community, delivery, and individual levels), screening processes, and community engagement. Effective strategies for increasing screening uptake include patient navigation and other interventions for structural barriers, reminders and clinical decision support, and data to continuously track metrics and guide targets for improvement. Community resource gaps should be addressed to assure high-quality services irrespective of racial/ethnic and socioeconomic status. One model combinespopulation-based proactive outreach screening with screening delivery at in-person or virtual points of contact, as well as community engagement. Patient- and provider-based behavioral interventions may be considered for increasing screening demand and delivery. Providing a choice of screening tests is recommended for CRC screening, and access to colonoscopy is required for completion of the CRC screening process.

How nurse practitioners can advocate for local, state, and federal policy to promote colorectal cancer prevention and screening

ABSTRACT

Colorectal cancer (CRC) is the second most common cause of cancer deaths for men and women, combined, even though it is the most preventable, treatable, and beatable cancer. Polyp removal during colonoscopy is one major way to help prevent CRC, but it can also be prevented by modifiable risk factor reduction. The National Colorectal Cancer Roundtable's campaign "80% in Every Community" is an effort to address disparities in the less-screened populations and communities. The nurse practitioner (NP) can assist health care organizations to develop policies for high-quality screening programs and create system changes to promote CRC prevention and screening. Professional organizations provide an easy way to become involved in policy change at the health system, local, state, and federal levels. State and federal policies affect patient access to care and adherence to the CRC prevention and screening recommendations. Fourteen states have not yet elected to expand Medicaid. Every NP has the knowledge, skills, and ability to advocate for the expansion of Medicaid in these remaining states to reduce this access to care barrier for underserved patients and communities.

Impact of COVID-19 Pandemic on Colorectal Cancer Screening Program

Introduction

One of the main clusters of coronavirus disease-2019 (COVID-19) has been identified in Italy. Following European and local guidelines, Italian endoscopy units modulated their activity. We aimed at analyzing the need and safety to continue selective colorectal cancer screening (CRCS) colonoscopies during the COVID-19 pandemic.

Patients and Methods

We carried out a retrospective controlled cohort study in our “COVID-free” hospital to compare data of the CRCS colonoscopies of the lockdown period (March 9 to May 4, 2020) with those of the same period of 2019 (control group). A pre/post endoscopic sanitary surveillance for COVID-19 infection was organized for patients and sanitary staff.

Results

In the lockdown group, 60 of 137 invited patients underwent endoscopy, whereas in the control group, 238 CRCS colonoscopies (3.9-fold) were performed. In the lower number of examinations during the lockdown, we found more colorectal cancers (5 cases; 8% vs. 3 cases; 1%; P = .002). The “high-risk” adenomas detection rate was also significantly higher in the “lockdown group” than in controls (47% vs. 25%; P = .001). A multiple regression analysis selected relevant symptoms (hazard ratio [HR], 3.1), familiarity (HR, 1.99), and lockdown period (HR, 2.2) as independent predictors of high-risk lesions (high-risk adenomas and colorectal cancer). No COVID-19 infections were reported among staff and patients.

Conclusions

The overall adherence to CRCS decreased during the pandemic, but the continuation of CRCS colonoscopies was efficacious and safe.

Colorectal cancer-screening program improves both short- and long-term outcomes: a single-center experience in Trieste

Screening programs (SC) have been proven to reduce both incidence and mortality of CRC. We retrospectively analyzed patients who underwent surgical treatment for CRC between 01/2011 and 01/2017. The current screening program in our region collects patients aged from 50 to 69. For this reason, out of a total of 600 patients, we compared 125 patients with CRC founded during the SC to 162 patients who presented with symptoms and were diagnosed between 50-69 years old (NO-SC). 45% patients in the SC group were diagnosed as AJCC stage I vs 27% patients in the NO-SC group; 14% vs 20% were stage II, 14% vs 26% were stage III, and 3% vs 14% were stage IV (p 0.002). We found a significant difference in surgical approach: 89% SC vs 56% NO-SC patients had laparoscopic surgery (p 0.002). In the NO-SC group, 16% patients underwent resection in an emergency setting. Only 5% patients in the SC group had postoperative complications vs 14% patients in the NO-SC group (p 0.03). We had a 2-year OS of 86%, being 95% in the SC group and 80% in the NO-SC group (p 0.002). Likewise, the whole 2-year DFS was 77%, whereas it was 90% in the SC group and 66% in the NO-SC group (p 0.002). Screening significantly improves early diagnosis and accelerated surgical treatment. We obtained earlier stages at diagnosis, a less invasive surgical approach, and lower rates of complications and emergency surgery, all this leading to an improvement in both OS and DFS.

Causes of Socioeconomic Disparities in Colorectal Cancer and Intervention Framework and Strategies

Colorectal cancer (CRC) disproportionately affects people from low socioeconomic backgrounds and some racial minorities. Disparities in CRC incidence and outcomes might result from differences in exposure to risk factors such as unhealthy diet and sedentary lifestyle; limited access to risk-reducing behaviors such as chemoprevention, screening, and follow-up of abnormal test results; or lack of access to high-quality treatment resources. These factors operate at the individual, provider, health system, community, and policy levels to perpetuate CRC disparities. However, CRC disparities can be eliminated. Addressing the complex factors that contribute to development and progression of CRC with multicomponent, adaptive interventions, at multiple levels of the care continuum, can reduce gaps in mortality. These might be addressed with a combination of health care and community-based interventions and policy changes that promote healthy behaviors and ensure access to high-quality and effective measures for CRC prevention, diagnosis, and treatment. Improving resources and coordinating efforts in communities where people of low socioeconomic status live and work would increase access to evidence-based interventions. Research is also needed to understand the role and potential mechanisms by which factors in diet, intestinal microbiome, and/or inflammation contribute to differences in colorectal carcinogenesis. Studies of large cohorts with diverse populations are needed to identify epidemiologic and molecular factors that contribute to CRC development in different populations.

Association of Race and Socioeconomic Status With Colorectal Cancer Screening, Colorectal Cancer Risk, and Mortality in Southern US Adults

IMPORTANCE

Colorectal cancer (CRC) screening is rarely studied in populations who may face additional barriers to participate in cancer screening, such as African American individuals and individuals with low socioeconomic status (SES).

OBJECTIVE

To examine the associations of CRC screening and modalities with CRC incidence and mortality by race and SES.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the Southern Community Cohort Study, which enrolled more than 85 000 participants from community health centers or stratified random sampling of the general population in 12 states in the southeastern United States. The present study included data from cohort members who were eligible for CRC screening as recommended by expert organizations based on age and family history. Participants completed questionnaires from 2002 to 2009 and were contacted again from 2008 to 2012. Linkages to state cancer registries and the National Death Index as of December 31, 2016, identified incident CRC and vital status. Data analysis was performed from January 1, 2018, to October 30, 2019.

MAIN OUTCOMES AND MEASURES

Incident CRC (n = 632) and mortality (n = 10 003). Cox proportional hazards regression models evaluated associations between screening modalities and CRC risk and mortality. Information on fecal occult blood test use was only obtained on the follow-up questionnaire. Self-identified race was measured as African American/black, white, or other, and SES was defined by household income.

RESULTS

This study included 47 596 participants (median baseline age, 54 years [interquartile range, 10 years]; 32 185 [67.6%] African American; 28 884 [60.7%] female; and 26 075 [54.8%] with household income <$15 000). A total of 24 432 participants (63.9%) had never undergone CRC testing at baseline. The CRC testing assessed at baseline and follow-up interviews was associated with significant CRC risk reduction (hazard ratio [HR], 0.55; 95% CI, 0.44-0.70 for ever colonoscopy at baseline). Results were similar in analyses stratified by race (African American: HR, 0.65; 95% CI, 0.50-0.85; white: HR, 0.44; 95% CI, 0.27-0.70) and household income (<$15 000: HR, 0.63; 95% CI, 0.46-0.86, ≥$15 000: HR, 0.49; 95% CI, 0.35-0.69). Ever sigmoidoscopy at baseline was associated with CRC risk reduction (HR, 0.66; 95% CI, 0.51-0.87), and undergoing fecal occult blood test in the interval between baseline and follow-up interview was associated with CRC risk reduction (HR, 0.75; 95% CI, 0.57-0.98). Inverse associations were also observed between CRC mortality and receipt of colonoscopy (HR for women, 0.39; 95% CI, 0.21-0.73; HR for men, 0.69; 95% CI, 0.40-1.18) and sigmoidoscopy (HR for women, 0.37; 95% CI, 0.16-0.85; HR for men, 0.82; 95% CI, 0.46-1.47); however, the association did not extend to fecal occult blood test (HR for women, 1.02; 95% CI, 0.62-1.70; HR for men, 1.03; 95% CI, 0.55-1.93).

CONCLUSIONS AND RELEVANCE

In this study, CRC test rates were low among African American individuals and those with low SES. The findings suggest that screening, particularly with colonoscopy, is significantly associated with reduced risk of CRC and mortality. The CRC disparities experienced by individuals with low SES and African American individuals may be lessened by improving access to and uptake of CRC screening.

Time to Follow-up After Colorectal Cancer Screening by Health Insurance Type

INTRODUCTION

The purpose of this study was to test the hypothesis that patients with Medicaid insurance or Medicaid-like coverage would have longer times to follow-up and be less likely to complete colonoscopy compared with patients with commercial insurance within the same healthcare systems.

METHODS

A total of 35,009 patients aged 50-64years with a positive fecal immunochemical test were evaluated in Northern and Southern California Kaiser Permanente systems and in a North Texas safety-net system between 2011 and 2012. Kaplan-Meier estimation was used between 2016 and 2017 to calculate the probability of having follow-up colonoscopy by coverage type. Among Kaiser Permanente patients, Cox regression was used to estimate hazard ratios and 95% CIs for the association between coverage type and receipt of follow-up, adjusting for sociodemographics and health status.

RESULTS

Even within the same integrated system with organized follow-up, patients with Medicaid were 24% less likely to complete follow-up as those with commercial insurance. Percentage receiving colonoscopy within 3 months after a positive fecal immunochemical test was 74.6% for commercial insurance, 63.10% for Medicaid only, and 37.5% for patients served by the integrated safety-net system.

CONCLUSIONS

This study found that patients with Medicaid were less likely than those with commercial insurance to complete follow-up colonoscopy after a positive fecal immunochemical test and had longer average times to follow-up. With the future of coverage mechanisms uncertain, it is important and timely to assess influences of health insurance coverage on likelihood of follow-up colonoscopy and identify potential disparities in screening completion.

Modifiable Failures in the Colorectal Cancer Screening Process and Their Association With Risk of Death

BACKGROUND & AIMS

Colorectal cancer (CRC) deaths occur when patients do not receive screening or have inadequate follow-up of abnormal results or when the screening test fails. We have few data on the contribution of each to CRC-associated deaths or factors associated with these events.

METHODS

We performed a retrospective cohort study of patients in the Kaiser Permanente Northern and Southern California systems (55-90 years old) who died of CRC from 2006 through 2012 and had ≥5 years of enrollment before diagnosis. We compared data from patients with those from a matched cohort of cancer-free patients in the same system. Receipt, results, indications, and follow-up of CRC tests in the 10-year period before diagnosis were obtained from electronic databases and chart audits.

RESULTS

Of 1750 CRC deaths, 75.9% (n = 1328) occurred in patients who were not up to date in screening and 24.1% (n = 422) occurred in patients who were up to date. Failure to screen was associated with fewer visits to primary care physicians. Of 3486 cancer-free patients, 44.6% were up to date in their screening. Patients who were up to date in their screening had a lower risk of CRC death (odds ratio, 0.38; 95% confidence interval, 0.33-0.44). Failure to screen, or failure to screen at appropriate intervals, occurred in a 67.8% of patients who died of CRC vs 53.2% of cancer-free patients; failure to follow-up on abnormal results occurred in 8.1% of patients who died of CRC vs 2.2% of cancer-free patients. CRC death was associated with higher odds of failure to screen or failure to screen at appropriate intervals (odds ratio, 2.40; 95% confidence interval, 2.07-2.77) and failure to follow-up on abnormal results (odds ratio, 7.26; 95% confidence interval, 5.26-10.03).

CONCLUSIONS

Being up to date on screening substantially decreases the risk of CRC death. In 2 health care systems with high rates of screening, most people who died of CRC had failures in the screening process that could be rectified, such as failure to follow-up on abnormal findings; these significantly increased the risk for CRC death.

Importance of Age-Specific Insurer Perspective on Lifetime Cost Effectiveness of Colorectal Cancer Screening

In "Contrasting Effectiveness and Cost-Effectiveness of Colorectal Cancer (CRC) Screening under Commercial Insurance vs. Medicare", Ladabaum et al. model different CRC screening scenarios that vary the combination of payer, perspective, screening ages, and time horizons. Fecal occult blood testing (FOBT), fecal immunochemical testing (FIT), colonoscopy and flexible sigmoidoscopy were all cost effective compared to no screening, even if initiating or stopping at age 65 years. Assuming perfect adherence, FIT and FOBT were cost saving and dominated colonoscopy. Screening between ages 50 and 64 years appeared relatively costly if only a limited time horizon was considered since the benefits accrue after age 65 years under Medicare.

Expanding the Scope of Evidence-Based Cancer Care

This article explores how oncology research can be expanded to ensure that research spending results in maximum benefit. The focus has shifted to the value and quality of care, which view cancer care with the perspective of the patient at the center and cover the spectrum of care. Because there is no agreed-upon definition for value in cancer care, we overview various contributions to defining value and quality in oncology. We outline how cancer care costs are measured in the United States and explore outcome measures that have been proposed and implemented to enable us to assess value in oncology.

Role of liquid biopsies in colorectal cancer

Colorectal cancer (CRC) is the third most common cancer worldwide, with a global incidence of over 1 million cases. In the era of personalized medicine, tumor sampling is essential for characterizing the molecular profile of individual tumors. This provides pivotal information regarding optimal sequencing of therapy and emergence of drug resistance, allowing for timely therapy adjustment. However, tumor tissue sampling offers static information in a single time point and area of disease at the time of biopsy, which may not entirely represent the heterogeneity of molecular alterations. Moreover, tumor biopsies often involve invasive procedures with potential risks to patients. Less invasive, safer, and real-time methods such as liquid biopsies have generated increasing interest as a surrogate of solid tumor biopsies. Liquid biopsy allows for noninvasive survey with detection of cell-free circulating tumor DNA (ctDNA) or circulating tumor cells. Blood-based assays are the most widely studied. Additionally, the quantity of ctDNA detected has been shown to correlate with tumor burden and enables assessment of tumor heterogeneity. In this article, we discuss the concept of liquid biopsies including ctDNA and circulating tumor cell, and their current application in the diagnosis and management of CRC. We suggest that liquid biopsies can be successfully used to characterize the molecular profile of CRC, monitor disease, detect minimal residual disease after surgery, and identify therapeutic targets and mechanisms of drug resistance. This strategy could potentially imply an early change in treatment, sparing unnecessary side effects, and minimizing health costs. Combined radiological and liquid biopsy assessments will likely become more standard in CRC oncology. However, large prospective studies are needed to definitively establish the role of liquid biopsy.

Value Of Waiving Coinsurance For Colorectal Cancer Screening In Medicare Beneficiaries

Financial barriers to colorectal cancer screening persist despite the Affordable Care Act (ACA). Medicare beneficiaries may face 20 percent coinsurance for a screening colonoscopy when the procedure includes the removal of polyps or follows a positive fecal screening test. Using an established microsimulation model, we estimated that waiving this coinsurance would result in 1.7 fewer colorectal cancer deaths (a decrease of 13 percent) and $17,000 higher colorectal cancer-related costs (an increase of 0.6 percent) for the Centers for Medicare and Medicaid Services per 1,000 sixty-five-year-olds, assuming a 10-percentage-point increase in the rates of first colonoscopy screening, follow-up, and surveillance. If the rates did not change, waiving coinsurance would increase total costs by $51,000 (1.9 percent) per 1,000 sixty-five-year-olds. Estimated screening benefits were comparable when fecal testing was assumed to be the primary screening method. Moreover, waiving coinsurance would be cost-effective if the screening rate increased by 0.6 percentage points, assuming a willingness-to-pay threshold of $50,000 per quality-adjusted life-year gained. Thus, the waiver is likely to have a favorable balance of health and cost impact.

Colorectal cancer screening: An updated review of the available options

Colorectal cancer (CRC) is a significant cause of morbidity and mortality worldwide. However, colon cancer incidence and mortality is declining over the past decade owing to adoption of effective screening programs. Nevertheless, in some parts of the world, CRC incidence and mortality remain on the rise, likely due to factors including “westernized” diet, lifestyle, and lack of health-care infrastructure and resources. Participation and adherence to different national screening programs remain obstacles limiting the achievement of screening goals. Different modalities are available ranging from stool based tests to radiology and endoscopy with varying sensitivity and specificity. However, the availability of these tests is limited to areas with high economic resources. Recently, FDA approved a blood-based test (Epi procolon^®) for CRC screening. This blood based test may serve to increase the participation and adherence rates. Hence, leading to increase in colon cancer detection and prevention. This article will discuss various CRC screening tests with a particular focus on the data regarding the new approved blood test. Finally, we will propose an algorithm for a simple cost-effective CRC screening program.

Colorectal cancer screening: Opportunities to improve uptake, outcomes, and disparities

Colorectal cancer screening has become a standard of care in industrialized nations for those 50 to 75 years of age, along with selected high-risk populations. While colorectal cancer screening has been shown to reduce both the incidence and mortality of colorectal cancer, it is a complex multi-disciplinary process with a number of important steps that require optimization before tangible improvements in outcomes are possible. For both opportunistic and programmatic colorectal cancer screening, poor participant uptake remains an ongoing concern. Furthermore, current screening modalities (such as the guaiac based fecal occult blood test, fecal immunochemical test and colonoscopy) may be used or performed suboptimally, which can lead to missed neoplastic lesions and unnecessary endoscopic evaluations. The latter poses the risk of adverse events, such as perforation and post-polypectomy bleeding, as well as financial impacts to the healthcare system. Moreover, ongoing disparities in colorectal cancer screening persist among marginalized populations, including specific ethnic minorities (African Americans, Hispanics, Asians, Indigenous groups), immigrants, and those who are economically disenfranchised. Given this context, we aimed to review the current literature on these important areas pertaining to colorectal cancer screening, particularly focusing on the guaiac based fecal occult blood test, the fecal immunochemical test and colonoscopy.

Race/Ethnicity and Adoption of a Population Health Management Approach to Colorectal Cancer Screening in a Community-Based Healthcare System

BACKGROUND

Screening outreach programs using population health management principles offer services uniformly to all eligible persons, but racial/ethnic colorectal cancer (CRC) screening patterns in such programs are not well known.

OBJECTIVE

To examine the association between race/ethnicity and the receipt of CRC screening and timely follow-up of positive results before and after implementation of a screening program.

DESIGN

Retrospective cohort study of screen-eligible individuals at the Kaiser Permanente Northern California community-based integrated healthcare delivery system (2004-2013).

SUBJECTS

A total of 868,934 screen-eligible individuals 51-74 years of age at cohort entry, which included 662,872 persons in the period before program implementation (2004-2006), 654,633 during the first 3 years after implementation (2007-2009), and 665,268 in the period from 4 to 7 years (2010-2013) after program implementation.

INTERVENTION

A comprehensive system-wide long-term effort to increase CRC that included leadership alignment, goal-setting, and quality assurance through a PHM approach, using mailed fecal immunochemical testing (FIT) along with offering screening at office visits.

MAIN MEASURES

Differences over time and by race/ethnicity in up-to-date CRC screening (overall and by test type) and timely follow-up of a positive screen. Race/ethnicity categories included non-Hispanic white, non-Hispanic black, Hispanic/Latino, Asian/Pacific Islander, Native American, and multiple races.

KEY RESULTS

From 2004 to 2013, age/sex-adjusted CRC screening rates increased in all groups, including 35.2 to 81.1 % among whites and 35.6 to 78.0 % among blacks. Screening rates among Hispanics (33.1 to 78.3 %) and Native Americans (29.4 to 74.5 %) remained lower than those for whites both before and after program implementation. Blacks, who had slightly higher rates before program implementation (adjusted rate ratio [RR] = 1.04, 99 % CI: 1.02-1.05), had lower rates after program implementation (RR for period from 4 to 7 years = 0.97, 99 % CI: 0.96-0.97). There were also substantial improvements in timely follow-up of positive screening results.

CONCLUSIONS

In this screening program using core PHM principles, CRC screening increased markedly in all racial/ethnic groups, but disparities persisted for some groups and developed in others, which correlated with levels of adoption of mailed FIT.