Improving Colorectal Cancer Screening

Abstract

Thousands of lives could be saved annually if everyone underwent appropriate colorectal cancer (CRC) screening. Community education programs are needed to encourage people to see his or her physician, while every physician must take it upon himself or herself to screen every person over the age of 50 for colorectal cancer. If comprehensive screening were to take place, additional endoscopists would be needed to meet the demand.

Introduction

Colorectal cancer (CRC) is the second most common cause of cancer related death in the United States. The survival rates decrease as the stage of the disease at diagnosis increases. Unlike many cancers, early stages of the disease are identifiable and often treatable. Colon polyps have clearly been shown as a precursor to colon cancer. If identified and removed early, colon cancer can be prevented. It is well known that colonoscopy can identify and remove polyps prior to their development into cancer. The American Cancer Society recommends average risk patients over the age of fifty undergo a flexible sigmoidoscopy every 5 years, a colonoscopy every 10 years, a double contrast barium enema every five years, or a CT colonogram every five years to identify cancer or polyps. According to the American Cancer Society, approximately 26,000 deaths per year could be prevented if everyone over the age of 50 was properly screened. Every person over the age of 50 that seeks any type of medical care should be counseled on colorectal cancer screening.

The first barrier to a patient being screened for colorectal cancer is the patient being seen by a physician. Many people choose not to go to a doctor until there is a problem rather than seeking preventative care. In a study published by the National Rural Health Association in 2007, one of the most important independent predictors of being up to date on colorectal caner screening was having visited a health care practitioner for a checkup in the past year¹. Community programs and national attention are aimed at encouraging people to have regular contact with their health care providers and to request screening. As members of the health care community, whether primary care physicians or surgeons, it is our responsibility to be certain that every patient over the age of 50 is appropriately screened. According to a study by the Iowa Research Network, there were two main reasons for patients not being screened, the physician did not initiate the discussion or the patient refused screening². The main reasons physicians gave for not initiating the screen was a lack of opportunity, concern about cost, distraction by other issues, the expectation of refusal, or the physician forgot². Colorectal cancer screening needs to become a routine part of every doctors visit to catch as many people as possible. It is unfair to the patient to assume he or she would refuse or be unable to afford screening without first providing the facts and options available.

Patients who were seen by a physician were more likely to be screened if they had a personal or family history of polyps or cancer, or if they asked for a colorectal cancer screening test. In a study of Iowa family physicians, the percentage of patients up to date on CRC screening varied by 5% to 75% depending on the physician³. Most of the patients who were up to date had symptoms that could indicate colorectal cancer prior to screening³. The physician recommendation and manner of presenting the recommendation greatly influenced the likelihood of the patient undergoing the screening test³. The main reasons for patients refusing screening are due to cost, lack of interest, fear of screening or lack of symptoms². Many of these fears and misunderstandings can be allayed with appropriate counseling by the physician. In fact, physicians who were more adamant about screening and those who used the phrase “I recommend” rather than “they recommend” had a higher success rate². The need for a complete discussion on the necessity of colorectal cancer screening was further evidence in a survey of rural patients over the age of 50, which showed the adequacy of discussion was more important than the access to colorectal cancer screening for the patient to be up to date⁴.

Aside from the opportunity to increase early diagnosis of colorectal cancer and potentially save lives, it is in the physician’s best interest to diagnose colorectal cancer as early as possible to avoid potential litigation. A retrospective review published in the Annals of Internal Medicine, found 7% of the claims involving a diagnostic error that harmed the patient were in regard to colorectal cancer⁵. The most common findings that should have lead to endoscopic evaluation were iron deficiency anemia, positive fecal occult blood test, and hematochezia⁶. A breakdown in communication between the provider and the patient or lack of follow up, especially after an abnormal test, were the main reasons patients were not adequately evaluated for colorectal cancer⁶.

While access to endoscopy was not found to be related to completion of colorectal cancer screening in rural patients⁴, it should be of concern as the overall patient population ages. In a study from Montana in 2008, only 17% of demand would be met if every eligible adult chose colonoscopy as their primary form of screening⁷. Endoscopy was only available to 58% of practices in rural Kansas as found by a survey performed in 2003⁴. Gastroenterologists perform two thirds of all colonoscopy procedures with most of the remaining third being performed by general surgeons⁸. The ACGME recently increased the requirements for surgeons to successfully complete residency training from 25 endoscopic procedures to 50 colonoscopies with a separate requirement for gastroduodenoscopies, in an attempt to better train general surgeons to help meet the future demand. Family practice physicians perform 65% of all sigmoidoscopies⁸ and have been shown to be able to safely perform colonoscopies when adequately trained^9,10,11. The need for skilled endoscopists will only increase over time as the population ages and the health care crisis worsens. All physicians need to take an active role in screening patients and those physicians with the skills to perform colonoscopy need to be encouraged to increase the availability of screening.

Biography

Lynn Happel, MD, FACS, MSMA member since 2010, is an Assistant Professor of Surgery University of Missouri-Kansas City School of Medicine.

Contact: happell@umkc.edu