Clinical Pearls & Morning Reports
The percentage of U.S. residents with up-to-date screening for colorectal cancer has not increased appreciably since 2010 and remains at approximately 60%. The National Colorectal Cancer Roundtable has established a goal of 80% adherence to colorectal cancer screening by the year 2018. To achieve the highest level of adherence to colorectal cancer screening, it may be best to provide participants a choice, because the “best” strategy is the one that they will adhere to consistently. A new Review Article elaborates.
Q: What interventions may increase patient participation in colorectal cancer screening?
A: Various interventions used in randomized, controlled trials have been shown to increase patient participation in screening; such interventions include sending patients invitations from their primary care provider, sending reminder letters and making telephone calls, and mailing fecal occult blood test kits to patients’ homes. The most successful programs use patient navigators to reduce logistic barriers, address cultural issues, and encourage participants to undergo screening; the use of patient navigators is especially important in underserved populations.
Q: How can the benefit of colorectal cancer screening be maximized?
A: Maximizing the benefit of colorectal cancer screening requires a programmatic approach to implementing screening strategies. The quality of a screening program should be measured by its ability to identify patients who are due for screening, provide access to screening, assess adherence to the screening test and to follow-up colonoscopy if a noncolonoscopy screening test is positive, document test outcomes and disseminate accurate follow-up recommendations, identify patients with a negative test to follow them for repeat screening at the appropriate intervals, and provide timely surgery for cancers.
A: Additional factors that might influence colorectal screening strategies include race, lifestyle factors, or aspirin use. For example, among black men and women, the rates of death from colorectal cancer are 28.4 and 18.9 per 100,000 population, respectively; among white men and women, the corresponding rates are 18.7 and 13.2 per 100,000 population. Obesity, tobacco smoking, low physical activity, high intake of alcohol, high intake of red or processed meat, and low intake of fruits and vegetables are associated with increased risk of colorectal cancer, and regular use of aspirin has been associated with reduced risk. However, none of these factors are currently used to differentiate screening strategy, age of screening initiation, or surveillance intervals.
A: Although the risk of colorectal cancer increases with age, the competing risk of death from other diseases and the risk of serious complications from colonoscopy also increase with age. Several national organizations recommend that screening for patients between 76 and 85 years of age should be tailored on the basis of the presence of coexisting illnesses and that screening should be stopped after patients reach 85 years of age. A microsimulation model suggested that the intensity of prior screening and the individual risk of colorectal cancer should also be considered in determining the age at which to stop screening. Patients without a notable coexisting illness who are at average or higher risk for colorectal cancer and have had no prior screening would be expected to benefit from screening into their 80s.