Colorectal Cancer: Screening More Patients at Lower Cost

reprinted from Issue 14, Spring 2012 of Frontiers of Medicine (PDF)

“Colorectal cancer is a serious problem, and not enough people are receiving routine screening, especially among the uninsured and underserved population,” said James Allison, MD (center), with Lukejohn Day, MD, and Lisa Golden, MD.

Colorectal cancer is the third most common cancer in both men and women, and is expected to cause nearly 50,000 deaths in the United States this year, according to the American Cancer Society. If caught early by routine screening, the prognosis for patients with colorectal cancer is quite good. Unfortunately, about 40 percent of Americans who meet criteria for screening have never been screened, and a disproportionate number of uninsured and underserved patients are diagnosed with advanced cancers. Physicians at UCSF have been working to improve the rate of routine screening and thereby improve the prognosis for patients with colorectal cancer.

“Colorectal cancer is a serious problem, and not enough people are receiving routine screening, especially among the uninsured and underserved population,” says James Allison, MD, adjunct investigator at the Kaiser Division of Research. In most cases, colorectal cancer develops slowly from a benign polyp, a process which can take up to 10 years. About one in four Americans has a polyp by age 50, but only a small proportion of those polyps develops into cancer. For people without a family history of colorectal cancer or other risk factors, routine screening after the age of 50 is recommended.

Debate Over Best Screening Method

The best method for screening the general population has been hotly debated. Two national task forces each developed a menu of screening options, which include stool tests – in which a patient collects a small feces sample that is then analyzed for signs of bleeding caused by colon polyps or colorectal cancer – and structural exams, such as colonoscopy – in which a gastroenterologist inserts a flexible tube with a camera through the anus to look for polyps or cancer in the colon.

In 2000, Katie Couric’s broadcast of her own colonoscopy on the “Today” show led to much discussion in the media and a documented increase in the colonoscopy rates. That year, Congress mandated that Medicare cover screening colonoscopy once every 10 years, and the American College of Gastroenterology recommended colonoscopy as the “preferred strategy” for colorectal cancer screening.

Successful Screening at Lower Cost

Unfortunately, colonoscopy is an inva-sive procedure that can cost thousands of dollars, and it is not readily available to all who need it. “Colonoscopy is a good screening test, but it is not the only good option,” says Allison.

UCSF faculty members have developed a model to increase screen-ing rates among average-risk patients by offering an easy-to-use test that costs about $8 – the fecal immuno-chemical test (FIT) – rather than using colonoscopy for initial screening.

Allison and his colleagues have conducted extensive research on various stool tests. They published articles in the New England Journal of Medicine and the Journal of the National Cancer Institute showing the effectiveness of the FIT in detecting blood in the stool from larger polyps and cancer, which tend to bleed.

Unlike earlier stool tests, such as the guaiac tests for fecal occult blood, FIT requires only one sample (rather than three) and does not require dietary and medication restrictions. “The FIT is effective in identifying patients with large polyps and cancer, and is easy and inexpensive enough to administer annually, thus allowing plenty of time for these slow-growing polyps and cancers to be identified before they become fatal,” says Allison. “With the new and improved choices for fecal occult blood testing (FOBT), annual FOBT testing can play an important role in colorectal cancer screening.”

Improving Screening Rates: The Ocean Park Health Center Experience

Lisa Golden, MD, medical director of Ocean Park Health Center (OPHC) – a San Francisco Department of Public Health clinic which provides primary care to mostly low-income, uninsured patients in the Sunset and Richmond districts – wanted to improve her clinic’s screening rates for colorectal cancer. In 2008, OPHC’s screening rates for colorectal cancer among their 2,000 patients aged 50 and older was about 40 percent.

“We realized that screening was being offered by the provider alone, and that was a bottleneck,” says Golden. “We started looking at a team approach to care, involving our medical assistants and nursing staff.” By training these other members of the medical team to initiate discussions with patients about the importance of preventive care and taking the test, screening rates increased to about 67 percent.

At that time, OPHC used FOBT as a first-line screening tool for colorectal cancer. They wanted to make the switch from the more finicky FOBT to the FIT, which is easier for patients to use. However, FIT costs about $8, compared to about $4 for the FOBT. Golden partnered with the California Department of Public Health and the Centers for Disease Control and Prevention to obtain grant funds to offset the increased FIT cost. These grant funds also allowed OPHC to give them prepaid mailer envelopes, which allowed patients to mail the sample directly to the SFGH lab, rather than having to bring it in person to OPHC. In addition, the Clinic developed patient educational materials about the importance of preventive care and colo-rectal screening in various languages.

“We told patients that this new test was much easier to use, that you could mail it back in, and that it was not yet available elsewhere within the Department of Public Health system,” says Golden. “When people feel like they’re getting something new and improved, they’re going to seriously think about following through.” With the new FITs, OPHC’s screening rates have increased to 73 percent in the past year – and Golden and her team are working to increase those rates even further in the future.

Improving Diagnostic Colonoscopy Rates

Patients who have a positive FIT are referred to San Francisco General Hospital (SFGH), the safety net hospital in the UCSF system, for a diagnostic colonoscopy. SFGH performs about 1,700 colonoscopies annually; however, wait times can exceed four months. What was needed was a better system to ensure that patients who have a positive test had a timely follow-up colonoscopy and appropriate management.

San Francisco General Hospital now offers group colonoscopy education classes to help streamline access to the procedure. At the end of class, participants receive a colonoscopy appointment within three weeks.

To streamline patients’ access, UCSF gastroenterologist Lukejohn Day, MD, and his colleagues at SFGH are now offering a program known as “direct access colonoscopy.” Through this program, patients with a positive FOBT or FIT first attend a group colonoscopy education class in English, Spanish or Cantonese that explains how to prepare for a colonoscopy. Participants then receive an appointment for the procedure within three weeks. By reconfiguring providers’ schedules and offering direct access colonoscopy, SFGH has been able to increase the number of colonoscopies they can offer by almost 20 percent over the last two years, and have reduced waiting times for patients with a positive FOBT or FIT by 50 percent.

“We’re hoping to replicate OPHC’s success across all our clinics here,” says Day, who is leading these efforts. Within the next year, he projects that all clinics at SFGH and across the San Francisco Department of Public Health (DPH) system will switch to offering FIT to the approximately 27,000 patients eligible for routine colorectal cancer screening.

In addition, for patients who are not eligible for SFGH’s direct access process for colonoscopies, DPH physicians teamed up with Operation Access, a nonprofit which mobilizes licensed volunteer medical professionals, hospitals and other medical facilities to provide donated outpatient surgeries and procedures to low-income, uninsured patients. In 2010, Operation Access provided 95 donated diagnostic colonoscopies throughout the Bay Area, with an average value of $6,345 per procedure, according to Jennifer Errante Paidipati, director of the Operation Access Institute.

Operation Access has also helped share information about the OPHCSFGH model screening program, convening meetings throughout California to share best practices and help local communities improve colorectal cancer screening programs. “FIT is not a second-rate screening test,” says Paidipati. “It helps us target people who really need colonoscopy, rather than using colonoscopy to do routine screenings.”

Higher Quality, Lower Costs

“This is an important improvement,” says Talmadge E. King, Jr., MD, chair of the Department of Medicine. “The model they have developed – using the FIT as a screening procedure, involving not just the physician but the entire care team in offering colorectal cancer screening to the patient, partnering with gastroenterologists to ensure rapid diagnostic colonoscopy in appropriate patients, and developing patient-centered educational materials – is an excellent example of the type of change we can make to improve quality and reduce cost.”

The OPHC-SFGH model is also being promoted by the California Colorectal Cancer Coalition (C4), the California branch of the American Cancer Society, and the California Department of Public Health to increase screening in other underserved communities serviced by a safety net hospital, says Allison.

“The one thing most associated with success in screening programs is having your primary care physician saying, ‘You need to be screened,’” says Allison. “My goal is to inform primary care physician that FIT offers a way to screen large numbers of patients, especially in the underserved and uninsured population.”

In 2010, Operation Access provided 95 donated diagnostic colonoscopies throughout the Bay Area, with an average value of $6,345 per procedure.

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