Medical Device Daily Washington Editor

WASHINGTON – Disease prevention is seen as a sure way to keep the nation’s healthcare tab from swamping the economy, and yesterday’s session at the National Academy of Sciences (Washington) highlighted the hoped-for benefits of screening for one of the deadliest of all cancers: colorectal cancer.

Sponsored by the Institute Of Medicine (IOM; Washington), the session was titled “Implementing Colorectal Cancer Screening: Workshop Advice on How to Move Evidence-Based Recommendations into Practice.” Several items were on the agenda, but the mindsets of patients and doctors received considerable attention.

Ralph Coates, MD, associate director of science at the National Office of Public Health Genomics of the Centers for Disease Control and Prevention (Atlanta), said a 2003 IOM report indicated “a 29% reduction in cancer deaths from modest efforts to implement what is known from social sciences and biomedical research.” Coates also said that evidence-based screening and preventive activities are not fully deployed and that “thousands of lives are needlessly lost” each year as a result.

Coates noted that recent recommendations offered by the National Cancer Institute included more resources for state-based programs for cancer control and prevention, and financial support for a colorectal cancer (CRC) screening program for the poor and the uninsured.

Bernard Levin, MD, founding chairman of the World Gastroenterology Organization Foundation (Washington) said the annual incidence of CRC worldwide is 945,000, with mortality at almost half a million a year. He described CRC as “the third most common cause of cancer and the second leading cause of cancer death in the United States.”

On the other hand, the incidence is on the decline, which he said is “attributable to screening and removal of adenomas.”

“There are a few well-recognized predisposing conditions,” Levin said, including genetic factors, inflammatory bowel disease and ulcerative colitis. “About 10% to 30% of patients have a family history,” he said, but “most individuals fall into the sporadic or average risk category” at between 65% and 85%.

Red meat and tobacco consumption remain known risk factors, but “the role of fruits and vegetables is still controversial,” Levin said.

“Five-year survival is related to the stage of diagnosis,” Levin said, noting that diagnosis of CRC at stage I offers about a 93% rate of survival out to five years while at the other end, stage IV diagnosis offers only an 8% survival rate to half a decade.

George Isham, MD, chief medical officer at HealthPartners (Minneapolis), said that a recent GAO report on CRC screening indicated that 20 states “had laws in place requiring private insurance coverage of CRC screening” as of May 2004, and that most of the plans reviewed by GAO “covered all four [FDA-approved] CRC tests.”

Isham also noted that a survey of insurance companies that are members of America’s Health Insurance Plans (AHIP; Washington) indicated that industry is on board. “More than 90% of health plans covered all four types of recommended screening procedures” in 2002, he said, adding that data from 2006 indicated that 83% of high-deductible plans also offered first-dollar coverage for colonoscopies.

Isham pointed out that while coverage is much broader than in times gone by, “there is [still] considerable variation in the rates of screening.” He said that the national variation in CRC screening for at-risk patients in commercial plans is 22 percentage points, with Massachusetts coming in first at 66.3% of all appropriate patients screened. For Medicare plans, the range is 26.8 percentage points.

Isham said that while “coverage is no longer seen as a major barrier to increasing screening rates for those with insurance,” a number of factors have dampened patient enthusiasm for the procedures. Among these are the inconvenience of the preparation for the procedure – as anyone who has had a colonoscopy can testify – and ignorance about the test.

However, he also noted that “all of the women in focus groups had heard negative stories about the tests,” including that they are painful and embarrassing. “Very distasteful” is another phrase that came up in connection with the procedure. These responses are from a 1999 report on CRC published by the Institute for Clinical Systems Improvement (ICSI; Bloomington, Minnesota).

Patients in these focus groups said that “emotional support during the screening” would make the experience easier to bear, Isham said, but they also noted a difference in the marketing tactics employed by automotive maintenance businesses and physician practices. “Some noted with irony that they get service reminders for their cars, but no preventive [medical] service reminders,” he said.

On the prevention side, Isham said that ICSI data showed that patients often demonstrate “a lack of motivation to sustain a healthy lifestyle,” but also said that physicians “feel responsible, yet cannot motivate patients to change their lifestyles” unless other actors converge on the patient’s mindset. Lack of time during appointments to address lifestyle issues and lack of reimbursement for discussions with patients that amount to health counseling were said to be barriers for doctors in such a pursuit.

Isham said that the ICSI data suggested that employers “believe they are responsible for the health of their employees and their families,” but that employers are not certain where to focus their efforts. “At best, 40% to 50% of employees use preventive service benefits,” he said.

In order to boost preventive CRC screening, health plans might try “health fairs and public service campaigns on the importance of getting screened,” Isham said, but he added that pay-for-performance also was an essential ingredient to get the physician side of the equation more involved. Claims data, he noted, are a great source of information on sub-populations that are less involved in screening than they should be, “including Latino member and African Americans.” He concluded by noting that “primary care needs help,” but he also said “patients need education and engagement before they are patients.”

However, after all else is said and done, Isham said, “the key to improving CRC screening rates lies in listening carefully to our patients.”