Colorectal cancer is a relatively common disease which leads to significant morbidity and mortality. According to data from the World Health Organization (WHO) GLOBOCAN database, the incidence of CRC varies around the world, with the highest incidence rates in Australia and New Zealand, Europe and North America, and the lowest rates are found in Africa and South-Central Asia. With over 1.2 million new cases and 608,700 deaths, colorectal cancer remains, however, the third most commonly diagnosed cancer in males and the second in females. [1]
Over the last decade, both the incidence and mortality have been slowly but steadily decreasing in the United States, were colorectal cancer remains the third most common cancer for both men and women and the second-leading cancer killer. [2]. Based on the available data, annually approximately 136,830 new cases of large bowel cancer are diagnosed, of which 96,830 are colon and the remainder rectal cancers [3]. Annually, approximately 50,310 Americans die of colorectal cancer, accounting for approximately 9% of all cancer deaths.
Importance of screening
Early screening and treatment can be extremely successful in preventing colorectal cancer deaths. Approximately 90% of people with colorectal cancer that is found early and treated appropriately are still alive five years later.
With electronic health records, we can set up inexpensive systems to remind patients to do annual home colon cancer screening tests and achieve a very high success rate…
Although screening with fecal occult blood testingor FOBT and colonoscopies has shown to dramatically decrease the mortality of colorectal cancer, actual screening rates remain suboptimal. Screening rates are especially low for people with low incomes and members of underrepresented minority groups. Although FOBT should be done annually to detect colorectal cancer and to reduce mortality, this often does not happen. “Only three fifths of the adults in the United States age 50 to 75 overall are up to date on their screening.. Serious disparities persist by income, education, race/ethnicity and other groups,” explained Richard Kronick, PhD, director ofthe Agency for Healthcare Research and Quality (AHRQ). “This study indicates that intense outreach can increase screening and save lives.”
Successful Outreach helps
According to a new study by researchers at Northwestern Medicine?, funded by the Agency for Healthcare Research and Quality (AHRQ) and is published in June 16, 2014 edition of JAMA Internal Medicine, in low-income and minority communities where colonoscopies may be prohibitively expensive for many residents, less-invasive, more frequent testing combined with automated reminders, can yield dramatic improvements in colorectal cancer screening rates.
Findings from the study showed that community health center patients who received follow-up, which includes outreach by mail, automated telephone and text messages, and calls by a health center staff member if no response was given in three months, were more than twice as likely to complete an at-home colon cancer screening test. This was true even though most patients in the study were poor, uninsured, had limited English proficiency and a low understanding of health information.
The study
“With electronic health records, we can set up inexpensive systems to remind patients to do annual home colon cancer screening tests and achieve a very high success rate,” explained David W. Baker, MD, MPH, Chief of Internal Medicine and Geriatrics and the Michael A. Gertz Professor of Medicine at Northwestern University Feinberg School of Medicine, the study’s author. “We can achieve success even for patients with multiple financial, literacy and cultural barriers to colorectal cancer screening.”
Effective alternative
In the United States, the majority of colorectal cancer screening is done by colonoscopy, even though the procedure is expensive and invasive, and several safe and effective recommended alternatives exist. In addition to colonoscopy, other recommended screening options include sigmoidoscopy and fecal occult blood test or FOBT. In this study, Baker and his team used fecal occult blood testing, which can be completed at home with a single stool sample. FOBT must be conducted annually to catch colon cancer before it is too advanced to cure.
Prior to the study, it was not known whether patients would adhere to an annual at-home testing schedule for colorectal cancer.
The researchers identified 450 patients who received their care through a network of community health centers in Chicago, Ill. The overwhelming majority of the patients studied were uninsured Latino women and all had had a negative result with a previous at-home FOBT.
In this study, patients were divided into two groups, a usual care group and an intervention group. Usual care included computerized reminders, standing orders to give patients home tests and provider feedback. The intervention group received usual care and:
- a mailed reminder letter, a free home test with low-literacy instructions and a postage-paid return envelope;
- automated phone and text messages reminding them that a home test was being mailed to them and when they were due for screening;
- automated phone and text reminders two weeks later for those who did not return the home test and,
- personal outreach from a trained professional after three months if a test was not completed.
The researchers found that the intervention was very successful, with 82.2% of the patients in the intervention group completing the FOBT within six months of the screening due date compared to 37.3% of the patients in the usual care group.
“This intervention greatly increased adherence to annual colorectal cancer screening,” Baker explained. “It is possible to improve annual screening for vulnerable populations with relatively low-cost strategies, and we know that earlier detection of cancer through screening will save lives.”
The next step in this work is for Baker’s team is to work with community health centers that want to implement similar outreach programs to improve colorectal cancer screening rates. Baker further noted that he has already spoken to health centers in the Midwest and Pacific Northwest, and has provided them with materials to start similar programs.
Complete and Up-to-date
Earlier this year Baker and David Liss, PhD, MA, a research assistant professor in Medicine, General Internal Medicine and Geriatrics, at the Northwestern University Feinberg School of Medicine, also co-authored a comprehensive study of colorectal screening rates in the United States. In this unrelated study funded by AHRQ. the authors noted that the screening rates for whites (62%) is more than double that of Spanish-speaking Hispanics (30.6%). After adjustments for socioeconomic factors and access to care based on data from the 2010 Behavioral Risk Factor Surveillance System(BRFSS), the number for whites remained 24% higher than Spanish-speaking Hispanics and 22% higher than Asians. A remarkable observation was that the disparity between whites and English-speaking Hispanics was much smaller. After adjustments, Hispanic-English speakers were only 6% less likely to be screened than whites.
Commenting on these results which were published in the March 2014 edition of the American Journal of Preventive Medicine, Baker note
d “These findings that even if traditionally uninsured groups gain insurance coverage through the Affordable Care Act, disparities for low-income and minority groups are likely to continue. The remedy is to conduct specific outreach programs designed to maximize colorectal screening.” [5]
“Although racial and ethnic disparities in colorectal cancer screening will not be easy to eliminate. we’re making important progress in identifying low-cost, practical solutions to tackle screening barriers in vulnerable populations. The study published in JAMA Internal Medicine shows that targeted patient outreach can dramatically improve colorectal cancer screening rates.”
For more information:
[1] Globocan Database. Last accesses Jun 16, 2014 [Website]
[2] American Cancer Society. Cancer Facts & Figures 2014. Last Accessed June 16, 2014 [Website]
[3] Baker DW, Brown T, Buchanan DR, et al. Comparative Effectiveness of a Multifaceted Intervention to Improve Adherence to Annual Colorectal Cancer Screening in Community Health Centers: A Randomized Clinical Trial. JAMA Intern Med. Published online June 16, 2014. doi:10.1001/jamainternmed.2014.2352. [Article]
[4 ]Baker DW, Brown T, Buchanan DR, Weil J, Cameron KA, et al. Design of a randomized controlled trial to assess the comparative effectiveness of a multifaceted intervention to improve adherence to colorectal cancer screening among patients cared for in a community health center. BMC Health Serv Res. 2013 Apr 29;13(1):153. [Article][PubMed]
[5] Liss DT, Baker DW. Understanding current racial/ethnic disparities in colorectal cancer screening in the United States: the contribution of socioeconomic status and access to care. Am J Prev Med. 2014 Mar;46(3):228-36. doi: 10.1016/j.amepre.2013.10.023.[Article][PubMed]
Photo:David Baker, MD, MPH, chief of Medicine-General Internal Medicine and Geriatrics (left) and David Liss, PhD, MA , a research assistant professor in the same division (right), have co-authored a comprehensive study of colon cancer screening rates in America.Photo Courtesy:?2014Northwestern University Feinberg School of Medicine/Northwestern Medicine,Chicago, Ill.
Copyright ? 2014 InPress Media Group/Sunvalley Communication. All rights reserved. Republication or redistribution of InPress Media Group/Sunvalley Communication content, including by framing or similar means, is expressly prohibited without the prior written consent ofInPress Media Group/Sunvalley Communication. InPress Media Group/Sunvalley Communication shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. Onco’Zine and Oncozine are registered trademarks and trademarks of Sunvalley Communication around the world.
