Resource Allocation for Colorectal Cancer Screening

Naimish Pandya, MD

October 2010, Vol 1, No 5 - VBCC Perspectives


More than 142,000 estimated new cases of colorectal cancer will be diagnosed in the United States in 2010, and more than 51,000 will die from this disease this year.1 However, this could have been prevented among all individuals if the cancer was caught in an early stage. Unlike many other cancers, we recognize that in most cases there is a clear link from benign polyp formation through progression to eventual colorectal cancer. If these are successfully identified early, and eventually removed, colorectal cancer can be prevented. There are numerous screening tools currently approved for the use of identifying colon cancer among asymptomatic individuals, including fecal occult blood testing (FOBT), immunochemical FOBT, double-contrast barium enema, flexible sigmoidoscopy, and colonoscopy. Recommendations from various task forces and organizations vary, but all have mostly agreed that, among the general population, a colonoscopy performed once every 10 years after age 50 is useful to identify cancer early and is also cost-effective. Few organizations have also recommended using FOBT and sigmoidoscopy testing between these 10-year intervals. Although screening rates have increased since the 1980s, only 50% to 60% of the population is estimated to have been screened in 2006. This dismal rate is attributed to lack of awareness, barriers to access to healthcare, lower education level, low minority participation, and avoidance of undergoing a bowel preparation for colonoscopy evaluation.2 Many strategies are being developed to address these issues and improve overall screening rates.

In trying to address some of these concerns, additional noninvasive tests have been developed and added to the repertoire of screening tools. Computed tomography (CT) colonography is a noninvasive look at the colon using a CT scan and is recommended to be performed once every 5 years. Advantages of this procedure include avoidance of sedation and an invasive procedure, and being fairly safe and quick. However, disadvantages include require ment of a full bowel prep, inability to identify small lesions, ultimate requirement of a colonoscopy (if suspicious lesions are found that require biopsy), exposure to unnecessary radiation, and finding extracolonic lesions that increase unnecessary procedures to the patient and cost to the healthcare system. At the current cost of the procedure, the Centers for Medicare & Medicaid Services has recently determined that it is not a cost-effective screening tool and has refused reimbursement. 3 Stool DNA testing avoids the unpleasantries of a bowel prep and the invasive procedure and sedation. However, it, too, is neither specific nor sensitive enough, when compared with a colonoscopy, and would still require the invasive procedure, should it be positive. Furthermore, because it performs various genetic analyses, the cost of the procedure is quite exorbitant. A recent analysis determined that this test is only cost-effective if screening adherence increased by more than 50% its current rate; otherwise, the cost of the test would have to be about 10% its current cost levels to justify its use.4

Screening Rates the Real Issue
Although new screening tools perhaps add to improved detection and potentially improved patient experience while undergoing the testing, neither of these new tools would address the underlying problem of low screening rates. Supposedly, these tools would just add to the menu of options for the patients to choose from when deciding to undergo screening, likely adding to the confusion of the lay person in determining which is the better screening test. Indeed some US states have passed legal mandates that all screening tools be available to citizens based on guidelines set forth by various medical societies and task force opinions. Unfortunately, discussions on the pros and cons of various tests and the consequences of results are never preemptively discussed by healthcare professionals (or occur infrequently) or are not processed properly by all patients. Therefore, it is appropos for third-party payers to weigh in on the appropriateness of each screening tool, and use financial incentives to direct the public toward the more medically and costeffective test. As a practicing gastrointestinal medical oncologist, it is regrettable to be treating so many patients annually, when one recognizes that many of these cases were likely preventable. Progress in medical care, both in diagnostics and in therapeutics, occurs by developing ever more molecular, more sophisticated, and more modern tools that are less unpleasant or burdensome to the patient. However, given the high colorectal cancer mortality that exists today, it would be more useful, at the population level, to spend precious capital in overcoming barriers to screening that numerous patients face. Improving this will not only drive down costs of screening tests, which could allow for newer and better screening tools, but also drive down costs of overall healthcare-related expenses for colorectal cancer by prevention.

References

  1. Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin. 2010;60:277-300.
  2. Holden DJ, Jonas DE, et al. Systematic review: enhancing the use and quality of colorectal cancer screening. Ann Intern Med. 2010;152: 668-676.
  3. Knudsen AB, Lansdorp-Vogelaar I, Rutter CM, et al. Cost-effectiveness of computed tomographic colonography screening for colorectal cancer in the Medicare population. J Natl Cancer Inst. 2010;102:1238-1252.
  4. Lansdorp-Vogelaar I, Kuntz KM, Knudsen AB, et al. Stool DNA testing to screen for colorectal cancer in the Medicare population: a cost-effectiveness analysis. Ann Intern Med. 2010;153:368-377.