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Organized CRC Program Significantly Increases Screening Rates
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The implementation of an organized screening program of annual fecal immunochemical tests combined with colonoscopy demonstrated a significant, and rapid, increase of colorectal cancer screening participation, according to results of a dynamic cohort of health plan members at an institution.
The results also demonstrated that as colorectal screening participation increased over a 15-year period, cancer mortality decreased more than 50% during that time.
“We started colorectal cancer screening with flexible sigmoidoscopy in 1994 and were doing large volumes of procedures,” Theodore R. Levin, MD, chief of Gastroenterology at Kaiser Permanente Medical Center, Walnut Creek, and a research scientist at Kaiser Permanente Northern California, told Healio Gastroenterology and Liver Disease. “Yet when the National Committee on Quality Assurance incorporated colorectal cancer screening into its Health Care Effectiveness Data and Information Set measure in 2004 our performance was below what we wanted to provide to our patients.”
Douglas A. Corley, MD, PhD , a research scientist at Kaiser Permanente Northern California and study co-author, said that after seeing encouraging results from research evaluating fecal immunochemical tests (FIT), the Kaiser network decided to implement the tests to try to increase screening participation.
“We expected that sending FIT kits through the mail would be a great way to reach patients who may have declined screening with flexible sigmoidoscopy or were not coming into the office often enough to be reminded to be screened,” Corley told Healio Gastroenterology and Liver Disease. “We saw an initial rapid uptake of screening and our rates increased to about 65%.”
Levin, Corley and colleagues used a dynamic cohort of Kaiser Permanente Northern California health plan members from 2000 to 2015 to evaluate if an organized colorectal cancer screening program could achieve and maintain the 80% or higher screening target proposed by various organizations.
Additionally, the researchers wanted to determine if changes in screening rates would correlate to changes in colorectal cancer incidence and mortality.
Prior to 2006, colorectal cancer screening within the cohort was predominantly performed using sigmoidoscopy and gFOBT and was always performed by physician request, according to the results.
Screening transitioned region-wide in 2007 to direct-to-patient annual FIT outreach for members aged 60 to 69 years who were not screening up-to-date by other methods and was expanded to members aged 51 to 75 years in 2008.
Colonoscopy did remain an option during this period.
The researchers sampled patient characteristics from 2000, 2008 and 2015. During each year, patients were predominantly aged 51 to 64 years (68.5%-74%), female (52.5%-53%) and non-Hispanic white (58.4%-64.4%).
From 2000 to 2005, screening participation was from 39.7% to 40.5%. However, participation began to rise as FIT was being implemented.
Members up-to-date with screening significantly increased from 38.9% in 2000, to 82.7% in 2015 (P < .01).
Initially, age-adjusted colorectal cancer incidence rates increased from 95.8 cases/100,000 (95% CI; 88.1-103.4) in 2000 to a high of 117.8 cases/100,000 (95% CI; 110.4-125.2; P < .01) in 2008.
However, overall age-adjusted colorectal cancer incidence rates decreased 25.5% between 2000 and 2015 (P < .01).
Age-adjusted incidence-based mortality rates decreased by 52.4%, from 30.9 deaths/100,000 (95% CI; 26.6-35.3) in 2000 to 14.7/100,000 (95% CI; 12.3-17.1) in 2015.
“The implications of these results are that a meaningful impact [can be made] on colorectal cancer incidence and mortality by increasing screening rates using a combination of FIT and colonoscopy,” Levin said. “This can be achieved in the real world and not just in clinical trials.”
Corley did acknowledge that while their approach is a good start, they did have some structural advantages.
“[We had] an integrated health care delivery system with primary care and specialists working together, a pre-paid financial model giving us more flexibility with how we use resources than a traditional fee for service system, and a comprehensive integrated electronic record providing real time information on who is up to date with screening,” he said. “[But] even without those advantages, everyone can start by offering FIT screening as an alternative to colonoscopy. The first step, though, is to measure your population and see who needs to be screened.” – by Ryan McDonald
Disclosures: The researchers report no relevant financial disclosures.
Perspective
Back to TopDarrell Gray, II, MD, MPH
This study clearly demonstrates the impact of coordinated outreach and in-reach strategies on colorectal cancer screening uptake and follow-up of abnormal FIT in a large, diverse population within an integrated health system. It provides further evidence that a screening rate of 80% among such a population is both achievable and sustainable and that routinely offering FIT as an option for screening is an effective strategy in accomplishing this goal. Importantly, as shown in the significant decrease in the burden of disease (both incidence of early and late stage disease and mortality) among the study population, it also underscores the fact that colorectal cancer screening saves.
Replicating and, more importantly, sustaining this successful approach in less resourced and/or integrated clinical settings, especially those without their own health plan, is likely to be challenging. Infrastructure – particularly, a system for reliably capturing and tracking data on screening uptake and follow-up, coordinating mailings of FIT kits for their patient population, and providing decision-support that is not office-visit based or reliant on health care provider recommendation – may be the greatest barrier to implementation. However, it is not insurmountable. Prior studies that have evaluated the impact of FIT and colonoscopy outreach in safety-net hospital settings offer valuable insight.
Nonetheless, I find the results of this study to be encouraging and believe they have significant clinical and policy implications. It contributes to the growing body of literature on evidence-based practices in offering and delivering colorectal cancer screening and illustrates the impact of attaining the goal set forth by the National Colorectal Cancer Roundtable of 80% of age-eligible adults being screened.
Perspective
Back to Top
Douglas J. Robertson, MD, MPH
Over the past decades, rates of colorectal cancer incidence and mortality have fallen within the United States. This has largely been accomplished by opportunistic efforts at screening and largely, and increasingly, with colonoscopy.
In this context, the study by Levin and colleagues reporting the outcomes of their colorectal cancer screening program within the Kaiser Permanent Northern California health plan is important. First, it highlights the impact on screening adherence by implementing direct-to-patient annual FIT outreach in addition to on request colonoscopy. Over about 15 years, the percent of individuals up to date with screening increased over 40%! Second, the results demonstrate the “real world” impact of improving colorectal cancer screening rates using a multi-modality approach with FIT. Specifically, colorectal cancer mortality within the population fell a bit over 50%. We know from large clinical trials that colorectal cancer screening can work. But to demonstrate such benefit within a clinical population in general practice speaks to the potential power of organized screening.
Unarguably, relatively “closed” populations like a health maintenance organization or the Veterans Administration have distinct advantages in applying programmatic efforts like the ones described by Levin and colleagues. For example, these systems often have a single underlying electronic medical record that lends itself to close follow up of the population (eg, to send repeated annual tests even as individuals move) and auditing of program results (eg, determination of the percent moving from FIT positive to colonoscopy). If the target of screening 80% of the population is to be realized, it will be important to learn lessons from the efforts described in this paper. Unarguably, there will be challenges trying to implement such programs within less organized settings. But the magnitude of the results should be a great motivator to overcome those barriers. By reaching greater proportions of our U.S. population with screening, using options like FIT in addition to colonoscopy, we can continue to bend colorectal cancer rates downward.
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