According to the American Cancer Society, colorectal cancer is the second leading cause of cancer-related deaths in the United States. In 2020, approximately 53,200 Americans are expected to die from colorectal cancer. The good news is that several colorectal cancer (CRC) screening options exist, and early detection can translate into better patient outcomes. Despite the existence of effective screening options, colorectal cancer has the dubious distinction of being the easiest to prevent yet least prevented form of cancer. When colorectal cancer is detected early at stage I or II, the 5-year survival rate for patients is 90 percent, according to the American Cancer Society. Still, screening numbers remain well below current public health goals, and most colorectal cancer isn't identified until it has progressed to the later stages of the disease.
Becker’s Hospital Review recently spoke with Jay Zdunek, DO, CMO at Austin (Texas) Regional Clinic, Robert Tracy, MD, medical director of quality at Kentucky-based St. Elizabeth Physicians, and Allison Church, manager of quality transformation at St. Elizabeth Physicians, about strategies for improving CRC screening rates. They discussed how shared decision-making, in combination with a portfolio of different CRC screening options, is helping more patients complete this very important preventive testing. Implementation of shared decision-making approaches to CRC screening may impact stagnant screening rates. Shared decision-making offers patients a voice in their own care journeys and is a key component of patient-centered care. For CRC screening, providers can offer patients multiple screening options, which could increase the likelihood of a patient being screened by 23 percent, according to the National Colorectal Cancer Council Roundtable.
Choice ignites change
Today’s patients have more access to information about their health and healthcare providers than ever before, meaning many patients are eager to have more sophisticated healthcare interactions. Rather than relying solely on what providers tell them to do, many patients want to have a conversation about options.
"We all are more likely to buy into decisions when we have a stake in how they are made," Dr. Zdunek said. "It's no different in healthcare. The patient needs to be engaged in decisions. That's paramount for higher levels of cooperation and commitment."
Education about colorectal cancer is an essential part of the shared decision-making process. Some patients are reluctant to participate in screening because they fear that tests will identify a problem.
"We educate people about the progression of colorectal cancer which begins with pre-malignant polyps," Dr. Tracy said. "By finding these polyps during screening, we can prevent patients from undergoing a lot of additional testing, surgery and possibly chemotherapy. Once people understand how screening works, it helps reduce the resistance."
The ability to offer different options for CRC screening is another component of share decision making. Austin Regional Clinic, for example, offers traditional colonoscopies, fecal occult blood (FOBT) tests and multi-target stool DNA (MT-sDNA) tests. St. Elizabeth Physicians has also expanded its CRC testing alternatives to include colonoscopies, MT-sDNA and FIT tests.
"There's no single approach to CRC testing that will work for all patients," Dr. Zdunek said. "At the end of the day, it's about finding which alternative will work best for the individual and enable them to feel comfortable completing the process."
The time commitment required for a colonoscopy is another barrier to getting tested, since it means taking time off work and some people have concerns about the bowl preparation process. "The discussions and shared decision-making about MT-sDNA and FIT are what have helped move our needles with regard to CRC screening," Dr. Tracy said. "Some folks who have said they would never do a colonoscopy are willing to be screened using a different method."
Dr. Zdunek added, "It used to be a bigger fight when the only options were flexible sigmoidoscopy and colonoscopy. Overall, we've seen much improved acceptance for CRC screening due to the advent of DNA testing."
Beyond meeting patient desires for more choice, offering multiple options for CRC screening may translate into more screenings, and more screenings means better outcomes. In a study of nearly 1,000 patients published in the Archives of Internal Medicines, participants whose providers exclusively recommended colonoscopy completed screening at a rate of 38 percent. The participants that were given a choice between FOBT and colonoscopy completed CRC screening at a rate of 69 percent. Adherence in FOBT-only arm was no different than in choice arm. Randomized study of adults aged 50-79 at average risk of CRC conducted in a single-site safety-net healthcare system.
Without organizational commitment, CRC screening rates won’t improve
To address gaps in CRC screening, organizational focus is essential. Individual physicians can't singlehandedly increase CRC screening rates. If health system leaders and administrators don't support this goal, it's unlikely to be successful. Improving the rates of cancer screening across populations requires leadership and widespread individual ownership among clinicians.
Austin Regional Clinic is using a top-down approach to achieve improvements in its CRC screening rates. According to Dr. Zdunek, "We have a commitment that flows through our medical home, IT department, scheduling department, primary care offices and the GI and surgery departments. Across the board, multiple levels of the organization are working together to increase the ease of getting patients into the system and the screening completed."
The population health team handles mass mailings to reach as many people as possible. That reduces the burden on primary care providers. To remind patients about CRC screening, Austin Regional Clinic has also implemented alerts in the patient portal. In addition, when the nursing staff or physicians open the EHR, reminders notify them if the patient is due for a screening test.
Positive patient experience is key when it comes to preventive screenings
Three years ago, St. Elizabeth Physicians launched its campaign to increase CRC screening rates. A cornerstone of the initiative is greater convenience for patients through streamlined processes.
"One of the big things that we implemented is direct scheduling of colonoscopies with our GI providers and surrounding partners," Ms. Church said. "While the patient is in the exam room, we can pull up the schedule and tell them immediately when there is availability for the procedure and schedule it on the spot."
Discussions about CRC screening during primary care appointments can be impactful. St. Elizabeth Physicians are able to offer multiple modalities including colonoscopy, MT-sDNA, or FIT test, so patients can leave their appointment with an established path to screening completion.
"To further support patients, we have added a benefits check across all our CRC screening options," Ms. Church said. "We've also implemented nurse navigators to discuss CRC test results with patients and ensure appropriate follow-up with specialists when needed."
Weekend wellness clinics are another element of St. Elizabeth Physicians’ CRC screening campaign. These have proven to be very popular with patients. Patients can come to a Saturday clinic, meet with nurses and quickly close multiple health gaps related to diabetes care, cancer screenings and immunizations. A mammogram van is in the parking lot offering screenings on the spot. In addition, patients can work with their providers to determine the CRC screening test right for them and be able to schedule or order the tests at that time. Point-of-care testing is also available for A1C levels, blood pressure and microalbumin.
"Patients have been very responsive to this approach because it's quick and they can address several issues in a short period of time," Dr. Tracy said. "Convenience is key in healthcare thesedays. Caregivers for older people really like the weekend clinics because they don't have to take time off work."
As CRC screening rates rise, patient outcomes can improve
Improving CRC screening rates requires leadership to establish a specific goal and launch a coordinated effort across health system to achieve that goal. St. Elizabeth Physicians has a goal to have 80 percent of its population screened for CRC by the end of 2020. As of February, the organization had hit 71 percent. Austin Regional Clinic has also set internal metrics around CRC screening, with a goal of being best in class in Texas and in the top 10 percent in the United States.
Reaching these objectives requires a change in mindset. "We need to focus on prevention and wellness. That's a big shift because we are trained to treat disease," Dr. Tracy said.
To engage physicians, St. Elizabeth Physicians has implemented quality measures around CRC screening which are tied to provider compensation. The organization has also achieved CMS Five Star ratings for preventative services, including CRC screening. Last year alone, providers at St. Elizabeth Physicians captured over 700 precancerous polyps and early colon cancer in patients.
Early detection makes it possible to intervene with patients before their situation is critical. "When we detect adenomatous polyps, altered DNA and abnormal cells associated with cancer or precancer, people are in a better position to avoid colorectal cancer in the long term," Dr. Zdunek said. "That's the end game we're trying to achieve."
Ms. Church agreed, "With cancer screening programs, data shows that being tested earlier leads to better outcomes. We are seeing a transition from later staging identification to much earlier, which often leads to positive patient outcomes."
More options mean more progress on colorectal cancer screening
New options and more information have transformed the way CRC screening is conducted. Listening to patients, hearing their concerns and offering testing options that align with their needs are all essential. Shared decision-making means explaining different screening options, including the required frequency of the tests, the commitment required for each, the costs and the pros and cons. Choice ignites change. The bottom line is this: The more patients screened for CRC, the more lives that can be impacted. As the U.S. Preventative Services Task Force noted, "The best screening test is the one that gets done."
As screening rates increase, progress will continue to be made in the war on colorectal cancer. Dr. Zdunek noted, "When I look at where we've come in colorectal screening from the time I started practicing 30 to 40 years ago, it's night and day. That speaks volumes about the new techniques that are available."