Colorectal cancer is the third leading cause of cancer related deaths in both men and women. More than 53,000 people were projected to die of colorectal cancer in 2020, with more than 3,500 of those deaths attributable to individuals under the age of 50, according to estimates from the American Cancer Society. While CRC rates have broadly decreased in recent decades, the trend is changing for younger patients. From 2012 to 2016, incidence rates increased by 2.2 percent annually in individuals younger than 50 years.1
With thousands of lives on the line, the U.S. Preventive Services Task Force (USPSTF) revised their screening recommendations to target younger patients more aggressively. The USPSTF now recommends colorectal cancer screening beginning at age 45 for average risk patients.2*
Becker’s Hospital Review recently spoke with experts from two leading health systems about these new recommendations and how their organizations will engage with younger patients to begin colorectal cancer screening as soon as they are eligible:
- Lisa Ravindra, MD, internal medicine, Rush University Medical Center in Chicago
- Nicole Trieste, RN, director, ambulatory care gaps and best practices, Danville, Pa.-based Geisinger
Bringing down barriers to CRC screening
Based on market research, individuals between the ages of 45 and 49 reported a below-average likelihood of getting screened for CRC in the next six months.3 Patients in this demographic group are somewhat unusual since they are more likely than older populations to have younger children and hectic work schedules. Although they may recognize the importance of CRC screening, many face obstacles associated with scheduling the procedure.
"We are all very busy and the thought of sitting on hold for several minutes to schedule a test that no one’s really excited about is always a big deterrent," Dr. Ravindra said. "If we can improve those workflows and make them easier, that should be a priority."
Health systems are looking at ways to improve the scheduling process such as direct lines to schedulers and access to quick appointments. Another alternative is patient self-scheduling using the online portal. That may be particularly beneficial for tech-savvy individuals in the 45-to-49-year-old age group.
Discussing different screening options is also essential. "We are fortunate that for CRC screening, we have multiple modalities that are approved and effective," Dr. Ravindra said. "While the gold standard continues to be colonoscopy, some people are still hesitant due to the invasiveness of the procedure or having to take a day off work. Offering alternatives like the mt-sDNA home-based stool test is really important."
Geisinger has configured its EHR with documentation and order sets for various CRC screening alternatives including colonoscopy, mt-sDNA and fecal immunochemical test (FIT). If patients elect to use mt-sDNA or a FIT kit, the care caps team conducts outreach to encourage test completion.
"We contact patients who ordered mt-sDNA 60 to 90 days earlier, but haven't returned the kit, to answer questions and address concerns," Ms. Trieste said. "If patients have a positive mt-sDNA or FIT test result, our team also follows up if they don’t schedule a colonoscopy."
Leading health systems also recognize physician education as critical to success. Rush University Medical Center expects to publish newsletters and clinical reminders, hold lectures and make announcements at gastroenterology department meetings to ensure clinicians are aware of the CRC screening recommendation changes.
4 Action Steps for Smarter Cancer Screening
- Include average-risk patients aged 45 years and older in all CRC screening outreach efforts.
- Prioritize clinician education to ensure staff are aware of new cancer screening recommendations.
- Update EHR algorithm to identify patients for appropriate health maintenance screenings and services.
- Equip EHRs with real-time alerts to notify clinicians when a patient is eligible for screening at the point of care.
With EHR systems, providers can proactively engage patients
EHR systems use algorithms to identify when patients are due for health maintenance activities ranging from CRC screenings to Pap smears, mammograms and vaccines. These algorithms drive a variety of clinical reminders.
"Whenever there's a guideline change like the new USPSTF recommendations, the first step is to change the EHR algorithm so we can capture the new population," Dr. Ravindra said. "I'm a member of Rush University Medical Center's Epic Ambulatory Enhancement and Optimization Committee. At our next meeting, I’m planning to propose a change to the CRC screening algorithm which will make it easier to do a lot more outreach."
Research suggests proactive communication is important. According to The Healthy World Report, almost 40 percent of patients say they would follow their physician’s orders if they received some kind of reminder or nudge between visits.4
Based on information in its EHR system, Geisinger has developed a portfolio of patient communications to promote awareness and action around CRC screenings. "We send out an annual happy birthday message to patients encouraging the importance of routine appointments to address gaps in care like CRC screenings," Ms. Trieste said. "These messages provide patients with a health calendar of their open care gaps, when those are due and information about how to contact a care gaps staff member to schedule the recommended screening."
Patient engagement at the point of care is effective for increasing screening rates
Despite reminders, it’s not uncommon for patients to put off routine and preventive healthcare. Unfortunately, this behavior has become even more pronounced since the start of the COVID-19 pandemic. As a result, many patients have developed significant care gaps.
Clinicians are now taking every possible opportunity to communicate with patients about the need for preventive care measures like CRC screenings. "We used to think of the annual physical visit as the time when primary care doctors would talk about age-appropriate health screenings and vaccines," Dr. Ravindra said. "Now I'm taking the opportunity to address health screenings at any type of patient visit, even if someone is coming in for knee pain or anxiety."
During these face-to-face visits, EHR data makes it easier for providers to identify which messages to convey to patients. Geisinger, for example, runs a daily Anticipatory Management Program report which shows all gaps in care at the patient level. Teams utilize this report for pre-visit planning and at the point of care.
Geisinger also uses EHR alerts. These automated alerts display at the point of care when patients are overdue for CRC screenings. "The alerts fire for nurses while they are rooming patients," Ms. Trieste said. "If the nurse doesn’t select an acknowledgment reason or the nurse selects ‘decline’ if the patient isn’t agreeable, the alert will fire again for the provider."
Dr. Ravindra believes that effective communications don't simply alert patients that they're eligible for a CRC screening. They must also help patients understand why they shouldn’t wait any longer. To strengthen Rush University Medical Center's CRC-related messaging, Dr. Ravindra has been working closely with the organization’s marketing team.
Geisinger has taken a similar approach. In addition to its EHR-driven tools, Geisinger has developed a shared decision-making tool which is a patient handout specific to CRC screenings. Providers review this user-friendly and engaging document with patients during visits. It highlights current CRC statistics, outlines the importance of CRC screening and briefly describes the different screening options.
A call to action: Now is the time to embrace new CRC screening recommendations
Successfully expanding CRC screening to younger patients requires buy-in and participation across the healthcare ecosystem. Providers must begin by educating physicians, ensuring younger patients are included in CRC outreach efforts, and updating the EHR and technology solutions to support these changes. Health systems leaders must also prepare for downstream barriers, such as advocating for insurance coverage to include screenings for younger patients.
"Generally, screening tests are covered with no out-of-pocket costs," Dr. Ravindra said. "If colorectal cancer screenings aren’t covered at that rate for people ages 45 to 49, we will have a really hard time encouraging patients to get screened. That could be a big barrier."
Ms. Trieste agreed that insurance company involvement is critical. Geisinger plans to incorporate younger patients into its CRC outreach efforts once it receives confirmation from major payers that they will cover preventive CRC screening and future screening.
It will take significant effort to get newly qualified, younger patients on board with the testing. To make the decision easier, leading health systems are pursuing various engagement activities and offering different screening choices. Both Dr. Ravindra and Ms. Trieste commented, "At the end of the day, the best colorectal screening option is the one that gets done."
1. ACS. Colorectal cancer facts and figures 2020-2022. Atlanta: American Cancer Society; 2020.
2. Davidson KW, Barry MJ, Mangione CM, et al. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(19):1965- 1977. doi: 10.1001/jama.2021.6238
3. Internal data. Exact Sciences Corporation, 2019.
4. Televox. A Fragile Nation in Poor Health. Mobile, AL: Televox; (2015)