Eliminating financial barriers and providing more direct contact among patients and physicians and providers are the best ways to improve the rate of screening for colorectal cancer, a National Institutes of Health Consensus Conference recommended Thursday after meeting for three days this week in Bethesda, Md. The recommendations are not binding on any group or agency--they simply represent the best advice of experts in the field about what would be the optimum approach to solving the problem.
Colorectal cancer is the second-leading cause of cancer death in the United States and part of the reason for that is limited screening, because the disease is highly curable if caught early. As recently as 1997, only 20% to 30% of the eligible population--primarily those over the age of 50--underwent screening. By 2008, the percentage was up to 55%, but that is still very low compared with screening for other cancers, which can reach 80% to 90%. Experts would like to see the rate get up to at least 80%, and the consensus panel was convened to consider ways to do that.
One way is to have better insurance coverage. High co-pays and lack of insurance cause many people to ignore calls for screening. Some insurance companies, such as Kaiser Permanente, as well as the Veterans Affairs health system, have achieved much higher screening rates by offering better coverage for the testing, and the panel recommended that others follow suit. A national program to provide free screening has begun in 22 states, but it is too soon to see if that is working.
Another problem that may be more difficult to overcome is fear of pain during the procedure itself and disgust at the preparations that are necessary for colonoscopies. The pain is minimal and does not occur if the patient is sedated. It is necessary to clear out the colon before screening, and that requires imbibing large quantities of a foul-tasting liquid to induce diarrhea, and there seems to be little that can be done about that now. Less invasive tests are available, but they are not as accurate and must be repeated more often. And positive results from them require followup with more invasive tests.
"We recognize that some may find colorectal cancer screening tests to be unpleasant and time-consuming," said Dr. Donald Steinwachs of Johns Hopkins University, chairman of the panel. But "we also know that recommended screening strategies reduce colorectal cancer deaths. We need to find ways to encourage more people to get these tests."
The panel also noted that, if the screening rate can be increased, there will be a higher demand for screening facilities and new ones may have to be constructed.
The most common screening methods include:
-- Fecal occult blood tests and immunochemical tests, which look for blood in the feces not visible to the naked eye. It should be repeated every year after age 50.
-- Sigmoidoscopy, an internal examination of the lower part of the large intestine with a small television camera attached to a flexible tube inserted into the anus. It should be repeated every five years.
-- Double-contrast barium enema, an X-ray examination of the intestines following the intake of contrast material. It should be repeated every five years.
-- Colonoscopy, an internal examination of the entire large intestine. It should be repeated every 10 years.
-- Computed tomography colonoscopy, often called a virtual colonoscopy. The colon and rectum are observed with a CT scanner. It should be repeated every five years.
-- Fecal DNA, an examination of feces searching for DNA shed from tumors. It is not clear how often it should be repeated.
More information about colorectal cancer screening is available here.
-- Thomas H. Maugh II