Abstract
While recommendations call for adults aged 50 years or older to receive colorectal cancer screening, far too many still do not undergo the potentially life-saving procedure. Studies of the US population published late last year found that between 1998 and 2004, only 1 in 4 Medicare beneficiaries were screened, and that as of 2005, half of people aged 50 years or older had never had a screening colonoscopy, considered the gold standard of the screening modalities. Although screening colonoscopy is recommended for adults aged 50 years or older, many do not receive this procedure. Health professionals, insurers, public health advocates, and the government need to work harder to get the word out that colorectal cancer screening can save lives, said Grace Elta, MD, president of the American Society for Gastrointestinal Endoscopy (ASGE) and a professor in the department of internal medicine at the University of Michigan Health System in Ann Arbor. The American Cancer Society estimated that in 2007, almost 154 000 people would be diagnosed with colorectal cancer and 52 180 people would die from the disease. That places colorectal cancer as the fourth most diagnosed cancer and the second most deadly. Yet it is also one of the most treatable forms of cancer—if detected early. According to the ASGE, the 5-year relative survival rate for people treated for an early stage of colorectal cancer is more than 90%, but only 39% of such cancers are found at this early stage. Elta said that although screening rates are low, they have been increasing slowly. “I think it takes a while to change practice styles and the public's perception of what is good and necessary,” she said. The barriers to broader acceptance of this screening, according the ASGE, are a lack of public awareness about colorectal cancer and the benefits of regular screening, inconsistent recommendations for screening by clinicians, uncertainty of coverage by insurance, concerns about painful or embarrassing tests, and a hesitancy to discuss diseases of the colon and rectum. Researchers from Case Western Reserve University in Cleveland identified 153 469 Medicare beneficiaries who were cancer-free and aged 70 years or older in 1998 (the first year Medicare reimbursed for colorectal cancer screening) and were followed up through 2004. The findings were published in Cancer (Cooper GS and Kou TD. Cancer. 2008;112[2]:293-299). The researchers found only 25.4% of patients had undergone complete screenings by 2004, including 17.6% who had colonoscopy and 2.9% who had flexible sigmoidoscopy. Patients who were white and younger had higher screening rates, as did those who had already had a screening test prior to the study period. Analyses of the entire population recommended to receive colorectal cancer screening show similar shortfalls. The US Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ) found that 50.1% of the population aged 50 years or older had never had a screening colonoscopy. In a statistical brief, the AHRQ delved into the numbers to reveal differences by sex, race, education, insurance standing, and marital status (http://www.meps.ahrq.gov/mepsweb/data_files/publications/st188/stat188.pdf). For example, using data gathered from 15 000 households participating in the Medical Expenditure Panel Survey for 2005, the AHRQ found that 57.5% of people aged 50 to 64 years had never received colonoscopy screening compared with 39.4% of those aged 65 years or older. As for race, 66.9% of Hispanic adults aged 50 years or older, 55.8% of blacks, and 47.1% of whites had never received the procedure. And among people aged 50 to 64 years, 77.1% of those who were uninsured had never had a colonoscopy screening compared with 60.6% of those with public insurance, such as Medicaid, and 54.1% of those with private insurance. One reason for the low rates of colonoscopy may be mixed messages from official recommendations. The US Preventive Services Task Force, while strongly recommending screening for colorectal cancer in people aged 50 years or older, downplays colonoscopy as the preferred method, saying it is unclear whether the increased accuracy of colonoscopy compared with other screening methods offsets the procedure's additional complications (up to 0.3% of all tests), inconvenience, and costs. Elta, though, defended colonoscopy (which has a 95% or greater sensitivity for cancer and a 100% specificity for cancer and polyps) as the preferred screening modality. “Clearly, any colon cancer screening technique is better than none at all, but colonoscopy is the gold standard due to its accuracy and due to the fact that it allows polypectomy at the time of polypdetection,” she said.
Journal
JAMA
– American Medical Association
Published: Feb 13, 2008
Keywords: colorectal cancer screening,screening
