Q&A With Cathy Eng, MD: Unmet Needs in the Management of Metastatic Colorectal Cancer Care
May 14, 2020 12:00pm
The National Colorectal Cancer Roundtable may have come up short in its goal to get 80% of American adults ≥50 years screened for colorectal cancer by 2018, but David A. Greenwald, MD, told his audience at the 2018 American College of Gastroenterology Annual Meeting that the group can point to smaller victories that deserve recognition.
David A. Greenwald, MD
The National Colorectal Cancer Roundtable (NCCRT) may have come up short in its goal to get 80% of American adults ≥50 years screened for colorectal cancer (CRC) by 2018, but David A. Greenwald, MD, told his audience at the 2018 American College of Gastroenterology Annual Meeting that the group can point to smaller victories that deserve recognition.
In 2012, 65.5% of adults ≥50 years were screened for CRC. That increased to 67.3% by 2016, resulting in an additional 5.1 million screenings. Screening has also helped fuel a 20-year decline in CRC incidence and mortality.
CRC screening had plateaued around 59% from 2010 to 2013. After the 80% by 2018 initiative was launched in March 2014, the screening rate increased to 63% in 2015.1 If screening prevalence remains at the 2015 level, the roundtable estimated that through 2030, 39,700 CRC diagnoses and 37,200 CRC deaths will be prevented. Had the country achieved the 80% goal, the result would be an estimated 277,000 fewer cases and 203,000 fewer CRC deaths by 2030.
“How did we do?” said Greenwald, director of clinical gastroenterology and endoscopy at Mount Sinai Hospital and co-chair of the roundtable’s Public Awareness and Social Media Task Group. “I think we did wonderfully. There are successes all over the place.”
The NCCRT introduced the 80% by 2018 initiative to increase CRC screening rates and ultimately eliminate the disease. Eventually, 1700 organizations signed on to the project.
The roundtable produced materials to encourage adults to get screened, created microcampaigns to target specific groups and thought leaders, and employed political grassroots efforts.
A number of organizations met the 80% by 2018 goal, with 3 achieving a 90% screening rate: Centro De Salud De Lares and Centro De Servicios Primarios De Salud, in Puerto Rico, and in Alaska, the Aleutian Pribilof Islands Associations. The Veterans’ Administration System achieved a rate of 82% by 2016. The national rate at the time was 65%.
“There are 80% success stories all over the place,” Greenwald said. “You can celebrate successes anywhere they happen. It doesn’t necessarily mean that 80% of the country needs to be screened, but [that] 80% of a church [congregation] could be screened. Or 80% of the people working in a large corporation could be screened. And those are all successes.”
Greenwald cited 2 providers, C.L. Brumback Primary Care Clinics in Florida and the New York Citywide Colon Cancer Control Coalition (C5) in New York City, that have had great success in increasing screening rates in their communities. Brumback, a federally qualified health center, implemented a range of new programs, including care team education and training, fecal immunochemical tests, and something called “poop-on-demand.” If a patient came to the office for another reason and was capable of producing a sample, providers would perform an unscheduled screen for CRC.
The work paid off. Screening rates at the clinic went from 21% in 2013 to 82% in 2016. C5 helped improve the screening rate in New York City from 41.7% in 2003 to 68.5% in 2016. The coalition’s efforts also helped reduce racial disparities in screening. Screening rates were significantly higher for whites in 2003, but by 2010, the disparities were eliminated and by 2016, African Americans and Latinos were slightly more likely to get screened than whites.
Disparities in CRC-specific survival have declined in New York City as well. Survival has improved for all racial/ethnic groups since 2003, and among African Americans, it has declined to the point that it is nearly equal to that of whites.
No state achieved the 80% goal. Vermont (61.3%), Maine (60.7%), New Hampshire (58.7%), and North Dakota (52.3%), however, had the best results. Alabama (18.6%) and Oklahoma (21.2%) had the worst. Alabama was the only state to have a screening rate below 20%.
States have generally seen growth in the percentage of people with up-to-date screening results. “Up-to-date” is defined as adults aged 50 to 75 years who’ve received a fecal occult blood test (FOBT) within the past 12 months, sigmoidoscopy within the past 5 years with FOBT within 3 years, or colonoscopy within 10 years. From 2012 to 2016, Hawaii (8.2%), Kentucky (6.5%), and North Dakota (5.9%) saw the greatest increases, and Georgia (4.4%) saw the greatest decline.2
CRC screening rates have typically been low due to negative connotations associated with colonoscopies and a lack of affordability of screening. Greenwald also noted that many people without symptoms or a family history of CRC underwent screening.
Screening rates have also been far lower than screening rates for breast or cervical cancer. According to a National Institutes of Health survey, the rate for CRC screening was just 47% in 2005.1 Since 80% by 2018 was initiated, screening rates for CRC are more in-line with those other tests. Pap smear rates rose to approximately 90% and mammogram rates to almost 80% by 2015. Rates of CRC screening increased from roughly 30% in 2000 to approximately 60%.3
“In 2000 and 2003, there was an enormous gap between screening for colorectal cancer [and] that of mammography or pap smears,” Greenwald said. “By 2015, that gap [had] been almost closed and the trajectory of colorectal cancer screening [had] gone up.” As the year comes to an end, the NCCRT is shifting its focus to look beyond 2018. The roundtable hasn’t come up with a new name for the campaign, but the mission remains the same. “The message will be: Get screened,” Greenwald said. “Pretty simple.”