Improving Adherence to CRC Screening: A Primary Care Physician’s Guide

Announcer:
You’re listening to Clinician’s Roundtable on ReachMD, and this episode is sponsored by Exact Sciences. Here’s your host, Dr. Charles Turck.

Dr. Turck: 
Welcome to Clinician’s Roundtable on ReachMD. I'm Dr. Charles Turck, and joining me to discuss strategies for improving patient adherence to screening tests for colorectal cancer, or CRC, is Ms. Sarah Enslin. She's a physician assistant at the University of Rochester Medical Center in New York. Ms. Enslin, it's great to have you with us. 

Ms. Enslin:
Thank you. It's great to be here today.

Dr. Turck:
Now just to give us some background, what can you tell us about the current CRC screening rates in the United States? 

Ms. Enslin:
Yeah. So colorectal cancer is the second leading cause of cancer-related death in the United States with over 150,000 new cases projected to be diagnosed in 2024 and more than 50,000 deaths expected from the disease. Despite the effectiveness of screening in reducing both the incidence and mortality of colorectal cancer, those screening rates remain suboptimal across the country, which we can see from those statistics. 

As of the most recent estimates, only 59 percent of adults who are eligible for colorectal cancer screening are up to date with the current screening recommendations, and this includes regular screening beginning at age 45 for those average-risk adults. We know also that screening is even lower among specific populations, including your racial and ethnic minorities, those with lower social economic class, the uninsured, and the underinsured. And so Black Americans, Hispanic Americans, and Native Americans are particularly affected by these disparities in screening access. 

Additionally, we have to acknowledge that the COVID pandemic further complicated this. There were disruptions in routine healthcare that led to a significant drop in screenings, and there is data that showed in April of 2020, there was a 90 percent reduction in colorectal cancers at the height of the pandemic. So although we've been able to rebound somewhat with our screening since then, healthcare providers continue to face that challenge of catching up with the backlog of delayed screenings. The national goal is 80 percent of eligible individuals are up to date on colorectal cancer, so we still have a bit of work to do on that. 

Dr. Turck:
And what are the factors that are in play and driving those suboptimal screening rates? 

Ms. Enslin:
Yeah, that's a great question. There's a lot of factors that really are contributing to this. I think one of the biggest ones is lack of awareness. So many individuals, particularly those in underserved communities, are not aware of the current colorectal cancer screening guidelines or that they should start at age 45. Younger individuals don't see their healthcare providers routinely if they're healthy because they may not be prioritizing that. I think that lack of education is really playing a really big role in either delayed or missed screenings. I also think that some individuals are not prioritizing preventive health, and that can happen for a lot of different reasons, right? There's maybe a perceived feeling that they're either asymptomatic or they're healthy and they're not experiencing symptoms. Social determinants of health can play a role in that. Their level of education certainly influences how people think about and approach healthcare. I think also those screening rates again are lower among racial and ethnic minorities. Sometimes there's a historical mistrust of health systems, and so being able to overcome that barrier is going to be really important for us to make some improvement in this. 

Dr. Turck:
For those just joining us, this is Clinician’s Roundtable on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Sarah Enslin about the screening of colorectal cancer, or CRC, in the United States.

So with the data you just discussed in mind, Ms. Enslin, let's look at ways that we could help address low screening rates in the primary care setting. First, what counseling strategies would you recommend to help other primary care providers talk to their patients about CRC screening and address their patients’ concerns? 

Ms. Enslin:
So I think the first thing that we can do is really education. It's sitting down with the patients to talk about what's the importance of detection of colorectal cancer and colon polyps and what's the patient’s individual risk factor for the development of colorectal cancer? And that's things like genetic syndromes and family history—family history not only of colon cancer, but also advanced adenomas. Also, personal history of malignancy, which we can then take into account and really give them their individualized risk assessment.

I think it's also important to normalize that conversation. People don't like to come in and talk about these things. When they come in with any bowel symptoms, they can be embarrassed about it. They also may have some fear of procedures themselves, and so whether it's because of sedation of colonoscopy or just the fact that they have to do a bowel prep, being able to address their own perceptions about colon cancer options. We also should be prepared to discuss other screening options besides colonoscopy. 

So we have fecal immunochemical tests. We have the multitarget stool DNA. We have the next generation multitarget stool DNA and multitarget stool RNA. There are blood-based tests. I think it's important to be able to give patients a full discussion and then participate in that shared decision-making. Also, follow up. So if we start these conversations early and continue to discuss them, we can make sure we're answering patient’s questions before they're due for that first index screening exam. If a patient’s initially resistant to it or reluctant, then having those conversations at routine follow-up visits could really help their adherence.

Dr. Turck:
Now are there any other tools or resources you use to educate patients on the importance of CRC screening?

Ms. Enslin:
Yeah. So I use a lot of different tools and resources, actually. I think all of us learn and retain information differently, and so I like to have a combination of things available that I can use, and I can decide which one based on the patient, their learning style, and their preferences. Certainly patient handouts and education materials can be helpful. So giving them clear, easy to understand brochures or flyers that are outlining the benefits of colorectal cancer, the different options that are available, and what to expect during a colonoscopy. Organizations like the American Cancer Society and the CDC have great materials for this.

I think visual aids are also helpful. Patients don't always know what the colon is or what is a colon polyp, and so use some kind of visual or infographic to show that. One of the most widely used and available tools is probably through the electronic health record. So giving patients information in the patient portal that they can then go back later and reference, read through, and send any follow-up questions to me.

And then, often I do send patients some information through websites like organizations like the American College of Gastroenterology where they have resources for patients, including podcasts and short videos, that will guide patients through the current guidelines, what to expect during a colonoscopy or stool-based test, and really just give them that information that they need.

Dr. Turck:
So then once we've had that discussion with patients, how else can we optimize the patient’s adherence to evidence-based recommendations when it comes to getting screened for colorectal cancer? 

Ms. Enslin:
Yeah. So I think these days really that electronic health record is helpful. Having patients who are enrolled in a patient portal and able to send them reminders for colorectal cancer screening are really helpful. Patients, especially if they're not scheduling the appointment as they're leaving the office or if they're not due immediately, our time between an office visit and when they're actually due for colorectal cancer screening can be months to years sometimes. So having that certainly is helpful. Also, patient reminders. Whether it's phone calls or text messages, emails, or sending it through a mailing service, I think all of those reminders are really going to be important for patients.

Dr. Turck:
And as we come to an end, Ms. Enslin, from a high-level global view, what impact would you say timely CRC screening has on patient outcomes?

Ms. Enslin:
I think this is really important. Timely colorectal cancer screening can have a profound impact on these patient outcomes. We know that it can improve survival rates and quality of life. The primary benefit of early screening is going to be that detection of colorectal cancer at its most treatable stages, so if we find colorectal cancer early—Stage 1, Stage 2—that 5-year survival rate can be as high as 90 percent, which is stark contrast from when we find in its late stages and that 5-year survival can drop below 15 percent. 

The other thing to keep in mind is the patient experience and their quality of life. So early intervention leads to less aggressive treatments generally and significantly better patient outcomes. Additionally, we know screening can prevent cancer altogether. Many colorectal cancer cases begin as noncancerous polyps in the colon and the rectum. So with regular screening, particularly colonoscopy, these polyps can be detected and removed before they ever become cancer, thus reducing that overall incidence and burden of colorectal cancer.

So I think that if we are able to make a big impact and shift that needle a little bit, close the gap on the patients that we're currently screening and that national goal of 80 percent, we really can help by identifying cancer early, potentially even preventing it. 

Dr. Turck:
With that potential impact in mind, I'd like to thank my guest, Ms. Sarah Enslin, for sharing her insights on how we can improve colorectal cancer screening rates. Ms. Enslin, it was great having you on the program. 

Ms. Enslin:
Thank you very much. Great to be here.

Announcer:
This episode of Clinician’s Roundtable was sponsored by Exact Sciences. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!