Increasing Colorectal Cancer Screening in Your Practice

By Erica Klevay, MA, Public Information Specialist for the Alabama Department of Public Health FITWAY Colorectal Cancer Prevention Program

Despite the availability of effective screening tests, colorectal cancer (CRC) continues to be the second leading cause of cancer deaths in Alabama. Many Alabamians are not regularly screened for CRC and are only diagnosed with the disease after it has reached an advanced stage, when treatment is more difficult. According to the Alabama Statewide Cancer Registry, from 2006-2010, 42.7 percent of CRC diagnoses in Alabama were made at a late stage (stage 3 or 4 based on AJCC 6). Because most people initiate CRC screening due to the recommendation of a physician, it is imperative that primary care physicians in Alabama make CRC screening a priority. Adding the fecal immunochemical test (FIT/iFOBT) as a test option and tweaking office protocols can improve your standard of care.

Add the FIT to your protocol

FIT/iFOBT is a new type of take-home stool test that is highly sensitive, inexpensive, and does not require diet or medication changes. Both FIT/iFOBT and guaiac FOBT detect occult blood in stool that may indicate the presence of polyps or CRC. However, there are important differences between the two types of stool tests. Some older guaiac FOBT lack the sensitivity required to adequately screen for CRC: only take-home high-sensitivity guaiac tests and the FIT/iFOBT are recommended. Also, while high-sensitivity, take-home guaiac FOBT is recommended, the FIT/iFOBT is superior in several ways:

 FIT/iFOBT is specific to human hemoglobin so there are fewer false positives and no diet or medicine restrictions, making FIT/iFOBT easier for patients to complete.

 Many types of FIT/iFOBT require only one or two samples.

 FIT/iFOBT is specific to lower gastrointestinal bleeding. Therefore, positive FIT/iFOBT results indicate bleeding in the colon or rectum.

 FIT/iFOBT comes in a variety of forms that involve less stool handling than guaiac tests.

FIT/iFOBT screening is covered by major insurers in Alabama, including Blue Cross/Blue Shield of Alabama (BCBSAL), Medicaid, and Medicare. Adding FIT/iFOBT can be cost effective due to the generous reimbursement rates available for FIT/iFOBT. Additionally, CRC screening can be selected to fulfill Centers for Medicare and Medicaid Services Meaningful Use Objectives to earn up to $63,750 in incentives. Several brands of CLIA waived FIT/iFOBT are available to purchase through medical supply distributors and laboratory companies. For free sample tests, call the Alabama Department of Public Health (ADPH) at 334-206-3336.

Give your patients a choice

Dr Allen Perkins, President of the Alabama Academy of Family Physicians, points out that physicians can increase the number of their patients who complete screening by offering several types of screening tests. While colonoscopy is an excellent screening test for CRC that should always be considered, he says that some people are unable to complete a screening colonoscopy. Common barriers to colonoscopy include the cost of the procedure, the time required to prepare for and complete the test, discomfort with bowel preparation and lack of transportation. He cited a recent study in the Archives of Internal Medicine that highlights the benefit of having multiple options for CRC screening. This study found that those offered a choice between colonoscopy and a stool test were more likely to complete screening than those offered only one type of test.*

Make CRC screening a priority

“We can improve screening rates in Alabama by making a concerted effort to identify patients who need screening, recommend screening to these patients and follow up to ensure that patients complete their tests” says Perkins. He points out that chart prompts and electronic health records are effective as physician reminders to recommend screening. Other tools such as emails, letters, or telephone calls can remind patients about scheduled endoscopic tests or to return take-home stool tests. “As practices are updating their data systems,” Perkins said, “please remember to update your office procedures to make CRC screening a routine part of patient care.”

More information about CRC screening and the FIT/iFOBT is available through the ADPH FITWAY Colorectal Cancer Prevention Program. The FITWAY Program is funded with a grant from the Centers for Disease Control and Prevention with a goal to screen 80% of Alabamians 50 and older by 2014. FITWAY focuses on improving CRC screening rates through increasing access to FIT/iFOBT. To learn more, visit the FITWAY website at adph.org/fitway or email erica.klevay@adph.state.al.us. The American Cancer Society also has an excellent resource for clinical quality improvement related to CRC screening at www.cancer.org/aspx/pcmanual/PCM.swf.

*Source: Inadomi JM, Vijan S, Janz NK, et al. Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies. Arch Intern Med.2012;172(7):575-582.