Thursday, October 3, 2013

Diabetes and Colorectal Cancer: Shared risk, Shared Screening


By Ashley Vice

FITway Alabama Colorectal Cancer Prevention Program

Completing the screening and rescreening cycle for colorectal cancer is a daunting task for medical practices across the state. The U.S. Preventative Services Task Force recommends colonoscopy every 10 years or a flexible sigmoidoscopy every 5 years or an annual stool test for average risk patients.  Identifying patients that need screening, encouraging compliance with recommended screening methods,  and repeating FIT/iFOBT tests annually (when used as the primary screening option) are just a few of the necessary, but challenging steps in reducing incidence and mortality of Alabama’s second-leading cancer killer.

The ideal patient panel for annual screening with FIT/iFOBT is average risk, compliant and in the provider’s office multiple times per year. That population exists in Alabama and it has a 30 percent higher risk for colorectal cancer: people with diabetes (1-2).

One in 10 Alabamians have been diagnosed with diabetes, an illness that negatively impacts quality of life and lifespan and brings with it a host of other health issues (3).  Those at risk for type 2 diabetes often mirror those at risk for colorectal cancer: patients over 50 years old or African Americans, for example.  Many of the risk factors for colorectal cancer also overlap with diabetes including obesity, sedentary lifestyle, and western diet (1-2, 4).

In addition to sharing risk factors and at-risk populations, diabetes may also cause or contribute to colorectal cancer through chronic insulin treatment, increased production of bile acids, and slower bowel transit (1,4-6). 

While data show that diabetic patients in Alabama are more likely to be screened for CRC than the general population, approximately 29 percent of the diabetic population in Alabama is not up to date on CRC screening (7).

Tracking screening within the chronic patient pool:

One way to target diabetic patients and other chronic disease sufferers for colorectal cancer screening is through electronic health records (EHR). By choosing colorectal cancer screening as one of your clinical quality measures (NQF 0034/PQRI 113) you can improve patient care, earn incentives up to $44,000 for Medicare or $63,750 for Medicaid depending on your patient population, and achieve three EHR objectives at once.

Providers can achieve the professional core objective by reporting ambulatory clinical quality measures. Two eligible professional menu objectives can be achieved by generating a list of patients by specific condition to use for quality improvement and sending patient reminders as needed for preventative and follow-up care.

A recent study published in the Annals of Internal Medicine showed that patients completed recommended screening more often when EHR-linked reminders and fecal occult blood testing kits were sent to them (9). Primary care facilities in the study created a registry through EHR which tracked when screening was due and automatically generated mailings. Patients who received automated reminders and mailouts were 26.3 percent more likely to be screened even without direct contact from a nurse or physician. The study also showed drastic increases in screening rates for patient groups who received automated information and staff follow-up.

For help setting up clinical decision support rules and patient alerts for colorectal cancer screening, physicians can contact the Alabama Regional Extension Center at (251) 414-8170.

Screening more patients overall:

Screening with a FIT test is a great way to increase screening in your practice by offering an easier, convenient method of screening for your patients. Patients offered a choice between colonoscopy and a stool test are more likely to be screened (8). Patients often have barriers to colonoscopy like fear and aversion, lack of adequate insurance coverage, inability to provide transportation or time off from work. Those barriers can be overcome with take-home stool tests.

Only high-sensitivity tests, like the FIT/iFOBT and high-sensitivity guaiac are recommended by the USPSTF as acceptable stool tests. Older, low-sensitivity  guaiac FOBT should no longer be used.

Take-home FIT/iFOBT screening is also covered by major insurers in Alabama including Blue Cross and Blue Shield of Alabama, Medicaid, and Medicare. Medicare reimburses $21.86 for a completed test (CPT Code: G0328QW).

To get more information on screening with the FIT contact the Alabama Department of Public Health Cancer Prevention Program: Ashley Vice 334-206-3336,

1.       Gioleme O, Diamantidis M, Katsaros M. Is diabetes a causal agent for colorectal cancer? Pathophysiological and molecular mechanisms. World Journal of Gasteroenterology 2011, 17, 444-448.

2.       Larsson S, Orsini N, Wolk A. Diabetes Mellitus and Risk of Colorectal Cancer: A Meta-Analysis. Journal of the National Cancer Institute 2005, 97, 22.

3.       Centers for Disease Control and Prevention. Diabetes Report Card 2012. Atlanta, GA: Centers for Disease Control and Prevention, US Department for Health and Human Services; 2012.

4.       Will J, Galuska D, Vinicor F, Calle E.E. Colorectal Cancer: Another Complication of Diabetes Mellitus? American Journal of Epidemiology 1998, 147(9).

5.       Sun L, Shiying Y. Diabetes Mellitus Is an Independent Risk Factor for Colorectal Cancer. Digestive Diseases and Sciences, Springer 2012, 57, 1586-1597.

6.       Coughlin S.S., Calle E.E., Teras T.R., Petrelli J, Thun M.J. Diabetes Mellitus as a Predictor of Cancer Mortality in a Large Cohort of US Adults. American Journal of Epidemiology 2004, 159(12).

7.       Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2012.

8.       Inadomi J.M., et al. Adherence to Colorectal Cancer Screening a Randomized Clinical Trial of Competing Strategies. Arch Intern Med. 2012, 172(7), 575-582.

9.       Green B.B., Wang C.Y., Anderson M.L., et al. An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening; a randomized trial. Annals of Internal Medicine. 2013, 158(5 pt 1): 301-311.

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