Medical Organizations Fear Women Aren’t Pursuing Colorectal Screenings

It’s Colorectal Cancer Awareness Month and two medical organizations are taking a stand to emphasize the importance of colorectal screening in women in hopes of further improving early detection and reducing deaths from the disease. Both the American College of Gastroenterology and the American College of Obstetricians and Gynecologists (ACOG) have released statements to increase the use of colorectal screening options in women.

Despite the progress in reducing cancer mortality, researchers with the American College of Gastroenterology found that only 50% of Medicare beneficiaries are receiving any sort of colorectal screening.

 “The American College of Gastroenterology is concerned that widely available screening strategies proven to prevent colorectal cancer remain woefully under-utilized in the Medicare population,” said Dr Delbert L. Chumley, clinical professor of medicine at the University of Texas Health Science Center at San Antonio and president of the American College of Gastroenterology. “Downward trends in colorectal cancer deaths highlight the remarkable benefits of colorectal cancer screening, but this lifesaving potential is unrealized for many Medicare patients, and these positive trends cannot be sustained if screening rates remain dismal.”  

According to research, female Medicare recipients report fear of the procedure and out-of-pocket costs among the leading barriers to obtaining potentially lifesaving screenings. Many women have concerns and fears that cannot be addressed due to some wrinkles in Medicare regulations concerning preprocedure visits for those seeking preventive screening. Currently, only patients who are experiencing symptoms and who are referred for colonoscopy for inquiry are covered to discuss the procedure with a gastroenterologist prior to the screening. That means those seeking preventive screening do not have the option of discussing issues such as preparation, sedation, process specifics, and potential out-of-pocket costs with their doctors. Ironically, a preventive case may actually turn into the more complicated case.

Further complicating matters, Medicare coverage and costs to patients can change during the procedure. Provisions found in the “Supporting ColoRectal Examination and Education Now” (SCREEN) Act passed during previous sessions of Congress caused this wrinkle. So, for instance, if a polyp is found and removed during the screening, the procedure is not coded as a “screening,” and patients are responsible for 20% copay.

“[D]octors don't know which patients will or will not have a polyp before the screening, meaning we cannot inform the patient beforehand whether there will be any cost sharing or not. If the procedure is performed, and there are no polyps or other issues then the patient is clear and would not be responsible for any additional cost sharing. But if a polyp is removed, the procedure moves from a screening to a therapeutic procedure, and all of the sudden out-of-pocket costs apply,” explained Dr March E. Seabrook, consultant in gastroenterology, Columbia, South Carolina, and chair of American College of Gastroenterology’s National Affairs Committee. “The law is well-intentioned, but there's a gap in it.”  

“The American College of Gastroenterology believes Congress must fix this unintentional quirk in Medicare cost-sharing because the ability to remove a polyp before it turns into cancer is the reason for including this provision in the Patient Protection and Accountable Care Act in the first place-to create an incentive for screening in order to prevent cancer-and precisely the reason why the US Preventive Services Task Force gave colorectal cancer screening its highest rating for recommended preventive services,” added Seabrook.

ACOG’s Committee Opinion

Recognizing that colorectal cancer is diagnosed in more women than all gynecologic cancers combined, ACOG released a committee opinion urging all ob/gyns to recommend colorectal cancer screening for their patients. The committee opinion can be found in the March issue of Obstetrics & Gynecology.

The authors of the statement cite low, underused, and inappropriately ordered screens in women 50 years or older. For instance, the authors found that only 63% of women 50 years or older had undergone colonoscopy or sigmoidoscopy in the past 10 years or had received a fecal occult blood test within the past year. They also found screens ordered at too frequent intervals and, for women younger than 50 years, screens had been inappropriately ordered.

In their statement, the authors include a review of available screens and information that ob/gyns can use to discuss with their patients, including the differences between the screens that detect adenomatous polyps and cancer and those that primarily detect cancer. The report addresses colonoscopy, flexible sigmoidoscopy, double-contrast barium enema, computed tomography colonography, Guaiac-based fecal occult blood test, fecal immunochemical test, and stool DNA tests. Since the colon and rectum can be examined in a single session and a biopsy/polypectomy can be performed at the same time, the statement authors concluded that generalist ob/gyns should recommend colonoscopy as the top choice for screening.

Colorectal cancer is the third leading cause of cancer death in women, lagging only behind lung and breast cancer. Every year, more than 70,000 women receive a diagnosis of colorectal cancer, and more than 24,000 women die of the disease. Prospective randomized trials and consensus among health experts support screening as a way to reduce the number of deaths associated with the disease, primarily by reducing the incidence of advanced disease by detecting early-stage adenocarcinomas and removing adenomatous polyps.

More Information

• S.1511: Supporting ColoRectal Examination and Education Now (SCREEN) Act of 2009
• ACOG Committee Opinion: Colonoscopy and Colorectal Cancer Screening Strategies

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 References

• American College of Gastroenterology. Lifesaving potential of colorectal cancer screening unrealized for many Medicare beneficiaries. Obstetrics & Gynecology 117:766-771.
• Kling J. ACOG Encourages ob-gyns to recommend colorectal screening. Medscape. March 1, 2011.