Guest Update by Dr. Robert Croyle
The Imperative of Improving Colorectal Cancer Screening Rates
A study published last October in Cancer modeled how different scenarios - each of which took into account changes in screening, risk factors, and optimal use of chemotherapy - would influence mortality rates from colorectal cancer, the second leading cause of cancer death. In every scenario, mortality was decreased by varying degrees over the next two decades, but in each case the most influential factor was improved screening rates.
It's a troubling fact, however, that colorectal cancer screening rates continue to lag well behind those for other cancers. This is discouraging given that, when caught early, colorectal cancer is highly curable.
The reasons behind this shortfall are complex, but there is widespread agreement that if significant improvements in colorectal cancer screening are to be realized, the primary care setting will be the most crucial contributor.
Indeed, the colorectal cancer screening research portfolio supported by NCI's Division of Cancer Control and Population Sciences (DCCPS) includes many studies set in community and primary care settings, including those that focus on minority, low-resource, and underserved populations.
Since 2001, researchers from DCCPS and the Agency for Healthcare Research and Quality (AHRQ) have been collaborating to develop research to improve colorectal cancer screening in primary care practice. These researchers - led by Dr. Carrie Klabunde from DCCPS' Applied Research Program - have published a paper in the August Journal of General Internal Medicine (JGIM) that reviews the published literature for innovative strategies to improve colorectal cancer screening rates and, as importantly, identifies some of the knowledge gaps that should be considered high priorities for future research.
This review is particularly compelling because it uses recent recommendations from the Society for General Internal Medicine and American Academy of Family Physicians for a new primary care practice model as its frame. This influential model is built on six core elements: a team approach to care delivery, advanced information systems, patient-centered care, improved efficiency and quality of services, enhanced practice finances, and training opportunities.
Developing and reviewing strategies for screening improvements based on this new model will ensure their relevance to primary care practice. And, most of the strategies under investigation work well with this new model because they primarily target systems of care instead of the individual physician.
In the area of team delivery of care, for example, the JGIM review highlights studies that have shown how giving medical personnel other than the physician important responsibilities related to screening - including ordering tests and conducting telephone counseling - greatly increased fecal occult blood test rates. These results are consistent with the findings of other studies of preventive services and strongly support a multidisciplinary team approach in the primary care setting.
Use of electronic health records (EHRs) is also a subject of investigation. Studies have shown, for example, that these advanced information system tools allow medical practices to better track their patients' adherence to recommended screenings and automate activities like reminder calls. The JGIM review, however, underscored the sluggish adoption of EHRs and other advanced IT systems in primary care, and stressed that more research is needed to identify and help practices overcome the obstacles to adoption.
Nongovernmental organizations, such as the American Cancer Society, have played a key role in raising public awareness about the benefits of early detection. And we are confident that NCI- and AHRQ-funded research on colorectal cancer screening will generate useful interventions that will lead to more people receiving screening for this disease. The JGIM paper highlights innovative strategies as well as questions that must be answered to realize progress toward improving colorectal cancer screening rates - progress that could save many lives.