Questions about ‘80% by 2018’ campaign to boost colorectal cancer screening

The following is a guest blog post by Dr. Richard Hoffman, who has been reviewing health care news stories for us for years.  He recently became the Director of the Division of General Internal Medicine for the University of Iowa Carver College of Medicine/Iowa City VA Medical Center.

80% by 2018 logoI was recently invited to attend an “80% by 2018” kickoff event. This program, announced with considerable fanfare by the National Colorectal Cancer Roundtable during Colorectal Cancer (CRC) awareness month in March, aims to increase the proportion of U.S. adults who are current with CRC screening from about 65% to 80%.

Colorectal cancer is an important public health problem—it’s the 4th most frequently diagnosed cancer in the US and the 2nd leading cause of cancer death—and screening is effective. Clinical trials of screening programs based on fecal blood testing and flexible sigmoidoscopy have shown significant albeit small absolute risk reductions for being diagnosed with and dying from CRC—though no overall mortality benefit.   The good news is that CRC incidence and mortality have been steadily declining for decades.   Interestingly, these trends were first observed before screening became widespread—suggesting the concomitant importance of improved treatment and reducing population risk factors.

The alliterative effort to boost CRC screening, though, could be problematic. Most gastroenterologists and primary care clinicians consider colonoscopy to be the best screening test and efforts to achieve the screening target will likely focus on colonoscopy.   However, there is no direct evidence for the efficacy of colonoscopy and there is evidence that many people prefer to be screened with fecal blood tests. Furthermore, colonoscopies are expensive, require an onerous bowel preparation, and can cause complications such as bowel perforation and bleeding.

There are also important opportunity costs associated with colonoscopy and CRC screening. The lifetime risk of being diagnosed with CRC is only about 5%, meaning that screening for the remaining 95% of the population will not offer any benefit—just potential harms and costs. Efforts to increase CRC screening could divert limited health care resources that might be better allocated to more burdensome public health problems—smoking, obesity, or diabetes.

None of this nuance came through in stories and web articles such as these:

Rather than just promoting a message of more screening, media messages could help people think about screening smarter—a goal for health care to identify high-risk patients (those with a family history) who would have most to gain from screening. We should also ensure that patients with a previous history of pre-cancerous polyps get timely surveillance colonoscopies–polypectomy is associated with reducing the risks of CRC incidence and mortality.

Working towards a screening target also obscures the fact that cancer screening is a preference-sensitive decision.   A well-informed patient, aware of the potential benefits and harms, could reasonably decline CRC screening. A more appropriate target for 2018 might be that 80% of US adults have had the opportunity to make an informed decision about CRC screening.

That would make a terrific public health and media campaign.

Publisher’s Note;

On a related topic, Dr. Richard Lehman recently wrote on his BMJ journal review blog:

“I am hardly the most ardent advocate of cancer screening, but I had come to think there might be a place for some kind of screening for colorectal neoplasia. Now I’m not so sure. Flexible sigmoidoscopy appears to have the best effectiveness, but this survival meta-analysis states that it took 9.4 years (7.6 to 11.3) to observe an absolute risk reduction of 0.001 (one colorectal cancer related death prevented for every 1000 flexible sigmoidoscopy screenings). Have a think whether that would persuade you to go and have one.”

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Comments (7)

Please note, comments are no longer published through this website. All previously made comments are still archived and available for viewing through select posts.

Richard Wender

May 5, 2015 at 2:57 pm

Although shared decision making is a vital aspect of patient-centered care, conducting shared decision making for all preventive services is not realistic or appropriate. Primary care clinicians work hard to help patients control their blood pressure and their blood sugar and to deliver proven vaccines even though the majority of patients don’t experience a benefit. Clinicians are not routinely conducting formal shared decision making about whether to take blood pressure pills or not. Colon cancer screening falls into the same category. Every major guideline organization has concluded that the benefits of colon cancer screening substantially outweigh the risks and harms. Our primary job is to encourage and help patients get screening done, while informing them about the risks of procedures, like colonoscopy. As mentioned in my MedPage Today article, offering a choice of screening tests, in particular stool blood testing or colonoscopy, is critical (flexible sigmoidoscopy screening alone prevents fewer colon cancer deaths and has largely disappeared as a screening test in the U.S.). Ultimately, the patient makes the decision about whether to be screened or not, but increasing colon cancer screening rates is one of the extraordinary public health opportunities we can all own right now. Getting more people to participate in screening is a very appropriate goal.

Alan Cassels

May 5, 2015 at 3:24 pm

After doing a fair bit of research on screening (resulting in a book called Seeking Sickness: Medical Screening and the Misguided Hunt for disease) I was frequently asked by interviewers: Of all the screening programs, which would you, yourself agree to submit yourself to? I replied that if I was a sexually active woman, I’d probably have a Pap test once in a while, and that I’ll look at the data on colon cancer screening in another five years to see if it’s worth it. I think the jury is out on colon cancer screening, and that, as Dr. Lehman notes above, if it is effective, like mammography or PSA testing the yield is very low, and the risks of over diagnosis high.. Having said that chasing polyps seems immensely satisfying for all involved even if the hunting down and removing polyps may or may not result in an overall benefit. Whatever we collectively think about colon cancer screening right now will surely seem over-enthusiastic in five years time.

    Tazia K. Stagg

    May 5, 2015 at 4:35 pm

    “Simple messages… sometimes”
    Who are some of the interviewers who asked you that question?

Tazia K. Stagg

May 5, 2015 at 3:30 pm

How did he conclude that “efforts… will likely focus on colonoscopy”?

I don’t think it’s a good idea to tell the public that declining CRC screening is a reasonable option.

The sentence “Efforts to increase CRC screening could divert limited health care resources that might be better allocated to more burdensome public health problems—smoking, obesity, or diabetes.” is also problematic.

Richard Hoffman

May 10, 2015 at 10:37 am

I’m glad to address the comments generated by my posting. I want to be clear that I am not discouraging clinicians from offering—or patients from accepting–colorectal cancer screening. I am also not proposing that clinicians routinely address colorectal cancer screening through an elaborate shared decision-making process. However, I do believe that patients should be well informed about options for screening—understanding the various tradeoffs involved with each testing decision–and that we should respect a patient’s informed decision to decline screening. While increasing colorectal cancer screening might be an appropriate goal to many, our limited health care resources could justifiably be allocated to addressing numerous other equally important public health opportunities.

The comment about colonoscopy utilization is based on national screening data, including from the Behavioral Risk Factor Surveillance System (MMWR 2013;62: 881), showing that colonoscopy has become by far the most commonly used screening test. Additionally, national surveys (Zapka J, et al. J Gen Intern Med 2012; 27:1150) report that primary care providers are increasingly recommending screening colonoscopy compared to fecal blood tests because they strongly believe colonoscopy to be the best test.

Daniel Pendick

May 11, 2015 at 12:02 pm

It would be helpful when reporting this big colonoscopy push to be aware of who we are asking the questions. When asking a gastroenterologist, I know I will hear an “upsell” on colonoscopy, “the gold standard.” When talking to a primary care doc, I often will hear that colon cancer screening is a decision, not a forgone conclusion, and less gilded tests (FOBT, sigmoidoscopy) are still on the table. In short consumer health advice pieces, it can be very, very hard to work in those different points of view, because readers often come into the transaction with the expectation of being told what to do.

Anjee Davis

May 13, 2015 at 8:47 am

I thought I would chime in. I understand the logic and reasoning behind the comments made in this blog. I would underscore the fact that colorectal cancer is the 2nd leading cause of cancer deaths for men and women, yet it is preventable and it is one of the most expensive to treat. Given those two facts when we tackle the issues of healthcare cost and resource allocation, prevention of this particular disease is critical as a part of an effort to reducing cost of cancer care. My second thought, would be with respect to the national goal of 80% by 2018. It was stated, “A more appropriate target for 2018 might be that 80% of US adults have had the opportunity to make an informed decision about CRC screening.” I can’t say I agree with that statement. It is an ambitious goal. In my 10 years working in colorectal cancer this is the first time I have seen over 100 groups (private, government and nonprofit) support a united effort that encourages colorectal cancer screening and supports understanding your options. The messages associated with this effort supports that there are multiple tests and that patients have a choice for CRC screening. Changing patient behavior and effectively implementing educational efforts are never simple and they are layered with geographic and cultural nuances and challenges. I think we all recognize that in public health. So as I see it, this particular effort to raise screening rates, this goal of 80% by 2018, reflects more than a number to strive for. It is recognition at the national level that we need to address (with urgency) this deadly and often silent cancer. As the president of a colorectal cancer advocacy organization, I believe this is an important step forward for our cause and our mission to reduce the burden of this cancer.