Changes needed to increase access to colorectal cancer screening

Colorectal cancer is the second highest cause of cancer death in the United States, expected to claim the lives of an estimated 49,190 people in 2016. The Affordable Care Act (ACA) aimed to increase access to CRC screening by not holding patients responsible for all costs of the procedure, yet current Medicare insurance beneficiaries lacking supplemental insurance may not be able to afford colon cancer screening and treatment. This policy disproportionally puts low-income Americans at risk and adds unnecessary strains on overall health care costs, according to a commentary in the May issue of the journal Gastroenterology.

“Study after study shows that screening saves lives,” said Chyke A. Doubeni, MD, MPH, chair and the Presidential Associate Professor of Family Medicine and Community Health at the Perelman School of Medicine at the University of Pennsylvania, and lead author of the commentary. “Yet many of those in the group most affected by this deadly disease are unable to afford the screening they critically need. We must renew efforts to ensure equitable access to and use of disease prevention, detection, and treatment services for colorectal cancer.”

For CRC screening, a full colonoscopy is necessary, where the doctor inspects the rectum and entire colon through a flexible lighted tube, and can remove any abnormal growth. The entire colon has to be cleansed before the colonoscopy, for which the patient is usually sedated

There are currently an estimated 55.5 million Medicare beneficiaries in the U.S. A 2010 Kaiser Family Foundation survey found that 14 percent lacked supplemental coverage. Until recently, colon cancer screening has been viewed as a one-time activity, while in practice, screening is a series of clinical activities to identify and test patients and perform diagnostic confirmation when necessary. This series of tests and steps include a diagnostic workup, which can include a biopsy to obtain a tissue sample or polypectomy, in which polyps are removed to prevent them from becoming cancerous.

The ACA did not address provisions in section 1834 (d) (3) (D) of the Balanced Budget Act of 1997, the authors note, thereby prohibiting Medicare from waiving the beneficiary’s share of coverage for screening costs when a diagnostic procedure is needed.

“Congress looks at screening the wrong way,” Doubeni says. “Now when you do a test, find a polyp, lesion, or positive result, the test is classified as a diagnostic with costs that can inhibit low-income patients without co-insurance from acting on it.”

These restrictions are in place at a time when longstanding disparities remain in mortality from colon cancer for Medicare beneficiaries and too few people in the United States are being screened.

Changes needed to increase access to colorectal cancer screening Among Medicare beneficiaries, those from low-income backgrounds have half the rate of screening of high-income groups, and a disproportionally high percentage of Medicare beneficiaries from low-income backgrounds lack the supplemental insurance needed to cover treatment after a positive screening. Previous research found that 63 percent of colon cancer deaths in 2010 could have been prevented if those patients had been screened. Additionally, increasing screening from 58 percent in 2013 to 80 percent by 2018 in the U.S. is estimated to lower disease incidence by 17 percent and lives lost to colon cancer by 19 percent.

Current insurance policies increase unnecessary health care expenditures, the authors suggest, noting that Medicare spent $2 billion on approximately 3.8 million colonoscopies in 2013, but spent $7.3 billion in 2010 on CRC treatment.

Doubeni, who is also a senior scholar in Penn Medicine’s Center for Clinical Epidemiology and Biostatistics, and co-authors Douglas A. Corley of Kaiser Permanente Division of Research and Ann G. Zauber of Memorial Sloan Kettering Cancer Center, recommend that Congress waive the coinsurance and copay for all diagnostic procedures associated with screening, as well as the coinsurance for colonoscopies after a positive test, and no longer classify screening tests as diagnostic. The authors next urge policymakers to consider value-based and evidence-based benefit in designing colon cancer coverage, and national policy groups to align their recommendations with the current science and practice of colon cancer screening.

The risk of developing colorectal cancer is increased in people with IBD, and is higher the more of the colon that is involved. Recent studies estimate that, although the occurrence of colon cancer in people with ulcerative colitis has decreased over the last 60 years to 1.2 in 1000 patients in any year, the risk increases the longer someone has IBD.

Screening patients for colon cancer can prevent the disease or help ensure more effective management through early detection, but the authors argue that changing the way the general public and insurers view screening is key to changing policy to save lives and lower costs.


The commentary is supported by U01CA151736 and U54CA163262 from the National Cancer Institute of the National Institutes of Health.



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