**4. When to stop screening?**

1978). These individuals should begin screening colonoscopy in adolescence (usually started 10-12 years old), and this should be repeated annually. Ultimately these patients should re‐ ceive prophylactic colectomy. Another such polyposis includes Attenuated Adenomatous Polyposis. As opposed to FAP (which involves hundreds to thousands of polyps diffusely spread throughout the colon), AAP is an oligopolyposis and typically involves <100 polyps. These polyps are more often right-sided and with a flat morphology. Patient's typically be‐ gin to have polyps appear in the 4th-5th decade of life and an average age of diagnosis of cancer at age 55 (Knudsen et al., 2003). Roughly 69% of patients with APP will eventually develop colon cancer. These patients should begin screening colonoscopy at age 25 and this should be repeated annually. Less common genetic polyposes a clinician may encounter in‐ volve: MUTYH-Associated Polyposis, Peutz-Jeghers Syndrome, and Juvenile Polyposis Syn‐ drome. MUTYH-Associated Polyposis is an autosomal recessive cancer syndrome (heterozygotes with one affected allele are at increased risk, but homozygotes show the larg‐ est increase in risk). Variations in phenotype have been described, from hundreds to thou‐ sands of polyps distributed throughout the colon. Lifetime prevalence of colon cancer is reported at 80% (Jenkins et al., 2006). These individuals should begin annual screening at age 18-20. Clinicians may also encounter Peutz-Jeghers Syndrome, which is an autosomal dominant disorder characterized by numerous hamartomatous polyps throughout the co‐ lon. These individuals carry a 39% lifetime risk of colon cancer and should have colonosco‐ py screening every 2-3 years beginning in their late teen years (McGarrity and Amos, 2006). Finally, pediatric clinicians may encounter Juvenile Polyposis, which is an autosomal domi‐ nant condition characterized by numerous polyps throughout the gastrointestinal tract. These individuals are often brought to the attention of a physician following an intestinal obstruction or gastrointestinal bleed as a consequence of the numerous polyps. These pa‐ tients carry a 10-38% lifetime colon cancer risk and should be screened annually beginning

The most common hereditary colon cancer syndrome is Lynch Syndrome, or Hereditary Non-Polyposis Colorectal Cancer. This too is an autosomal dominant condition, which is characterized by numerous, proximal adenomas. Affected individuals carry a 48-68% risk of colon cancer by age 60, with the majority being diagnosed between age 40-50 (Mecklin et al., 2007). Even more importantly, adenomas associated with HNPCC are typically more ag‐ gressive and advance to carcinoma quicker than would be otherwise expected. As such, these individuals should begin screening at age 20, and this should be repeated every 1-3

Nearly every clinician is sure to encounter a patient afflicted with Inflammatory Bowel Dis‐ ease (IBD). As such, it is important to recognize that these patients carry an increased risk for colon cancer, and they cannot be treated as average-risk individuals. The entity is refer‐ red to as Colitis-Associated Cancer, or CAC, and the resultant risk of eventual colon cancer

at age 15 (Howe et al., 1998; Jass et al., 1988).

42 Colonoscopy and Colorectal Cancer Screening - Future Directions

**3.8. CRC risk associated with Inflammatory Bowel Disease**

**3.7. Non-polyposis syndromes**

years.

As touched on previously, equally important to the initiation of an effective screening pro‐ gram involves the optimal age to finish the screening process. The question could be posed: "Why stop screening at all if it is an effective means to prevent morbidity and mortality from colon cancer?" However several factors should be considered including the fact that colonoscopy is not entirely without risk. The known complications associated with colono‐ scopy (e.g. bleeding, perforation, infection, diverticulitis), occur particularly in the elderly population. Furthermore, and especially true with regard to colorectal cancer screening, there exists a potentially long latency period from adenoma to carcinoma which may take years and even decades in some individuals. Elderly patients with an adenoma seen on screening may, and oftentimes do, perish as a result of other disease processes. Finally, lim‐ ited resources must also be taken into account. Each and every colonoscopy takes a concert‐ ed effort from a skilled colonoscopist and their support staff, and the required financial means on the part of the patient and/or government. As such it is necessary to establish evi‐ dence-based guidelines on when patients can safely stop colon cancer screening. The follow‐ ing section will delve further into this topic and the current recommendations for age at which to stop screening.

#### **4.1. Complications from screening colonoscopy**

In general, colonoscopy is a relatively safe, well-tolerated procedure by patients. The majori‐ ty of patients will never experience any complications, even if undergoing multiple colonos‐ copies throughout their lifetime. There are, however, significant and life-threatening complications that can occur. Although rare, given the enormous number of colonoscopies performed annually, it is important to be cognizant of the associated complications. In 2010, an analysis was released tracking complications rates among 18 large studies and involving over 685,000 colonoscopies (Ko and Dominitz, 2010). The most common complication seen was lower gastrointestinal bleeding, at roughly 0.1-0.6%. Fortunately, the far majority of these were not mortal bleeds. However, as most colonoscopies are undertaken in the outpa‐ tient setting, gastrointestinal hemorrhage can develop into a life-threatening event very quickly in a non-monitored setting. Next most common, bowel perforation posed a risk of less than 0.3% (Ko and Dominitz, 2010). These most often occur following barotrauma or mechanical trauma to the bowel wall. Again, although exceedingly rare, a perforated bowel has the potential to be lethal. A perforation can be clinically evident immediately after the incident occurs, however, small perforations in the bowel can lead to an insidious course that can ultimately result in severe peritonitis and rapid clinical decompensation. Diverticu‐ litis is also a well-established complication of colonoscopy, with a rate estimated at 0.04-0.08% (Ko and Dominitz, 2010). There also exists the known entity of post-polypectomy electrocoagulation syndrome (or post-polypectomy syndrome). Following electrocautery of the bowel wall, there is risk for a partial or transmural burn of the bowel wall. In cases of a transmural burn, patients experience symptoms of clinical peritonitis. This rarely proceeds to actual peritonitis (radiography does not visualize actual perforated bowel with free air in the peritoneum), and these patients can be managed via supportive care and antibiotics. However, resultant hospitalization and treatment is not without its own associated risks and costs, so this cannot be taken lightly either. The incidence of post-polypectomy electrocoagu‐ lation syndrome appears to be roughly 0.003%-0.01% (Ko and Dominitz, 2010). Infection as a result of colonoscopy is exceedingly rare, and can most times be attributed to poor infection control procedures involving equipment. Although the risk of transient bacteremia is postu‐ lated to be higher, the actual risk of an infection transmission purely as a result of colonosco‐ py is estimated at roughly 1 per 1.8 million procedures, with Pseudomonas and Salmonella species being the most commonly identified (Spach et al., 1993). Other case-reportable com‐ plications have included splenic rupture, acute appendicitis, and subcutaneous emphysema (Hirata et al., 1996; Humphreys et al., 1984; Kamath et al., 2009). Overall mortality from colo‐ noscopy remains controversial due to complicated comorbidities among those in studies tracking colonoscopy-related mortality. Estimates range from 0%-0.09% (Ko and Dominitz, 2010). Less serious complications include nausea, vomiting, diarrhea and bloating. Fortu‐ nately, these are usually self-limited within several days following the colonoscopy. As evi‐ denced above, colonoscopy does have rare but serious complications. However, it is important to note that complications are also related to the type of procedure performed (screening colonoscopy or polypectomy) and the age of those undergoing the procedure.

**4.2. Timing of progression from adenoma to carcinoma**

the average-risk elderly patient?

As mentioned previously, the progression from adenoma to carcinoma may take years and even decades. Some adenomas may never make the entire progression. The adenoma may never acquire all the necessary genetic mutations, or simply, an individual may not live long enough for the adenoma to significantly progress. As such, detecting an asymptomatic pol‐ yp in an elderly individual may have no significance whatsoever. In fact, while the risk of colonoscopy complications poses a real threat, the adenoma may prove to have no bearing on a patient's health. Currently, the most recent CDC data estimates that the average life ex‐ pectancy in the United States is 78.7 years (76.2 for males and 81.1 for females) (Centers for disease control and prevention, 2012). This brings into question the utility of screening eld‐ erly age individuals. At what age will a screening colonoscopy likely provide no benefit to

Issues in Screening and Surveillance Colonoscopy

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45

The following discussion pertains to those at average-risk as identified previously in the chapter. Individuals with predisposing factors (family history, genetic syndromes, inflam‐ matory disease) are not included in this grouping, and should continue with regularly scheduled colonoscopies as defined previously. Many of the adenomas identified in these high-risk groups have demonstrated a more rapid rate of progression to carcinoma, and

The incidence of colon cancer rises sharply with advancing age. Many studies have exam‐ ined this relationship over the past decades, and conclusive evidence supports this claim. In fact, the rate of colon cancer among those over 65 years of age is 254.2/100,000 persons, while the risk is substantially lower among those under 65, at 18.1/100,000 persons (NIH, 2009). Clearly, the elderly are at highest risk for developing colon cancer. Likewise, the eld‐ erly are also highest at risk for complications of colonoscopy. Extrapolating from the data previously provided, the complication rate amongst individuals 75-84 is 1330/100,000 peo‐ ple. Therefore, there would be roughly 5 times as many serious complications from colono‐ scopy as there would be actual diagnoses of cancer in the age group 75-84. Further, studies have been conducted looking at the chances of actually dying from colon cancer if diag‐ nosed late in life. Among those at age 75 (and in the middle quartile of expected life remain‐ ing), they have a 1.9% chance of actually dying from colon cancer (Walter and Covinsky, 2001). By age 85, this risk decreases to 1.6%. Among elderly patients with multiple co-mor‐ bidities, the chance of dying from colon cancer falls to 0.85%. For comparison, a 50-year old male in the middle quartile of life expectancy has a 2.3% and female a 2.2% chance of even‐ tually dying from colon cancer. While the incidence of colon cancer increases with age, it ap‐ pears the mortality from the disease actually declines (if the cancer develops at the later age). These elderly patients succumb to an illness other than colon cancer. Additionally, studies have likewise examined the actual amount of life gained due to screening colonosco‐ py among different age groups. Here too there is a clear association with age. Among asymptomatic individuals undergoing screening colonoscopy, younger age groups experi‐ ence a much larger benefit in terms of life gained. Among 50-54 year olds undergoing asymptomatic screening, there is roughly 0.84 years of life years gained (Lin et al., 2006). However, among individuals 80 years and above, only 0.13 additional years of life are

thus, they continue to need aggressive screening measures throughout their lifetime.

In assessing the risk of complications from colonoscopies it is important to consider the type of intervention to be employed during the procedure and the baseline characteristics of the patient. Many studies have analyzed data pertaining to complications particularly associat‐ ed with different age groups. For example, a retrospective cohort study from 1994-2009 ex‐ amined these risks among over 43,000 patients ages 40-85 (Rutter et al., 2012). They pooled hemorrhage, perforation, and diverticulitis as serious adverse events. They found an event rate of 4.7/1000 screening colonoscopies and 6.8/1000 for follow-up colonoscopies. Interest‐ ingly, there were significant differences between age groups. Among ages 40-49 there was a serious event rate of 4.2/1000, ages 50-64 3.7/1000, ages 65-74 7.9/1000, and for ages 75-84 13.3/1000. Thus the rate of complications clearly increases with age. They also noted an in‐ crease in events following polypectomy vs no intervention, however this proves less clini‐ cally relevant, as a clinician would certainly not forgo polypectomy based on this fact alone. With the above data, and other studies like it (Gatto et al., 2003), it becomes evident that be‐ yond a certain age, colonoscopies may be causing more harm than good.

#### **4.2. Timing of progression from adenoma to carcinoma**

has the potential to be lethal. A perforation can be clinically evident immediately after the incident occurs, however, small perforations in the bowel can lead to an insidious course that can ultimately result in severe peritonitis and rapid clinical decompensation. Diverticu‐ litis is also a well-established complication of colonoscopy, with a rate estimated at 0.04-0.08% (Ko and Dominitz, 2010). There also exists the known entity of post-polypectomy electrocoagulation syndrome (or post-polypectomy syndrome). Following electrocautery of the bowel wall, there is risk for a partial or transmural burn of the bowel wall. In cases of a transmural burn, patients experience symptoms of clinical peritonitis. This rarely proceeds to actual peritonitis (radiography does not visualize actual perforated bowel with free air in the peritoneum), and these patients can be managed via supportive care and antibiotics. However, resultant hospitalization and treatment is not without its own associated risks and costs, so this cannot be taken lightly either. The incidence of post-polypectomy electrocoagu‐ lation syndrome appears to be roughly 0.003%-0.01% (Ko and Dominitz, 2010). Infection as a result of colonoscopy is exceedingly rare, and can most times be attributed to poor infection control procedures involving equipment. Although the risk of transient bacteremia is postu‐ lated to be higher, the actual risk of an infection transmission purely as a result of colonosco‐ py is estimated at roughly 1 per 1.8 million procedures, with Pseudomonas and Salmonella species being the most commonly identified (Spach et al., 1993). Other case-reportable com‐ plications have included splenic rupture, acute appendicitis, and subcutaneous emphysema (Hirata et al., 1996; Humphreys et al., 1984; Kamath et al., 2009). Overall mortality from colo‐ noscopy remains controversial due to complicated comorbidities among those in studies tracking colonoscopy-related mortality. Estimates range from 0%-0.09% (Ko and Dominitz, 2010). Less serious complications include nausea, vomiting, diarrhea and bloating. Fortu‐ nately, these are usually self-limited within several days following the colonoscopy. As evi‐ denced above, colonoscopy does have rare but serious complications. However, it is important to note that complications are also related to the type of procedure performed (screening colonoscopy or polypectomy) and the age of those undergoing the procedure.

44 Colonoscopy and Colorectal Cancer Screening - Future Directions

In assessing the risk of complications from colonoscopies it is important to consider the type of intervention to be employed during the procedure and the baseline characteristics of the patient. Many studies have analyzed data pertaining to complications particularly associat‐ ed with different age groups. For example, a retrospective cohort study from 1994-2009 ex‐ amined these risks among over 43,000 patients ages 40-85 (Rutter et al., 2012). They pooled hemorrhage, perforation, and diverticulitis as serious adverse events. They found an event rate of 4.7/1000 screening colonoscopies and 6.8/1000 for follow-up colonoscopies. Interest‐ ingly, there were significant differences between age groups. Among ages 40-49 there was a serious event rate of 4.2/1000, ages 50-64 3.7/1000, ages 65-74 7.9/1000, and for ages 75-84 13.3/1000. Thus the rate of complications clearly increases with age. They also noted an in‐ crease in events following polypectomy vs no intervention, however this proves less clini‐ cally relevant, as a clinician would certainly not forgo polypectomy based on this fact alone. With the above data, and other studies like it (Gatto et al., 2003), it becomes evident that be‐

yond a certain age, colonoscopies may be causing more harm than good.

As mentioned previously, the progression from adenoma to carcinoma may take years and even decades. Some adenomas may never make the entire progression. The adenoma may never acquire all the necessary genetic mutations, or simply, an individual may not live long enough for the adenoma to significantly progress. As such, detecting an asymptomatic pol‐ yp in an elderly individual may have no significance whatsoever. In fact, while the risk of colonoscopy complications poses a real threat, the adenoma may prove to have no bearing on a patient's health. Currently, the most recent CDC data estimates that the average life ex‐ pectancy in the United States is 78.7 years (76.2 for males and 81.1 for females) (Centers for disease control and prevention, 2012). This brings into question the utility of screening eld‐ erly age individuals. At what age will a screening colonoscopy likely provide no benefit to the average-risk elderly patient?

The following discussion pertains to those at average-risk as identified previously in the chapter. Individuals with predisposing factors (family history, genetic syndromes, inflam‐ matory disease) are not included in this grouping, and should continue with regularly scheduled colonoscopies as defined previously. Many of the adenomas identified in these high-risk groups have demonstrated a more rapid rate of progression to carcinoma, and thus, they continue to need aggressive screening measures throughout their lifetime.

The incidence of colon cancer rises sharply with advancing age. Many studies have exam‐ ined this relationship over the past decades, and conclusive evidence supports this claim. In fact, the rate of colon cancer among those over 65 years of age is 254.2/100,000 persons, while the risk is substantially lower among those under 65, at 18.1/100,000 persons (NIH, 2009). Clearly, the elderly are at highest risk for developing colon cancer. Likewise, the eld‐ erly are also highest at risk for complications of colonoscopy. Extrapolating from the data previously provided, the complication rate amongst individuals 75-84 is 1330/100,000 peo‐ ple. Therefore, there would be roughly 5 times as many serious complications from colono‐ scopy as there would be actual diagnoses of cancer in the age group 75-84. Further, studies have been conducted looking at the chances of actually dying from colon cancer if diag‐ nosed late in life. Among those at age 75 (and in the middle quartile of expected life remain‐ ing), they have a 1.9% chance of actually dying from colon cancer (Walter and Covinsky, 2001). By age 85, this risk decreases to 1.6%. Among elderly patients with multiple co-mor‐ bidities, the chance of dying from colon cancer falls to 0.85%. For comparison, a 50-year old male in the middle quartile of life expectancy has a 2.3% and female a 2.2% chance of even‐ tually dying from colon cancer. While the incidence of colon cancer increases with age, it ap‐ pears the mortality from the disease actually declines (if the cancer develops at the later age). These elderly patients succumb to an illness other than colon cancer. Additionally, studies have likewise examined the actual amount of life gained due to screening colonosco‐ py among different age groups. Here too there is a clear association with age. Among asymptomatic individuals undergoing screening colonoscopy, younger age groups experi‐ ence a much larger benefit in terms of life gained. Among 50-54 year olds undergoing asymptomatic screening, there is roughly 0.84 years of life years gained (Lin et al., 2006). However, among individuals 80 years and above, only 0.13 additional years of life are gained. Thus, there is roughly a 6-fold difference in the actual effect of colon cancer screen‐ ing between the two groups. Although younger patients have a much lower chance of de‐ veloping colon cancer, they experience the lowest complication rate and benefit from the largest amount of life years gained if diagnosed and treated.

**4.4. Evidence based approach to ending screening**

**4.5. Surveillance after late stage cancer diagnosis**

dividuals?

in these patients.

The USPSTF currently recommends that colon cancer screening via colonoscopy be terminat‐ ed at age 75 (USPSTF, 2008). This recommendation is based upon a Decision Analysis publish‐ ed in 2008. Again, using two simulation models, the authors examined the average life-years gained and the number of colonoscopies that would be required based upon the age at which colonoscopy screening was stopped (and assuming a 10-year interval screening method in average-risk individuals). The authors primarily tested ceasing colonoscopy at age 75 vs 85. In essence, they found that by stopping screening at age 75, they decreased the number of lifeyears gained by only 2-5/1000 people. However, the number of colonoscopies needed de‐ creased by 348-398/1000 people. The ranges given signify the results from both simulation models. While some may argue that adding 2-5 life-years per 1000 people should take para‐ mount importance, this unfortunately cannot be the case given the limited resources as dis‐ cussed above. Until resources are infinite, it is necessary to funnel finances and medical staff toward the population that will most benefit from screening. Distributing the additional 348-398 colonoscopies to a younger population will result in more life-years gained, lives saved, and far fewer complications. Therefore, for the time being, it seems that ceasing colono‐

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47

scopy screening at age 75 is both responsible and in the best interest of society.

Lastly, it is important to recognize that not all colonoscopies will be performed for strictly screening purposes. Ultimately, the goal of colonoscopy is early diagnosis and curative treatment by either polypectomy or bowel resection. However, as colon cancer is unfortu‐ nately still such a large cause of mortality in the United States and the screening rate is not 100%, many individuals will still be diagnosed with late-stage and unresectable colon can‐ cer. This then poses the question, what is the utility in surveillance colonoscopy in these in‐

To date, limited data exists concerning this topic. The primary treatment for patients with diagnosed Stage IV inoperable colon cancer is palliative chemotherapy. Occasionally, che‐ motherapy may be able to shrink the tumor(s) to an operable state, but this is more often not the case among late-stage diagnoses due to multiple metastases. Studies have analyzed prognostic indicators among patients with inoperable disease and found that performance status, ASA-class, CEA level, metastatic load, extent of primary tumor, and chemotherapy were the only independent variables affecting prognosis in these patients (Stelzner et al., 2005). While the initial diagnostic colonoscopy can provide valuable tissue data and infor‐ mation regarding depth of invasion, at this time surveillance colonoscopy does not appear to play a role in the management beyond initial diagnosis. Given that there is no clear bene‐ fit to surveillance colonoscopy after diagnosis of inoperable colon cancer and there are a multitude of risks associated with the procedure, surveillance colonoscopy is not indicated

#### **4.3. The resource allocation factor**

It is also equally important to consider allocation of valuable resources when debating whether or not to forego colon cancer screening in the elderly. Colonoscopies, while costeffective, are expensive. Those uninsured may have to pay thousands of dollars for the pro‐ cedure, and those insured may have to pay copays, deductibles, etc. Moreover, the cost to society is enormous. Considering there are currently 74,008,000 Americans age 55 and above, there are millions of colonoscopies completed annually (Wagner et al., 1970). If there are no established recommendations on when it is appropriate to stop colonoscopy screen‐ ing, millions of dollars will be spent for a procedure that may have minimal impact on the health of those screened. Moreover, funding that could go toward more cost-effective treat‐ ments or screening programs would be needlessly diverted. Fortunately, the Affordable Care Act (ACA) recently instated a policy in which Medicare and Medicaid "shall not im‐ pose any cost sharing requirements for evidence-based items or services that have in effect a rating of 'A' or 'B' in the current recommendations of the United States Preventive Services Task Force." Therefore, the cost of a colonoscopy to the individual may be minimized, how‐ ever the cost to society will only grow. It is important to take into account the number of providers who can safely and effectively offer colonoscopy screening as well. Studies have demonstrated that colonoscopies performed by Gastroenterologists vs. non-Gastroenterolo‐ gists are both more cost-effective and more beneficial to the patient (i.e. trained endoscopists are better at detection) (Hassan et al., 2012). In fact, the American Cancer Society estimates a savings of roughly \$200,000,000 per year if all colonoscopies were performed by Gastroen‐ terologists (currently both Gastroenterologists and non-Gastroenterologists are able to per‐ form colonoscopy). Unfortunately, the number of gastroenterologists available to provide screening colonoscopies remains limited. Currently, there are roughly 10,400 practicing Gas‐ troenterologists in the United States. As screening compliance increases (and the absolute number of individuals meeting the indication for screening increases as well), there will be a severe shortage of practicing Gastroenterologists. As mentioned previously, as of now, there is a 58.3% compliance rate to colon cancer screening. As this number increases, the limited supply of Gastroenterologists will ultimately be overwhelmed. Even those who meet indica‐ tions for screening may be unable to obtain a colonoscopy in a timely manner. In effect, ev‐ ery colonoscopy performed on an elderly patient may mean one less colonoscopy for a young, healthy individual. Simply put, there must be established guidelines followed by all practitioners to ensure that screening colonoscopies are performed in the most cost-effective and life-preserving manner. Therefore, it is of paramount importance to take resource allo‐ cation into account when advising patients on whether to proceed with colonoscopy or not.

#### **4.4. Evidence based approach to ending screening**

gained. Thus, there is roughly a 6-fold difference in the actual effect of colon cancer screen‐ ing between the two groups. Although younger patients have a much lower chance of de‐ veloping colon cancer, they experience the lowest complication rate and benefit from the

It is also equally important to consider allocation of valuable resources when debating whether or not to forego colon cancer screening in the elderly. Colonoscopies, while costeffective, are expensive. Those uninsured may have to pay thousands of dollars for the pro‐ cedure, and those insured may have to pay copays, deductibles, etc. Moreover, the cost to society is enormous. Considering there are currently 74,008,000 Americans age 55 and above, there are millions of colonoscopies completed annually (Wagner et al., 1970). If there are no established recommendations on when it is appropriate to stop colonoscopy screen‐ ing, millions of dollars will be spent for a procedure that may have minimal impact on the health of those screened. Moreover, funding that could go toward more cost-effective treat‐ ments or screening programs would be needlessly diverted. Fortunately, the Affordable Care Act (ACA) recently instated a policy in which Medicare and Medicaid "shall not im‐ pose any cost sharing requirements for evidence-based items or services that have in effect a rating of 'A' or 'B' in the current recommendations of the United States Preventive Services Task Force." Therefore, the cost of a colonoscopy to the individual may be minimized, how‐ ever the cost to society will only grow. It is important to take into account the number of providers who can safely and effectively offer colonoscopy screening as well. Studies have demonstrated that colonoscopies performed by Gastroenterologists vs. non-Gastroenterolo‐ gists are both more cost-effective and more beneficial to the patient (i.e. trained endoscopists are better at detection) (Hassan et al., 2012). In fact, the American Cancer Society estimates a savings of roughly \$200,000,000 per year if all colonoscopies were performed by Gastroen‐ terologists (currently both Gastroenterologists and non-Gastroenterologists are able to per‐ form colonoscopy). Unfortunately, the number of gastroenterologists available to provide screening colonoscopies remains limited. Currently, there are roughly 10,400 practicing Gas‐ troenterologists in the United States. As screening compliance increases (and the absolute number of individuals meeting the indication for screening increases as well), there will be a severe shortage of practicing Gastroenterologists. As mentioned previously, as of now, there is a 58.3% compliance rate to colon cancer screening. As this number increases, the limited supply of Gastroenterologists will ultimately be overwhelmed. Even those who meet indica‐ tions for screening may be unable to obtain a colonoscopy in a timely manner. In effect, ev‐ ery colonoscopy performed on an elderly patient may mean one less colonoscopy for a young, healthy individual. Simply put, there must be established guidelines followed by all practitioners to ensure that screening colonoscopies are performed in the most cost-effective and life-preserving manner. Therefore, it is of paramount importance to take resource allo‐ cation into account when advising patients on whether to proceed with colonoscopy or not.

largest amount of life years gained if diagnosed and treated.

46 Colonoscopy and Colorectal Cancer Screening - Future Directions

**4.3. The resource allocation factor**

The USPSTF currently recommends that colon cancer screening via colonoscopy be terminat‐ ed at age 75 (USPSTF, 2008). This recommendation is based upon a Decision Analysis publish‐ ed in 2008. Again, using two simulation models, the authors examined the average life-years gained and the number of colonoscopies that would be required based upon the age at which colonoscopy screening was stopped (and assuming a 10-year interval screening method in average-risk individuals). The authors primarily tested ceasing colonoscopy at age 75 vs 85. In essence, they found that by stopping screening at age 75, they decreased the number of lifeyears gained by only 2-5/1000 people. However, the number of colonoscopies needed de‐ creased by 348-398/1000 people. The ranges given signify the results from both simulation models. While some may argue that adding 2-5 life-years per 1000 people should take para‐ mount importance, this unfortunately cannot be the case given the limited resources as dis‐ cussed above. Until resources are infinite, it is necessary to funnel finances and medical staff toward the population that will most benefit from screening. Distributing the additional 348-398 colonoscopies to a younger population will result in more life-years gained, lives saved, and far fewer complications. Therefore, for the time being, it seems that ceasing colono‐ scopy screening at age 75 is both responsible and in the best interest of society.

#### **4.5. Surveillance after late stage cancer diagnosis**

Lastly, it is important to recognize that not all colonoscopies will be performed for strictly screening purposes. Ultimately, the goal of colonoscopy is early diagnosis and curative treatment by either polypectomy or bowel resection. However, as colon cancer is unfortu‐ nately still such a large cause of mortality in the United States and the screening rate is not 100%, many individuals will still be diagnosed with late-stage and unresectable colon can‐ cer. This then poses the question, what is the utility in surveillance colonoscopy in these in‐ dividuals?

To date, limited data exists concerning this topic. The primary treatment for patients with diagnosed Stage IV inoperable colon cancer is palliative chemotherapy. Occasionally, che‐ motherapy may be able to shrink the tumor(s) to an operable state, but this is more often not the case among late-stage diagnoses due to multiple metastases. Studies have analyzed prognostic indicators among patients with inoperable disease and found that performance status, ASA-class, CEA level, metastatic load, extent of primary tumor, and chemotherapy were the only independent variables affecting prognosis in these patients (Stelzner et al., 2005). While the initial diagnostic colonoscopy can provide valuable tissue data and infor‐ mation regarding depth of invasion, at this time surveillance colonoscopy does not appear to play a role in the management beyond initial diagnosis. Given that there is no clear bene‐ fit to surveillance colonoscopy after diagnosis of inoperable colon cancer and there are a multitude of risks associated with the procedure, surveillance colonoscopy is not indicated in these patients.

### **5. Factors that impact effective screening**

Colonoscopy is an accurate and effective screening technique that is endorsed by many soci‐ eties including the American Cancer Society, U.S. Multi-society Task Force, American Col‐ lege of Radiology, and American College of Gastroenterology (ACG) (Levin et al., 2008; Rex et al., 2009; USPSTF, 2008). While it may seem that screening for CRC is a well-established and accepted standard of care, screening rates for CRC have only recently started to ap‐ proach that of other cancers. Increasing interest in the issue of best practice for CRC screen‐ ing is attributable to updates to screening guidelines as a result of recent studies indicating significant mortality benefits. In addition to changes in the actual screening guidelines, the goal of screening has shifted to focus on cancer prevention by removing polyps rather than simply cancer detection (USPSTF, 2008). Important factors exist that impact the effectiveness of available screening modalities for CRC, and these originate from physicians, patients, as well as from society. While current recommendations support initiation of screening at age 50 for all average risk men and women, earlier initiation is advocated for those at higher risk including African American men and women. Knowledge about these guidelines can im‐ pact screening practice. Consideration must also be given to the modality of CRC screening. The ACG recommends colonoscopy as the preferred mode of screening, and the gold stand‐ ard given it diagnostic and therapeutic potential (Rex et al., 2009). Studies demonstrate that most physicians overwhelmingly prefer colonoscopy as the test of choice (Guerra et al., 2007). In fact, 70% of PCPs strongly believe colonoscopy is the best available colorectal can‐ cer-screening test. Furthermore, a large proportion of physicians are concerned over law‐ suits if they do not offer screening colonoscopies. The fear of facing a lawsuit over colonoscopy complications can be outweighed by the fear of being sued if the procedure is not offered at all (McGregor et al., 2010; Varela et al., 2010). While CRC screening saves lives, the use of colonoscopy and other available options, remains suboptimal. Pinpointing the reasons why people are not getting screened, either by choice or by circumstance, is es‐ sential in order to increase screening outcomes and compliance. There are unquestionably many barriers to effective healthcare delivery in the US, let alone being able to appropriately screen for CRC (Hoffman et al., 2011). Barriers can be sorted into a few main categories: physician, patient, societal related factors. This section will touch on some of these obstacles.

colonoscopy, physicians need to be sensitive and attuned to patient preferences. Techniques other than colonoscopy may be more suitable for specific patients, given their individual cir‐ cumstances. For example, a recent study published in *Cancer* found that wealthy patients frequently opt for colonoscopy while lower socioeconomic groups tended to choose at home stool testing over endoscopy (Bandi et al., 2012). Patient preference varies by ethnicity as well, with African Americans less likely to choose endoscopy than Caucasians (Dimou et al., 2009). From their trial data, Inadomi and colleagues (Inadomi et al., 2012) predict that if co‐ lonoscopy were the only option offered, fewer patients would be screened. It is evident that the choice of screening test should take into consideration not only the physician's, but also the patient's perspective because some form of screening still remains superior to no screen‐ ing at all. Considering the evidence above, physicians should recommend one best option to their patients using evidence-based medicine and taking into account patient specific fac‐ tors. CRC screening guidelines are complicated and offering multiple options still requires

Issues in Screening and Surveillance Colonoscopy

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49

Although Medicare coverage has lessened these concerns, many physicians reported that health insurance remains very influential for screening recommendations (White et al., 2012). Of note, individuals of lower socioeconomic classes have expressed concerns that they experience a lack of screening offers from doctors. This is supported by physicians who admit they do not recommend colonoscopy, if patients do not have insurance or ready access. Another interesting difference in physician screening recommendation was the age of the physician, with younger physicians recommending the test more. Although this is merely speculation, younger physicians may be more comfortable ordering this

In practice, physicians often fail to mention CRC screening because of limited time, compet‐ ing issues, and forgetfulness. At times the many pressing issues that need to be addressed, preclude the lengthy discussion about available cancer screening tests. Additionally, many patients only go to a clinic to address urgent issues. These clinics are often overbooked and the main focus is to stabilize the acute problem. Some patients lack health insurance or are unwilling to wait for appointments (Guerra et al., 2007). At best, some physicians may rec‐ ommend a follow up health maintenance visit. In addition, one national survey suggested that the primary care physicians may not adequately discuss all test options available with average risk patients because they are under the assumption that this will be addressed in more depth by specialists. Screening rates suffer from lack of coordination between special‐ ists and PCPs (Doubeni et al., 2010). Physician forgetfulness and unfamiliarity with guide‐ lines is a preventable obstacle to screening (White et al., 2012). The screening and surveillance recommendations differ significantly for a subset of CRC patients with heredi‐ tary syndromes. There is a marked lack of knowledge about screening guidelines for highrisk populations based on family history and also ethnicity. Primary care physician recommendations are often inconsistent with published guidelines. Among those most inti‐ mate with guidelines, the gastroenterologists, only a fraction recommended genetic counsel‐

ing, which is also a part of appropriate screening (White et al., 2012).

shared decision making in practice (Zapka et al., 2011).

newer test (Zapka et al., 2011).

#### **5.1. The role of the physician in CRC screening**

Physician recommendations play a crucial role in the decision to get screened for CRC (Zap‐ ka et al., 2011). A mere discussion of CRC screening at the time of an office visit may be suf‐ ficient and motivate patients to complete CRC screening. Given the prominence of the physician factor it is important to consider elements that impact physician recommendation of colonoscopy to their patients. Collegial norms, patient preferences, and published evi‐ dence including guidelines from the ACS and USPSF have been identified as important ele‐ ments. Physicians in the US favor endoscopy and often fail to adequately present alternatives such as stool testing. One study found that 50% of the patients surveyed did not receive the test they requested, and most underwent a colonoscopy instead (Hawley et al., 2012). However, since all screening tests have some benefit, even if they are not on par with colonoscopy, physicians need to be sensitive and attuned to patient preferences. Techniques other than colonoscopy may be more suitable for specific patients, given their individual cir‐ cumstances. For example, a recent study published in *Cancer* found that wealthy patients frequently opt for colonoscopy while lower socioeconomic groups tended to choose at home stool testing over endoscopy (Bandi et al., 2012). Patient preference varies by ethnicity as well, with African Americans less likely to choose endoscopy than Caucasians (Dimou et al., 2009). From their trial data, Inadomi and colleagues (Inadomi et al., 2012) predict that if co‐ lonoscopy were the only option offered, fewer patients would be screened. It is evident that the choice of screening test should take into consideration not only the physician's, but also the patient's perspective because some form of screening still remains superior to no screen‐ ing at all. Considering the evidence above, physicians should recommend one best option to their patients using evidence-based medicine and taking into account patient specific fac‐ tors. CRC screening guidelines are complicated and offering multiple options still requires shared decision making in practice (Zapka et al., 2011).

**5. Factors that impact effective screening**

48 Colonoscopy and Colorectal Cancer Screening - Future Directions

**5.1. The role of the physician in CRC screening**

Colonoscopy is an accurate and effective screening technique that is endorsed by many soci‐ eties including the American Cancer Society, U.S. Multi-society Task Force, American Col‐ lege of Radiology, and American College of Gastroenterology (ACG) (Levin et al., 2008; Rex et al., 2009; USPSTF, 2008). While it may seem that screening for CRC is a well-established and accepted standard of care, screening rates for CRC have only recently started to ap‐ proach that of other cancers. Increasing interest in the issue of best practice for CRC screen‐ ing is attributable to updates to screening guidelines as a result of recent studies indicating significant mortality benefits. In addition to changes in the actual screening guidelines, the goal of screening has shifted to focus on cancer prevention by removing polyps rather than simply cancer detection (USPSTF, 2008). Important factors exist that impact the effectiveness of available screening modalities for CRC, and these originate from physicians, patients, as well as from society. While current recommendations support initiation of screening at age 50 for all average risk men and women, earlier initiation is advocated for those at higher risk including African American men and women. Knowledge about these guidelines can im‐ pact screening practice. Consideration must also be given to the modality of CRC screening. The ACG recommends colonoscopy as the preferred mode of screening, and the gold stand‐ ard given it diagnostic and therapeutic potential (Rex et al., 2009). Studies demonstrate that most physicians overwhelmingly prefer colonoscopy as the test of choice (Guerra et al., 2007). In fact, 70% of PCPs strongly believe colonoscopy is the best available colorectal can‐ cer-screening test. Furthermore, a large proportion of physicians are concerned over law‐ suits if they do not offer screening colonoscopies. The fear of facing a lawsuit over colonoscopy complications can be outweighed by the fear of being sued if the procedure is not offered at all (McGregor et al., 2010; Varela et al., 2010). While CRC screening saves lives, the use of colonoscopy and other available options, remains suboptimal. Pinpointing the reasons why people are not getting screened, either by choice or by circumstance, is es‐ sential in order to increase screening outcomes and compliance. There are unquestionably many barriers to effective healthcare delivery in the US, let alone being able to appropriately screen for CRC (Hoffman et al., 2011). Barriers can be sorted into a few main categories: physician, patient, societal related factors. This section will touch on some of these obstacles.

Physician recommendations play a crucial role in the decision to get screened for CRC (Zap‐ ka et al., 2011). A mere discussion of CRC screening at the time of an office visit may be suf‐ ficient and motivate patients to complete CRC screening. Given the prominence of the physician factor it is important to consider elements that impact physician recommendation of colonoscopy to their patients. Collegial norms, patient preferences, and published evi‐ dence including guidelines from the ACS and USPSF have been identified as important ele‐ ments. Physicians in the US favor endoscopy and often fail to adequately present alternatives such as stool testing. One study found that 50% of the patients surveyed did not receive the test they requested, and most underwent a colonoscopy instead (Hawley et al., 2012). However, since all screening tests have some benefit, even if they are not on par with

Although Medicare coverage has lessened these concerns, many physicians reported that health insurance remains very influential for screening recommendations (White et al., 2012). Of note, individuals of lower socioeconomic classes have expressed concerns that they experience a lack of screening offers from doctors. This is supported by physicians who admit they do not recommend colonoscopy, if patients do not have insurance or ready access. Another interesting difference in physician screening recommendation was the age of the physician, with younger physicians recommending the test more. Although this is merely speculation, younger physicians may be more comfortable ordering this newer test (Zapka et al., 2011).

In practice, physicians often fail to mention CRC screening because of limited time, compet‐ ing issues, and forgetfulness. At times the many pressing issues that need to be addressed, preclude the lengthy discussion about available cancer screening tests. Additionally, many patients only go to a clinic to address urgent issues. These clinics are often overbooked and the main focus is to stabilize the acute problem. Some patients lack health insurance or are unwilling to wait for appointments (Guerra et al., 2007). At best, some physicians may rec‐ ommend a follow up health maintenance visit. In addition, one national survey suggested that the primary care physicians may not adequately discuss all test options available with average risk patients because they are under the assumption that this will be addressed in more depth by specialists. Screening rates suffer from lack of coordination between special‐ ists and PCPs (Doubeni et al., 2010). Physician forgetfulness and unfamiliarity with guide‐ lines is a preventable obstacle to screening (White et al., 2012). The screening and surveillance recommendations differ significantly for a subset of CRC patients with heredi‐ tary syndromes. There is a marked lack of knowledge about screening guidelines for highrisk populations based on family history and also ethnicity. Primary care physician recommendations are often inconsistent with published guidelines. Among those most inti‐ mate with guidelines, the gastroenterologists, only a fraction recommended genetic counsel‐ ing, which is also a part of appropriate screening (White et al., 2012).

Studies have suggested that physicians may not be fully aware of patient's attitudes and val‐ ues towards screening. Physicians underestimated test discomfort and did not recognize the importance of helping patients make informed decisions for screening. In addition, several studies have shown that PCPs recommendations are affected by their demography includ‐ ing age, sex and ethnicity. For example, non-Caucasian physicians are less likely to recom‐ mend cancer screening compared to Caucasian doctors. Hispanic physicians in the US were found to be less likely to recommend CRC screening. In a study in Australia, general practi‐ tioners of Middle Eastern ethnicity estimated CRC incidence to be lower in immigrants com‐ pared to patients born in Australia, which may have resulted in lower recommendations of CRC screening for immigrants (Koo et al., 2012). Thus in general, primary care physicians need greater awareness about CRC rates and screening.

need for brief, direct encouragement from providers to educate patients about screening, particularly in the absence of symptoms or family history of CRC. Physicians can have great impact on CRC screening, particularly with lifesaving colonoscopy, which is greatly un‐

Issues in Screening and Surveillance Colonoscopy

http://dx.doi.org/10.5772/53111

51

In a questionnaire investigating the patient barriers to CRC screening, hesitation about screening was highest among never-screened respondents, intermediate among everscreened respondents who were overdue for testing, and lowest among the people adherent with guidelines suggesting that different obstacles exist within each target group. The only difference between those groups of patients is *prior screening status*. These results also dem‐ onstrate that people who have undergone screening are less fearful of the test itself, this could be attributed to the fact that they have first hand experience instead of false informa‐ tion or misconceptions. Patients who are more educated are likely to be aware of the risks

Low compliance for CRC screening by patients can be attributed to several factors including lack of insurance, cost, lack of knowledge of cancer and screening, not seeing a need for test‐ ing, embarrassment, lack of symptoms or health problems, fear of perceived pain, and anxi‐ ety of testing. This is in addition to failure by recommendation from a physician (Jones et al., 2010). Studies have suggested that many patients dread getting ready for and having the test and also worry about the test results. Additional research has found that the partici‐ pants did not understand the purpose of screening for cancer, were not able to distinguish between screening tests from any other tests and did not realize that screening is performed

Lack of knowledge is a major barrier to screening, particularly for immigrants, ethnic minor‐ ities, and underserved populations because of challenges in effective communication, as will be discussed later. Studies looking into lack of knowledge about colon cancer screening identified many other knowledge gaps including low health literacy. Some individuals did not have a basic understanding of human anatomy and were not able to identify the location of the colon nor its purpose. A subset of these individuals did not believe colon cancer exist‐ ed. Furthermore, a surprising amount of educated individuals could not accurately describe the colon's function, confusing it with the rectum and anus (Francois et al., 2009; Winterich

Those that had some fundamental knowledge of colon anatomy lacked an adequate under‐ standing about the causes and risk factors of colon cancer. Many individuals without symp‐ toms or family history do not feel concerned about this disease. Some are under the impression that causes of colon cancer center around food and thought that bowel cleansing was a good way to maintain or re-establish health. Others cited that they did not get screened because they did not smoke, drink, eat unhealthy foods, or participate in anal sex,

all of which they perceived to be high-risk behaviors (Francois et al., 2009).

derutilized in the US.

and benefits of CRC screening (Winterich et al., 2011).

*5.2.1. Patient attitudes, beliefs, and knowledge of CRC*

when a person feels well (Shokar et al., 2005).

et al., 2011).

While patients cite physician recommendation as the number one motivator for screening, oth‐ er factors might impact compliance. Research demonstrates that providing excessive choices can be overwhelming subsequently leading to confusion and indecision. Selection of one pre‐ ferred alternative may help simplify the discussion about screening (Inadomi et al., 2012). Studies that target physician recommendations have been shown to be more effective than those that focus only on the patient (Guerra et al., 2007). In contrast, others argue that options are needed because every CRC screening modality has its own strengths and limitations. Ad‐ ditionally, there does not seem to be a clear consensus among patients about preferred meth‐ ods. Thus, an important question arises: would patients be more willing to participate in screening, if they are given the opportunity to choose? Engaging patients in the decision-mak‐ ing process can improve satisfaction by taking into account each patient's unique needs. A pa‐ tient-centered approach improves screening compliance (Inadomi et al., 2012).

#### **5.2. Patient-based factors in CRC screening**

At the center of the discussion related to screening is the patient's participation in complet‐ ing the process. While low participation rates in screening related to infrequent or lack of follow-up is a difficult barrier to overcome, other factors are also important. It is notable that most of the data about reasons for screening non-compliance comes from direct physician report (Hoffman et al., 2011). Physicians reported offering screening to all of their high risk and most of their average risk patients, and most were surprised at the low adherence rates. Through their interactions with patients, physicians believed barriers to screening were fear of the test, embarrassment, lack of insurance, and lack of knowledge about cancer and screening. Interestingly, when patients were asked the same questions, they did not feel that discomfort or embarrassment kept them from undergoing the procedure. Patients reported lack of physician recommendation as one of the main factors for not getting tested, along with lack of symptoms that might suggest a colon neoplasm (Jones et al., 2010). Of course these studies are limited in terms of the particular patient population sampled and may not be applicable to all patients; however, it is important to note that patients place great impor‐ tance on the conversation with primary care providers about CRC screening (Fenton et al., 2011). Furthermore, this is directly linked to patient's knowledge about CRC and screening. Misconceptions continue to prevail as barriers to CRC screening, indicating a continued need for brief, direct encouragement from providers to educate patients about screening, particularly in the absence of symptoms or family history of CRC. Physicians can have great impact on CRC screening, particularly with lifesaving colonoscopy, which is greatly un‐ derutilized in the US.

In a questionnaire investigating the patient barriers to CRC screening, hesitation about screening was highest among never-screened respondents, intermediate among everscreened respondents who were overdue for testing, and lowest among the people adherent with guidelines suggesting that different obstacles exist within each target group. The only difference between those groups of patients is *prior screening status*. These results also dem‐ onstrate that people who have undergone screening are less fearful of the test itself, this could be attributed to the fact that they have first hand experience instead of false informa‐ tion or misconceptions. Patients who are more educated are likely to be aware of the risks and benefits of CRC screening (Winterich et al., 2011).

#### *5.2.1. Patient attitudes, beliefs, and knowledge of CRC*

Studies have suggested that physicians may not be fully aware of patient's attitudes and val‐ ues towards screening. Physicians underestimated test discomfort and did not recognize the importance of helping patients make informed decisions for screening. In addition, several studies have shown that PCPs recommendations are affected by their demography includ‐ ing age, sex and ethnicity. For example, non-Caucasian physicians are less likely to recom‐ mend cancer screening compared to Caucasian doctors. Hispanic physicians in the US were found to be less likely to recommend CRC screening. In a study in Australia, general practi‐ tioners of Middle Eastern ethnicity estimated CRC incidence to be lower in immigrants com‐ pared to patients born in Australia, which may have resulted in lower recommendations of CRC screening for immigrants (Koo et al., 2012). Thus in general, primary care physicians

While patients cite physician recommendation as the number one motivator for screening, oth‐ er factors might impact compliance. Research demonstrates that providing excessive choices can be overwhelming subsequently leading to confusion and indecision. Selection of one pre‐ ferred alternative may help simplify the discussion about screening (Inadomi et al., 2012). Studies that target physician recommendations have been shown to be more effective than those that focus only on the patient (Guerra et al., 2007). In contrast, others argue that options are needed because every CRC screening modality has its own strengths and limitations. Ad‐ ditionally, there does not seem to be a clear consensus among patients about preferred meth‐ ods. Thus, an important question arises: would patients be more willing to participate in screening, if they are given the opportunity to choose? Engaging patients in the decision-mak‐ ing process can improve satisfaction by taking into account each patient's unique needs. A pa‐

At the center of the discussion related to screening is the patient's participation in complet‐ ing the process. While low participation rates in screening related to infrequent or lack of follow-up is a difficult barrier to overcome, other factors are also important. It is notable that most of the data about reasons for screening non-compliance comes from direct physician report (Hoffman et al., 2011). Physicians reported offering screening to all of their high risk and most of their average risk patients, and most were surprised at the low adherence rates. Through their interactions with patients, physicians believed barriers to screening were fear of the test, embarrassment, lack of insurance, and lack of knowledge about cancer and screening. Interestingly, when patients were asked the same questions, they did not feel that discomfort or embarrassment kept them from undergoing the procedure. Patients reported lack of physician recommendation as one of the main factors for not getting tested, along with lack of symptoms that might suggest a colon neoplasm (Jones et al., 2010). Of course these studies are limited in terms of the particular patient population sampled and may not be applicable to all patients; however, it is important to note that patients place great impor‐ tance on the conversation with primary care providers about CRC screening (Fenton et al., 2011). Furthermore, this is directly linked to patient's knowledge about CRC and screening. Misconceptions continue to prevail as barriers to CRC screening, indicating a continued

tient-centered approach improves screening compliance (Inadomi et al., 2012).

need greater awareness about CRC rates and screening.

50 Colonoscopy and Colorectal Cancer Screening - Future Directions

**5.2. Patient-based factors in CRC screening**

Low compliance for CRC screening by patients can be attributed to several factors including lack of insurance, cost, lack of knowledge of cancer and screening, not seeing a need for test‐ ing, embarrassment, lack of symptoms or health problems, fear of perceived pain, and anxi‐ ety of testing. This is in addition to failure by recommendation from a physician (Jones et al., 2010). Studies have suggested that many patients dread getting ready for and having the test and also worry about the test results. Additional research has found that the partici‐ pants did not understand the purpose of screening for cancer, were not able to distinguish between screening tests from any other tests and did not realize that screening is performed when a person feels well (Shokar et al., 2005).

Lack of knowledge is a major barrier to screening, particularly for immigrants, ethnic minor‐ ities, and underserved populations because of challenges in effective communication, as will be discussed later. Studies looking into lack of knowledge about colon cancer screening identified many other knowledge gaps including low health literacy. Some individuals did not have a basic understanding of human anatomy and were not able to identify the location of the colon nor its purpose. A subset of these individuals did not believe colon cancer exist‐ ed. Furthermore, a surprising amount of educated individuals could not accurately describe the colon's function, confusing it with the rectum and anus (Francois et al., 2009; Winterich et al., 2011).

Those that had some fundamental knowledge of colon anatomy lacked an adequate under‐ standing about the causes and risk factors of colon cancer. Many individuals without symp‐ toms or family history do not feel concerned about this disease. Some are under the impression that causes of colon cancer center around food and thought that bowel cleansing was a good way to maintain or re-establish health. Others cited that they did not get screened because they did not smoke, drink, eat unhealthy foods, or participate in anal sex, all of which they perceived to be high-risk behaviors (Francois et al., 2009).

In addition to poor understanding about colon cancer, many misperceptions about colono‐ scopy itself were identified. One study captured the reasons some people did not like colo‐ noscopy including that the preparation was "inconvenient", "uncomfortable", and involved a "compromising position". Men of all races and levels of educational attainment shared the male specific gender barrier that they were turned off by the invasive nature of the colono‐ scopy. While males and females have similar screening rates, men expressed more initial hesitation about screening because of the fear that it threatens their masculinity. Men who associated their masculinity with these exams experienced them more negatively (Winterich et al., 2011). Interestingly, Winterich et al. (Winterich et al., 2011) found that as education in‐ creased, men's negative views of colonoscopy also seemed to increase. Most individuals of a low-educational attainment generally described the colonoscopy as a "good" test because of the culturally dominant view that medical care is important (Winterich et al., 2011).

*5.2.4. Cultural chasms*

trich et al., 2012).

Cultural beliefs can result in lower screening rates, for example, Italian- Australians, Mace‐ donian-Australians and Greek- Australians were found to believe that nothing can be done to treat 'malignant' cancers and that in fact, treatment of cancers may hasten death (Severino et al., 2009). They also believe that consumption of 'unnaturally' grown foods, eating foods sprayed with pesticides or experiencing strong emotions may cause cancer. Studies with Af‐ rican Americans have indicated that the lack of CRC knowledge, lack of physician recom‐ mendation, and a distrust of the health care system and providers impede screening; as well as a fatalistic belief (beliefs that screening and treatments are 'futile' since it is in "God's hands") which has also been reported as a barrier for CRC screening (James et al., 2002). A subset of individuals connected colon cancer with "someone putting a curse on you" (Fran‐ cois et al., 2009). Studies in Latino population suggest that fatalistic attitudes and fear of can‐ cer are barriers to cancer screening and misconceptions about the causes of cancer as well as

Issues in Screening and Surveillance Colonoscopy

http://dx.doi.org/10.5772/53111

53

Among other factors, family recommendations and cultural norms weighed heavily on per‐ ceptions about cancer and colonoscopy. For example, studies with Mexican and Hispanic communities have cited the need for strategies to distribute the information without causing any stigma or embarrassment. Privacy is highly valued in Mexican culture and thus individ‐ ualized educational sessions are a good approach. On the other hand, Hispanic communities prefer group educational workshops. Emphasis on family and being healthy to provide for the family was effective, as well as convincing women within families of the importance of screening. Latinos also tend to see doctors only when sick and combine traditional and home healing with physician prescribed medications. Religion and spirituality seem to im‐ pact the willingness to accept CRC screening, as does low income and less education (Ge‐

In a study of Haitian immigrants, preventive care was not emphasized by the community. Haitians make one of the largest immigrant groups in US and have the lowest percentage of insurance coverage. Instead of having a primary physician they seem to rely on emergency rooms and do not see a doctor unless there is something wrong, there is not an operating concept valuing 'check ups'. Undocumented persons, seek help only in an emergency situa‐ tion and instead rely on home remedies. These individuals expressed that they simply did not want to know if there was something wrong with them, because finding one problem

Efforts to empower patients to become involved in their own care have proven to be effec‐ tive. Health literacy campaigns in New York City have improved CRC screening rates. Community education is required to promote screening and public education campaigns are shown to be effective. For example Mr. Polyp ads, a public service announcement from the American Cancer Society, led many to ask their doctors about colonoscopies (Guerra et al., 2007). Population based interventions aimed at increasing the demand for screening include, reminders and incentives, mass and small media, group and one-on-one education. Bilin‐

perceived discomfort and embarrassment (Walsh et al., 2004).

might lead to other ones (Francois et al., 2009).

*5.2.5. Health literacy and educational outreach in CRC screening*

#### *5.2.2. Racial and ethnic disparities in CRC screening*

As mentioned earlier, screening rates differ based on race and ethnic groups. The National Health Interview Survey reported that racial disparities seen with CRC screening are related to socioeconomic status, however, racial disparities persist despite coverage for CRC screen‐ ing in a Medicare population (Wilkins et al., 2012). Compared to whites, blacks and Hispan‐ ics are less likely to be screened. Overall rates of CRC screening are estimated to be 50% and it is even lower for minorities. Screening rates vary even within a racial or ethnic group, e.g among Asians, Koreans and Vietnamese have lower rates of screening; among whites, those living in Appalachia have lower screening rates. Minority populations and low socioeco‐ nomic status are considered to be factors resulting in low CRC screening rates (Linsky et al., 2011). Research studies also suggest that immigrants may experience unique barriers such as language and cultural differences with their health care providers which can lead to poorer communication about the importance of screening (Goel et al., 2003).

#### *5.2.3. The language divide*

Patients who do not speak English are less likely to be screened (Linsky et al., 2011). Accord‐ ing to the 2005-2007 American Community Survey, minorities comprise 26% of the popula‐ tion, and nearly 20% of Americans speak a language other than English at home. By 2050, minorities could make up about half of the US population, with a similar increase in indi‐ viduals speaking a language other than English at home. Spanish speaking Hispanics are 43% less likely to receive CRC screening. Communication problems when discussing cancer screening are also documented with Vietnamese Americans (Linsky et al., 2011). Additional‐ ly, for Creole speaking Haitian Americans the language barrier may also be a factor in com‐ municating with physicians (Francois et al., 2009). While patient-physician language discordance presents a barrier, it is possible to address it through initiatives such as transla‐ tion services so that disparities in screening rates can be reduced.

#### *5.2.4. Cultural chasms*

In addition to poor understanding about colon cancer, many misperceptions about colono‐ scopy itself were identified. One study captured the reasons some people did not like colo‐ noscopy including that the preparation was "inconvenient", "uncomfortable", and involved a "compromising position". Men of all races and levels of educational attainment shared the male specific gender barrier that they were turned off by the invasive nature of the colono‐ scopy. While males and females have similar screening rates, men expressed more initial hesitation about screening because of the fear that it threatens their masculinity. Men who associated their masculinity with these exams experienced them more negatively (Winterich et al., 2011). Interestingly, Winterich et al. (Winterich et al., 2011) found that as education in‐ creased, men's negative views of colonoscopy also seemed to increase. Most individuals of a low-educational attainment generally described the colonoscopy as a "good" test because of

the culturally dominant view that medical care is important (Winterich et al., 2011).

communication about the importance of screening (Goel et al., 2003).

tion services so that disparities in screening rates can be reduced.

As mentioned earlier, screening rates differ based on race and ethnic groups. The National Health Interview Survey reported that racial disparities seen with CRC screening are related to socioeconomic status, however, racial disparities persist despite coverage for CRC screen‐ ing in a Medicare population (Wilkins et al., 2012). Compared to whites, blacks and Hispan‐ ics are less likely to be screened. Overall rates of CRC screening are estimated to be 50% and it is even lower for minorities. Screening rates vary even within a racial or ethnic group, e.g among Asians, Koreans and Vietnamese have lower rates of screening; among whites, those living in Appalachia have lower screening rates. Minority populations and low socioeco‐ nomic status are considered to be factors resulting in low CRC screening rates (Linsky et al., 2011). Research studies also suggest that immigrants may experience unique barriers such as language and cultural differences with their health care providers which can lead to poorer

Patients who do not speak English are less likely to be screened (Linsky et al., 2011). Accord‐ ing to the 2005-2007 American Community Survey, minorities comprise 26% of the popula‐ tion, and nearly 20% of Americans speak a language other than English at home. By 2050, minorities could make up about half of the US population, with a similar increase in indi‐ viduals speaking a language other than English at home. Spanish speaking Hispanics are 43% less likely to receive CRC screening. Communication problems when discussing cancer screening are also documented with Vietnamese Americans (Linsky et al., 2011). Additional‐ ly, for Creole speaking Haitian Americans the language barrier may also be a factor in com‐ municating with physicians (Francois et al., 2009). While patient-physician language discordance presents a barrier, it is possible to address it through initiatives such as transla‐

*5.2.2. Racial and ethnic disparities in CRC screening*

52 Colonoscopy and Colorectal Cancer Screening - Future Directions

*5.2.3. The language divide*

Cultural beliefs can result in lower screening rates, for example, Italian- Australians, Mace‐ donian-Australians and Greek- Australians were found to believe that nothing can be done to treat 'malignant' cancers and that in fact, treatment of cancers may hasten death (Severino et al., 2009). They also believe that consumption of 'unnaturally' grown foods, eating foods sprayed with pesticides or experiencing strong emotions may cause cancer. Studies with Af‐ rican Americans have indicated that the lack of CRC knowledge, lack of physician recom‐ mendation, and a distrust of the health care system and providers impede screening; as well as a fatalistic belief (beliefs that screening and treatments are 'futile' since it is in "God's hands") which has also been reported as a barrier for CRC screening (James et al., 2002). A subset of individuals connected colon cancer with "someone putting a curse on you" (Fran‐ cois et al., 2009). Studies in Latino population suggest that fatalistic attitudes and fear of can‐ cer are barriers to cancer screening and misconceptions about the causes of cancer as well as perceived discomfort and embarrassment (Walsh et al., 2004).

Among other factors, family recommendations and cultural norms weighed heavily on per‐ ceptions about cancer and colonoscopy. For example, studies with Mexican and Hispanic communities have cited the need for strategies to distribute the information without causing any stigma or embarrassment. Privacy is highly valued in Mexican culture and thus individ‐ ualized educational sessions are a good approach. On the other hand, Hispanic communities prefer group educational workshops. Emphasis on family and being healthy to provide for the family was effective, as well as convincing women within families of the importance of screening. Latinos also tend to see doctors only when sick and combine traditional and home healing with physician prescribed medications. Religion and spirituality seem to im‐ pact the willingness to accept CRC screening, as does low income and less education (Ge‐ trich et al., 2012).

In a study of Haitian immigrants, preventive care was not emphasized by the community. Haitians make one of the largest immigrant groups in US and have the lowest percentage of insurance coverage. Instead of having a primary physician they seem to rely on emergency rooms and do not see a doctor unless there is something wrong, there is not an operating concept valuing 'check ups'. Undocumented persons, seek help only in an emergency situa‐ tion and instead rely on home remedies. These individuals expressed that they simply did not want to know if there was something wrong with them, because finding one problem might lead to other ones (Francois et al., 2009).

#### *5.2.5. Health literacy and educational outreach in CRC screening*

Efforts to empower patients to become involved in their own care have proven to be effec‐ tive. Health literacy campaigns in New York City have improved CRC screening rates. Community education is required to promote screening and public education campaigns are shown to be effective. For example Mr. Polyp ads, a public service announcement from the American Cancer Society, led many to ask their doctors about colonoscopies (Guerra et al., 2007). Population based interventions aimed at increasing the demand for screening include, reminders and incentives, mass and small media, group and one-on-one education. Bilin‐ gual verbal communication and 'word of mouth' are also potentially very effective modali‐ ties. Blumenthal et al. (Blumenthal et al., 2010) tested three interventions intended to increase the rate of CRC screening among African Americans. They concluded that group education doubled screening rates and reduced out of pocket expenses. Furthermore, differ‐ ences in attitudes and perceived barriers among ethnic and minority population may need culturally tailored interventions. Focus groups with Hispanics identified fear of finding can‐ cer and fear of embarrassment from the examination, as screening obstacles. With this infor‐ mation, Varela et al. (Varela et al., 2010) developed targeted educational materials to promote colonoscopies among Hispanics. Similar educational materials could tap into faithbased programs like the successful Witness Project for breast cancer.

maintained; otherwise, patients will experience a fundamental disconnect in the patientphysician relationship that may discourage screening. The team-based approach does not

Issues in Screening and Surveillance Colonoscopy

http://dx.doi.org/10.5772/53111

55

Customized programs targeted to specific individuals may help improve patient participa‐ tion rates. Tailored screening guidelines have been advocated for certain groups based on noted prevalence and anatomic location of colonic lesions in these populations. For example, women are known to have an increased risk of right-sided polyps and cancer (Chu et al., 2011), while African Americans tend to develop colorectal cancer at an earlier age (Agrawal et al., 2005). The recommendation for tailored screening guidelines as suggested by the ACG have the potential to help address existing disparities in CRC but must be balanced by ease

Although screening rates for CRC remain suboptimal, there has been an overall upward trend. Endorsement from various recommending organizations helped promote awareness of CRC screening in the medical community. Supported by population-based studies, gas‐ troenterology organizations have promoted screening with colonoscopy as the best screen‐ ing test. The healthcare policy to support CRC screening through Medicare reimbursement was impactful in developing further acceptance. Medicare's decision to support screening colonoscopy had a significant impact on the popularity of this modality as other payers fol‐ lowed suit. With insurance companies willing to pay, doctors were more inclined to recom‐ mend screening and free to choose their preferred modality, colonoscopy. In fact, gastroenterologists report they are now performing many more colonoscopies than before. Some spend 50% to 80% of their time performing this one procedure, a dramatic increase

Public perception and support has greatly impacted the implementation of screening, espe‐ cially colonoscopy. All of the aforementioned factors are geared at gaining strong popular support, a necessary ingredient for any widespread screening practice. For example, pros‐ tate cancer screening became widely practiced on the basis of popular support, even without evidence of mortality reduction. Arguably the most influential aspect of colon cancer and screening awareness was the increasing presence of colonoscopy in the media. Famous peo‐ ple affected by colon cancer include Ronald Reagan, Audrey Hepburn, and Daryl Strawber‐ ry to name a few. Public interest in colonoscopy reached a turning point in March of 2000, the first colon cancer awareness month. This initiative was spearheaded by news icon Katie Couric, who advocated for CRC screening on the national stage by televising her own colo‐ noscopy after her husband's death (Cram et al., 2003). Similar appearances of colonoscopy in the media impacted CRC screening practices in the United States. Most recently, Dr. Oz underwent a colonoscopy on his eponymous television show. An editorial featured in the New York Times entitled "Going the distance-the case for true colorectal-cancer screening" garnered further support for colonoscopies stating that sigmoidoscopy, that only screens part of the colon, is comparable to mammography for only one breast. Numerous editorials and front page articles have featured colonoscopies (Ransohoff, 2005). For example a news‐

look to replace the physician, but can enhance patient-physician discourse.

of implementation as well as healthcare financing concerns.

**5.3. Public policies, outreach, and CRC screening**

from before (Ransohoff, 2005).

#### *5.2.6. Patient navigators and customized CRC screening*

As previously mentioned, ethnic and cultural differences can pose a great barrier to effective cancer screening. Patient advocates who help coordinate care provide an option for tackling screening disparities. Termed patient navigators, these individuals are laypersons from the community who help patients navigate the intricacies of the health care system (Lasser et al., 2011). They can better address the unique needs of a patient and are responsible for almost anything such as helping patients get insurance, finding transportation to doctors' appoint‐ ments, healthcare education, and emotional support. For example, patients that require in‐ terpreters are found to be less compliant with screening recommendations. Providing patients with a healthcare ambassador who speaks their preferred language has proven to be a simple yet extremely powerful intervention. In a randomized controlled trial, recently published in the Archives of Internal Medicine, researchers found quantifiable benefits from assigning black and non-English speaking patients with a healthcare navigator. These pa‐ tients had a greater likelihood of being screened by FOBT than control subjects (33.6% vs 20.0%; P<.001) and were also more likely to undergo colonoscopy (26.4% vs 13.0%; P,.001). Moreover, these patients had more adenomas detected (8.1% vs 3.9%; P<.06) and more cases of CRC prevented (Lasser et al., 2011). This study highlights the importance of a multidisci‐ plinary approach to medicine. The impact of patient navigators, especially on urban and ra‐ cial minorities, is demonstrated by numerous studies (Chen et al., 2008; Lasser et al., 2011; Lasser et al., 2009; Ma et al., 2009; Myers et al., 2008; Nash et al., 2006). A recent study found patient navigators to be effective for Creole or Portuguese speaking patients. This model can be observed in practice in Boston where Partners in Health routinely trains paramedical per‐ sonnel to assist in providing customized care for patients with HIV and TB in Haiti and Rwanda.

The benefit of a team approach to healthcare is further evidenced by studies demonstrating that the use of nurse practitioners and physicians assistants further streamlines healthcare delivery and improves screening compliance. Moreover, telephone counseling and printed materials can help improve follow up and overall quality of life in colorectal cancer survi‐ vors. Clouston et al. (Clouston et al., 2012) performed a study to evaluate use of a website and telephones on CRC screening rates and concluded that both increased compliance sig‐ nificantly. However, a strong and trusting family physician-patient relationship must be maintained; otherwise, patients will experience a fundamental disconnect in the patientphysician relationship that may discourage screening. The team-based approach does not look to replace the physician, but can enhance patient-physician discourse.

Customized programs targeted to specific individuals may help improve patient participa‐ tion rates. Tailored screening guidelines have been advocated for certain groups based on noted prevalence and anatomic location of colonic lesions in these populations. For example, women are known to have an increased risk of right-sided polyps and cancer (Chu et al., 2011), while African Americans tend to develop colorectal cancer at an earlier age (Agrawal et al., 2005). The recommendation for tailored screening guidelines as suggested by the ACG have the potential to help address existing disparities in CRC but must be balanced by ease of implementation as well as healthcare financing concerns.

#### **5.3. Public policies, outreach, and CRC screening**

gual verbal communication and 'word of mouth' are also potentially very effective modali‐ ties. Blumenthal et al. (Blumenthal et al., 2010) tested three interventions intended to increase the rate of CRC screening among African Americans. They concluded that group education doubled screening rates and reduced out of pocket expenses. Furthermore, differ‐ ences in attitudes and perceived barriers among ethnic and minority population may need culturally tailored interventions. Focus groups with Hispanics identified fear of finding can‐ cer and fear of embarrassment from the examination, as screening obstacles. With this infor‐ mation, Varela et al. (Varela et al., 2010) developed targeted educational materials to promote colonoscopies among Hispanics. Similar educational materials could tap into faith-

As previously mentioned, ethnic and cultural differences can pose a great barrier to effective cancer screening. Patient advocates who help coordinate care provide an option for tackling screening disparities. Termed patient navigators, these individuals are laypersons from the community who help patients navigate the intricacies of the health care system (Lasser et al., 2011). They can better address the unique needs of a patient and are responsible for almost anything such as helping patients get insurance, finding transportation to doctors' appoint‐ ments, healthcare education, and emotional support. For example, patients that require in‐ terpreters are found to be less compliant with screening recommendations. Providing patients with a healthcare ambassador who speaks their preferred language has proven to be a simple yet extremely powerful intervention. In a randomized controlled trial, recently published in the Archives of Internal Medicine, researchers found quantifiable benefits from assigning black and non-English speaking patients with a healthcare navigator. These pa‐ tients had a greater likelihood of being screened by FOBT than control subjects (33.6% vs 20.0%; P<.001) and were also more likely to undergo colonoscopy (26.4% vs 13.0%; P,.001). Moreover, these patients had more adenomas detected (8.1% vs 3.9%; P<.06) and more cases of CRC prevented (Lasser et al., 2011). This study highlights the importance of a multidisci‐ plinary approach to medicine. The impact of patient navigators, especially on urban and ra‐ cial minorities, is demonstrated by numerous studies (Chen et al., 2008; Lasser et al., 2011; Lasser et al., 2009; Ma et al., 2009; Myers et al., 2008; Nash et al., 2006). A recent study found patient navigators to be effective for Creole or Portuguese speaking patients. This model can be observed in practice in Boston where Partners in Health routinely trains paramedical per‐ sonnel to assist in providing customized care for patients with HIV and TB in Haiti and

The benefit of a team approach to healthcare is further evidenced by studies demonstrating that the use of nurse practitioners and physicians assistants further streamlines healthcare delivery and improves screening compliance. Moreover, telephone counseling and printed materials can help improve follow up and overall quality of life in colorectal cancer survi‐ vors. Clouston et al. (Clouston et al., 2012) performed a study to evaluate use of a website and telephones on CRC screening rates and concluded that both increased compliance sig‐ nificantly. However, a strong and trusting family physician-patient relationship must be

based programs like the successful Witness Project for breast cancer.

*5.2.6. Patient navigators and customized CRC screening*

54 Colonoscopy and Colorectal Cancer Screening - Future Directions

Rwanda.

Although screening rates for CRC remain suboptimal, there has been an overall upward trend. Endorsement from various recommending organizations helped promote awareness of CRC screening in the medical community. Supported by population-based studies, gas‐ troenterology organizations have promoted screening with colonoscopy as the best screen‐ ing test. The healthcare policy to support CRC screening through Medicare reimbursement was impactful in developing further acceptance. Medicare's decision to support screening colonoscopy had a significant impact on the popularity of this modality as other payers fol‐ lowed suit. With insurance companies willing to pay, doctors were more inclined to recom‐ mend screening and free to choose their preferred modality, colonoscopy. In fact, gastroenterologists report they are now performing many more colonoscopies than before. Some spend 50% to 80% of their time performing this one procedure, a dramatic increase from before (Ransohoff, 2005).

Public perception and support has greatly impacted the implementation of screening, espe‐ cially colonoscopy. All of the aforementioned factors are geared at gaining strong popular support, a necessary ingredient for any widespread screening practice. For example, pros‐ tate cancer screening became widely practiced on the basis of popular support, even without evidence of mortality reduction. Arguably the most influential aspect of colon cancer and screening awareness was the increasing presence of colonoscopy in the media. Famous peo‐ ple affected by colon cancer include Ronald Reagan, Audrey Hepburn, and Daryl Strawber‐ ry to name a few. Public interest in colonoscopy reached a turning point in March of 2000, the first colon cancer awareness month. This initiative was spearheaded by news icon Katie Couric, who advocated for CRC screening on the national stage by televising her own colo‐ noscopy after her husband's death (Cram et al., 2003). Similar appearances of colonoscopy in the media impacted CRC screening practices in the United States. Most recently, Dr. Oz underwent a colonoscopy on his eponymous television show. An editorial featured in the New York Times entitled "Going the distance-the case for true colorectal-cancer screening" garnered further support for colonoscopies stating that sigmoidoscopy, that only screens part of the colon, is comparable to mammography for only one breast. Numerous editorials and front page articles have featured colonoscopies (Ransohoff, 2005). For example a news‐ paper ad made the assertion, "your golden years deserve the gold standard of colon cancer screening" (American College of Gastroenterology [ACG], 2012). Additional marketing on the web has helped improve awareness among the public who increasingly use the web for health information (Cohen and Adams, 2011).

*5.3.3. Communication via current technologies*

rates (Fenton et al., 2011).

screening (Yabroff et al., 2011).

*5.3.4. Health insurance coverage for colonoscopy*

saving screening modality (Liu et al., 2012).

The use of systems strategies can improve physician delivery of healthcare. Systems strat‐ egies employ patient and physician screening reminders, performance reports of screening rates, and electronic medical records (Yabroff et al., 2011). Given time constraints, remem‐ bering to perform all routine screenings for every patient is difficult. The increasing use of electronic medical records (EMR) has helped physicians overcome this obstacle. Pop-up re‐ minders can help minimize forgetfulness, as well as the added pressure of remembering in‐ dividualized guidelines. These electronic prompts have the additional advantage of flexibility, which allows for screening to account for the patient's personal and family histo‐ ry. In one retrospective survey, the physicians that utilized this technology, which automati‐ cally provided appointments for CRC screening at a certain age, had the highest screening

Issues in Screening and Surveillance Colonoscopy

http://dx.doi.org/10.5772/53111

57

In addition to physician prompts, organized screening programs make use of patient re‐ minders to improve screening compliance. These programs reach out to all members of the population due for CRC screening via mailed reminders (Levin et al., 2011). In addition to outreach mailings, the Task Force on Community Preventive Services of the Centers for Dis‐ ease Control and Prevention recommend performance reports for doctors. Monetary incen‐ tive from insurance companies for completing age-appropriate screening is effective. Additionally, better reimbursements are needed to encourage spending time on preventive medicine (Guerra et al., 2007). Brouwers (Brouwers et al., 2011) conducted a systemic review that included 66 randomized controlled studies and a cluster of randomized controlled tri‐ als. They concluded that client reminders, small media and provider audit and feedback ap‐ pear to increase screening rates significantly. Despite evidence that systems strategies are effective, relatively few physicians report using a comprehensive plan to promote cancer

Ensuring health insurance coverage and usual source of care will most likely increase use among those who have never been screened. Following Medicare's example, private insur‐ ance coverage of CRC screening will be a step towards resolving the cost issue for physi‐ cians and patients. Asking patients to pay thousands of out of pocket expenses to undergo a colonoscopy, will not help increase the rates of this life saving procedure. In a step to in‐ crease testing accessibility and affordability, the Affordable Care Act will ask insurers to cover screening colonoscopies. This will include not only colonoscopy, but the use of anes‐ thesia (e.g. propofol) as opposed to conscious sedation (e.g., midazolam, fentanyl). Provid‐ ing increased options for sedation is likely to remove the patient barrier related to discomfort and make it more likely that individuals will comply with colonoscopy as a life-

#### *5.3.1. Healthcare access*

For patients to consider screening, it is important that to have insurance coverage, access to healthcare or both. Only 24% of uninsured Americans, who do not have a usual source of health care and are eligible, participate in CRC screening (Shapiro et al., 2012). Patients with higher incomes are likely to have health insurance and tend to have a consistent source of care. A recent systemic review reported that lower socioeconomic status was correlated with a higher incidence and mortality rate (Wilkins et al., 2012). Subramanian et al. (Subramanian et al., 2010) argue that when budgets are tight, options other than colonoscopies are better for screening, basing this on the premise that some form of screening is better than no screening at all. This study asserts that state and federal agencies have screening programs for the uninsured and underinsured that may not be able to support colonoscopy in their limited budget. However efficacy of the guaiac based fecal blood test depends on 100% com‐ pliance. This is often not practical and the study's authors admit that colonoscopy is still a better screening test if annual testing is not feasible.

In addition to financial access, geographic access can pose a problem for individuals in rural areas. In New York City and other urban centers, most hospitals and many private practices will offer colonoscopy; however, this is not the case in every part of the country. Several studies have found lower screening rates in rural versus nonrural areas (Wilkins et al., 2012). Geographic distance is a factor and individuals are less likely to be screened if the nearest colonoscopy-offering center is over an hour away. The rural countries in the study by Wilkins et al. (Wilkins et al., 2012) had higher poverty rates, lower educational level, lim‐ ited access to doctors, and less insurance coverage.

#### *5.3.2. National programs*

The benefits of a team approach to healthcare is further evidenced by national programs that help promote patient awareness and education about CRC screening. Health policy ini‐ tiatives need to underscore the importance of screening programs to improve quality of can‐ cer screening. Cancer registries may be of use to identify and monitor the incidence, stage of cancer and screening rate across regions. A CRC screening registry similar to Breast Cancer Surveillance Consortium could be established to monitor rates of screening, overuse, quality and complications. An ideal monitoring system should be able to estimate rates of screening regardless of patient's insurance status and demographic characteristics, assess use, appro‐ priateness and outcomes. Efforts should be made to support expansion, analysis and collab‐ oration of existing data sources and databases such as Clinical Outcome Research Initiative (CORI) endoscopy data base, the Cancer Research Network (CRN) and the Computed To‐ mography Colonography Registry.

#### *5.3.3. Communication via current technologies*

paper ad made the assertion, "your golden years deserve the gold standard of colon cancer screening" (American College of Gastroenterology [ACG], 2012). Additional marketing on the web has helped improve awareness among the public who increasingly use the web for

For patients to consider screening, it is important that to have insurance coverage, access to healthcare or both. Only 24% of uninsured Americans, who do not have a usual source of health care and are eligible, participate in CRC screening (Shapiro et al., 2012). Patients with higher incomes are likely to have health insurance and tend to have a consistent source of care. A recent systemic review reported that lower socioeconomic status was correlated with a higher incidence and mortality rate (Wilkins et al., 2012). Subramanian et al. (Subramanian et al., 2010) argue that when budgets are tight, options other than colonoscopies are better for screening, basing this on the premise that some form of screening is better than no screening at all. This study asserts that state and federal agencies have screening programs for the uninsured and underinsured that may not be able to support colonoscopy in their limited budget. However efficacy of the guaiac based fecal blood test depends on 100% com‐ pliance. This is often not practical and the study's authors admit that colonoscopy is still a

In addition to financial access, geographic access can pose a problem for individuals in rural areas. In New York City and other urban centers, most hospitals and many private practices will offer colonoscopy; however, this is not the case in every part of the country. Several studies have found lower screening rates in rural versus nonrural areas (Wilkins et al., 2012). Geographic distance is a factor and individuals are less likely to be screened if the nearest colonoscopy-offering center is over an hour away. The rural countries in the study by Wilkins et al. (Wilkins et al., 2012) had higher poverty rates, lower educational level, lim‐

The benefits of a team approach to healthcare is further evidenced by national programs that help promote patient awareness and education about CRC screening. Health policy ini‐ tiatives need to underscore the importance of screening programs to improve quality of can‐ cer screening. Cancer registries may be of use to identify and monitor the incidence, stage of cancer and screening rate across regions. A CRC screening registry similar to Breast Cancer Surveillance Consortium could be established to monitor rates of screening, overuse, quality and complications. An ideal monitoring system should be able to estimate rates of screening regardless of patient's insurance status and demographic characteristics, assess use, appro‐ priateness and outcomes. Efforts should be made to support expansion, analysis and collab‐ oration of existing data sources and databases such as Clinical Outcome Research Initiative (CORI) endoscopy data base, the Cancer Research Network (CRN) and the Computed To‐

health information (Cohen and Adams, 2011).

56 Colonoscopy and Colorectal Cancer Screening - Future Directions

better screening test if annual testing is not feasible.

ited access to doctors, and less insurance coverage.

*5.3.2. National programs*

mography Colonography Registry.

*5.3.1. Healthcare access*

The use of systems strategies can improve physician delivery of healthcare. Systems strat‐ egies employ patient and physician screening reminders, performance reports of screening rates, and electronic medical records (Yabroff et al., 2011). Given time constraints, remem‐ bering to perform all routine screenings for every patient is difficult. The increasing use of electronic medical records (EMR) has helped physicians overcome this obstacle. Pop-up re‐ minders can help minimize forgetfulness, as well as the added pressure of remembering in‐ dividualized guidelines. These electronic prompts have the additional advantage of flexibility, which allows for screening to account for the patient's personal and family histo‐ ry. In one retrospective survey, the physicians that utilized this technology, which automati‐ cally provided appointments for CRC screening at a certain age, had the highest screening rates (Fenton et al., 2011).

In addition to physician prompts, organized screening programs make use of patient re‐ minders to improve screening compliance. These programs reach out to all members of the population due for CRC screening via mailed reminders (Levin et al., 2011). In addition to outreach mailings, the Task Force on Community Preventive Services of the Centers for Dis‐ ease Control and Prevention recommend performance reports for doctors. Monetary incen‐ tive from insurance companies for completing age-appropriate screening is effective. Additionally, better reimbursements are needed to encourage spending time on preventive medicine (Guerra et al., 2007). Brouwers (Brouwers et al., 2011) conducted a systemic review that included 66 randomized controlled studies and a cluster of randomized controlled tri‐ als. They concluded that client reminders, small media and provider audit and feedback ap‐ pear to increase screening rates significantly. Despite evidence that systems strategies are effective, relatively few physicians report using a comprehensive plan to promote cancer screening (Yabroff et al., 2011).

#### *5.3.4. Health insurance coverage for colonoscopy*

Ensuring health insurance coverage and usual source of care will most likely increase use among those who have never been screened. Following Medicare's example, private insur‐ ance coverage of CRC screening will be a step towards resolving the cost issue for physi‐ cians and patients. Asking patients to pay thousands of out of pocket expenses to undergo a colonoscopy, will not help increase the rates of this life saving procedure. In a step to in‐ crease testing accessibility and affordability, the Affordable Care Act will ask insurers to cover screening colonoscopies. This will include not only colonoscopy, but the use of anes‐ thesia (e.g. propofol) as opposed to conscious sedation (e.g., midazolam, fentanyl). Provid‐ ing increased options for sedation is likely to remove the patient barrier related to discomfort and make it more likely that individuals will comply with colonoscopy as a lifesaving screening modality (Liu et al., 2012).

### **6. Conclusion**

This chapter has summarized the current body of knowledge related to colorectal cancer screening and surveillance recommendations in the context of addressing risk stratification, when to start and stop screening, as well as factors that impact screening rates. Overall, screening, detection, and removal of precancerous lesions allow for the prevention of CRC. It is notable that although strong evidence now exists for the mortality benefits of CRC screening, significant disparities remain in the disease thus giving rise to opportunities to address physician, patient, as well as societal factors that can improve screening rates.

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