Not all medical tests justify the risks they pose. In fact, some can be downright dangerous. Whole-body CT scans, for example, have been known to expose healthy patients to cancer-causing radiation. Then again, there are some tests so safe and so necessary that it can be dangerous, even deadly, for patients not to participate. Screening for colon cancer is one example.
Every year, more than 50,000 Americans die from colon cancer. And yet, as many as 1 in 3 colon cancer deaths could be avoided with proper screening.
That’s because the biology of colon cancer differs from most other malignancies, such as lung or brain, making it possible to identify and treat the problem long before it kills people. Colon cancer most often starts as a polyp (a growth on the inner lining of the colon or rectum, resembling a wart). It then takes an average of 10 years for this benign growth to evolve into an invasive cancer capable of spreading to the rest of the body. This 10-year window provides sufficient time for a physician to get ahead of a potentially deadly disease.
Given the medical community’s deep understanding of how to detect and prevent colon cancer, you’d think that doctors would screen 100% of at-risk patients. But you’d be wrong.
A new study reveals that more than 14,000 colon-cancer deaths in the United States (28% of all deaths from the disease) could be prevented every year if all care providers (doctors and hospitals) matched the screening and mortality rates of America’s highest-performing health systems.
Death rates drop as screening rates rise
In the 1990s, scientists made tremendous leaps toward understanding the biology and progression of colon cancer. Based on these findings, the physician leaders and practicing clinicians at the nation’s largest medical group set out to lead the nation in colon cancer prevention.
The results of those efforts were recently published in Gastroenterology and reveal large-scale improvements over a 15-year period within Kaiser Permanente (KP), a California-based health system. In 2000, participation in colon-cancer screening at KP was 39% among adults 51 to 75, the group most at risk. This was, at the time, consistent with national averages. By 2015, however, screening rates within KP climbed to nearly 83%, compared to only 66% nationwide.
Through an aggressive and targeted initiative within The Permanente Medical Group starting in 2006, deaths from colon cancer have dropped more than 52% since the study’s benchmark. As a result, KP patients are now 28% less likely to die from colon cancer than patients nationwide.
There’s much that both patients and practitioners can learn from this 28% gap between the best and the rest. Here are five things everyone should know about preventing unnecessary deaths from colon cancer:
1. The health system you choose matters.
Time and again, studies find that certain health systems are better equipped than others to prevent and manage serious diseases. Patients treated in the highest-performing integrated healthcare settings are 30% less likely to die of a heart attack or stroke, 40% less likely to die from sepsis, and 50% less likely to die from HIV or AIDS than those who aren’t. And, as this newest study demonstrates, these patients also have a nearly 30% lower chance of dying from colorectal cancer.
Despite what TV shows would have us believe, achieving medical excellence has as much (or more) to do with how a healthcare system is structured, reimbursed and technologically supported as with the skill or intelligence of individual doctors.
What distinguishes healthcare systems that achieve a higher screening rate for colon cancer is the collaboration (rather than competition) between doctors and whether doctors are paid for volume or value, which brings us to Nos. 2 and 3.
2. There’s more than one way to screen effectively.
The U.S. Preventive Task Force, an independent panel of disease-prevention experts, recommends three colorectal-cancer screening methods. Two of the diagnostic approaches require a physician to look inside the colon with a scope. For patients over 50, those options include a colonoscopy every 10 years or a sigmoidoscopy every five.
For decades, these have been the preferred screening methods of gastroenterologists. They’ve also been some of the most detested by patients. That’s because colonoscopies require patients to (a) miss two days of work, (b) clean out their intestines with a diarrhea-inducing liquid and (c) undergo a screening procedure during which the patient risks having the scope pushed through the large intestine perforating it and spilling stool into the abdomen.
To be clear, patients with a family history of colon cancer or previous polyps usually require colonoscopy, often on a more frequent schedule than every 10 years. However, for the overwhelming majority of Americans, there’s a simpler and more convenient way to go about screening for colon cancer.
Fecal testing (such as with the fecal immunochemical test or “FIT”) can be completed once a year from the comfort and privacy of one’s home. The test kit is small, about the size of a postcard, and the test itself incredibly easy to complete, requiring no more than five minutes of the patient’s time. You don’t need to schedule an appointment to take the test and, most important, there’s no bowel prep needed and no risk of complication. FIT kits can be mailed to your home or given to you by a doctor or nurse during a normal office visit.
Today, the majority of colon cancer screenings at Kaiser Permanente are done this way, which raises an important question: If KP has a higher screening rate and lower mortality rate than the national average, why doesn’t every gastroenterologist in the country follow the same protocols?
3. Pernicious payments keep colonoscopies in business. For decades now, the most prevalent reimbursement model in healthcare has been “fee-for-service,” which ensures doctors a set fee for each service they provide. And when physicians recommend a more complex test or procedure, they get paid even more, regardless of whether or not it’s proven to be safer or more reliable than the simpler alternative.
So, imagine you’re a gastroenterologist being reimbursed by a traditional health insurer. You can either (a) perform a colonoscopy on your patient and bill the insurance company thousands of dollars, or (b) hand your patient a FIT kit and bill the insurance company a few hundred dollars.
Given these options, it should come as no surprise that gastroenterologists almost always schedule a colonoscopy rather than proposing FIT screening.
4. Computers help prevent errors of omission.
To deliver the best care, doctors must have access to a comprehensive electronic health record (EHR), which contains data on patient health and makes that data available throughout the entire healthcare system. Unfortunately, as of March 2017, at least 1 in 3 care providers were still not using even a basic electronic health record, and far fewer physicians shared a single electronic system with their colleagues in the community.
Computerized systems prove especially useful in the prevention of colon cancer because when all medical professionals within a healthcare system have access to patient records, it’s far more likely that patients will know when they’re due for a preventive screening and they’ll stay up-to-date on their tests. And when all the physicians in a delivery system get paid based on the quality of their outcomes, not the volume of services they provide, there’s a much higher likelihood that patient safety and satisfaction will take precedent over money.
5. Americans value intervention over prevention. Across the country, both doctors and patients value medical interventions more than preventive medicine. Neither group perceives preventive care as all that difficult or important, despite the massive gaps in performance nationwide. As a result, doctors are paid 100 times as much to treat a heart attack or remove a cancerous tumor than to prevent them from happening in the first place. News media report extensively on new chemotherapeutic drugs that can prolong life by a few months, but they largely ignore colon-cancer screenings, which can improve and save tens of thousands of lives.
Three years after the end of the study period, there remains a 15% gap between national screening rates for colon cancer and the 80% goal set by National Colorectal Cancer Roundtable (NCCRT). According to the American Cancer Society (ACS), meeting those standards would prevent 277,000 new cases of colon cancer and 203,000 deaths over 20 years. However, achieving those clinical outcomes would require patients and practitioners to view prevention as a much more valuable service than they do today – and that won’t happen without major changes in the culture of medicine and the awareness of patients.
All of us can help prevent colon cancer
In recognition of the growing incidence of colon cancer among younger patients, the ACS recently lowered the recommended age for colon cancer screening from 50 to 45 among people of average risk. So, if you’re in the appropriate age group (45 to 75), get screened for colon cancer.
Take time to educate yourself about the less-invasive screening approaches available and ask your doctor if a fecal immunochemical test (or “FIT kit”) is appropriate for you, especially if you’re concerned about the more-invasive screenings or having to miss two days of work to get tested. This simple set of actions – doing your homework, asking questions and getting screened – could save your life.
Dr. Robert Pearl is the bestselling author of “Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong” and a Stanford University professor. Follow him @RobertPearlMD