Family physicians, along with their colleagues in other primary care specialties, play a key role in helping their Medicare patient populations survive -- or avoid altogether -- the potential devastation of a colorectal cancer (CRC) diagnosis.
That's according to a population-based, case-control study titled "Primary Care Utilization and Colorectal Cancer Incidence and Mortality Among Medicare Beneficiaries(annals.org)" in the Oct. 1 issue of Annals of Internal Medicine.
CRC takes a heavy toll on the health of Americans. For example, study authors estimated 142,820 new cases of CRC were diagnosed in the United States in 2013, and more than 50,000 individuals died from the disease. The cost to Medicare runs into the billions. And yet, according to researchers, fewer than 60 percent of U.S. adults ages 50 and older have ever received CRC screening, and just 39 percent of cases are diagnosed while the disease is still localized.
Lead researcher Jeanne Ferrante, M.D., M.P.H., talked to AAFP News Now about the study and summed up the most important message to family physicians in one sentence: "Increasing visits to primary care physicians (PCPs) decreases CRC incidence and mortality."
- A recently published study found that Medicare patients who had multiple primary care visits were less likely to develop or die from colorectal cancer (CRC).
- Researchers noted that primary care physicians often provide patients with CRC screening and polypectomy procedures and diagnose CRC when it is still at an early stage.
- Primary care physicians also encourage healthy behaviors, ask patients to not use tobacco products, urge patients to engage in preventive services, and coordinate patient care to reduce medication and laboratory errors.
"In this (study) population, only 49 percent of patients had ever received screening in a 10-year period," said Ferrante. Furthermore, she noted, researchers were surprised to learn that close to 30 percent of the population studied saw a primary care physician only once -- if at all -- in a two-year period.
For purposes of the study, primary care physicians were defined as those in general practice, family medicine, internal medicine, geriatric medicine and obstetrics-gynecology.
Ferrante urged family physicians to talk with their Medicare patients about establishing regular primary care visits and suggested two to five such visits should occur each year. "Since we found that primary care visits decrease CRC incidence through screening, it's important for primary care physicians to recommend or perform CRC screening (such as fecal occult blood testing)," said Ferrante.
Specific Study Findings
Individuals included in the study were 67 to 85 years old, had fee-for-service Medicare, and received a CRC diagnosis between 1994 and 2005. (Editor's Note: The AAFP recommends against routine colorectal cancer screening in individuals ages 76-85. See below under "More From AAFP.")
Researchers measured the number of primary care visits by patients in the four- to 27-month period before CRC diagnosis, CRC incidence, CRC mortality and all causes of mortality. They used Medicare claims histories up to 10 years before a patient's CRC diagnosis and assessed receipt of CRC screening and polypectomy procedures.
Researchers found that the likelihood of CRC diagnosis decreased with increasing primary care visits. Specifically,
- patients who had five to 10 primary care visits had 6 percent lower odds of a CRC diagnosis when compared with patients who had no or only one primary care visit;
- in patients who were diagnosed with CRC, they were more likely to receive a diagnosis of early-stage cancer or proximal cancer with increased primary care visits, and
- patients with five to 10 visits to a primary care physician had 22 percent lower odds of CRC mortality than patients with no or one primary care visit.
Furthermore, patients who saw a primary care physician at least two times in a year had close to 20 percent lower odds of all-cause mortality when compared with patients in the control group.
Researchers also found that patients who saw nonprimary care physicians also had lower rates of CRC incidence and mortality. "The effect of non-PCP visits may reflect the effect of PCP visits because these physicians facilitate referrals and access to specialists," wrote the authors.
CRC screening at primary care visits, polypectomy and early-stage CRC diagnosis all contributed to the positive association of primary care physician visits with lower CRC mortality, noted the authors. But they suggested that additional factors may be at play.
For instance, primary care physicians often encourage healthy behaviors such as diet and exercise and encourage patients to not use tobacco products. Primary care physicians also encourage patients to take advantage of available preventive services and coordinate patient care to reduce medication and laboratory errors.
"Another possibility is the healthy-user effect, in which healthier patients are more likely to seek primary care and adhere to medications or use preventive services," noted the authors.
Ensuring Access to Primary Care
Study authors lamented the fact that despite the availability of universal Medicare insurance, more than 20 percent of beneficiaries did not visit a primary care physician for two years and 10 percent of patients did not have contact with any physician.
They pointed out that these beneficiaries had more CRC incidence, CRC mortality and all-cause mortality.
"Medicare's recent expanded coverage for preventive care and annual wellness visits may help emphasize the importance of PCP visits and preventive screenings," wrote the authors. "However, the current difficulties in accessing primary care will be exacerbated by the looming primary care shortage along with the influx of newly insured adults using primary care because of recently enacted health reform law. Policies and programs are needed to increase access to and supply of PCPs."
Ferrante suggested that waiving copays or deductibles could help promote the importance and value of patients seeing their primary care physicians on a regular basis.
"We also need to make sure there is adequate access to primary care physicians through policy changes to increase the supply," said Ferrante. She added that a good place to start would be to increase training venues, stabilize pay inequities between primary care physicians and subspecialists, and build the prestige of primary care medicine as a specialty of great importance to all patients.
More From AAFP
Clinical Recommendations: Colorectal Cancer