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Help patients understand their CRC risk, options for screening
By Jason Domagalski, MD, FAAFP
The five-year survival rate for colorectal cancer is roughly 90% when detected before the disease spreads beyond the colon or rectum. Unfortunately, it’s estimated that roughly 60 million Americans who are eligible for screening or rescreening and at average risk for colorectal cancer aren’t taking steps to protect themselves.
Early detection is critical because as cancer spreads to distant parts of the body, the survival rate falls into the teens. We know primary care has an important role to play because studies have shown that patients who have primary care physicians have higher screening rates than those who do not have a usual source of care, are more likely to be diagnosed at earlier stages of CRC and are more than 50% less likely to experience late-stage CRC.
However, too many patients are putting off screening or avoiding it altogether, even when they have a primary care physician. Studies have identified time constraints, patient reluctance and scheduling challenges as barriers to screening.
CRC at FMX
Join Jason Domagalski, MD, FAAFP, for a session on colorectal cancer at the Family Medicine Experience, Oct. 5-9 in Anaheim, California. Domagalski’s session, sponsored by Exact Sciences, will cover screening modalities, guidelines and recommendations, and resources for family physicians.
Another noteworthy barrier may be a simple lack of awareness by both physicians and patients. Most primary care physicians likely know, and have adopted, updated United States Preventive Services Task Force guidelines to begin screening patients at age 45. In 2021, the task force added a B recommendation to screen patients aged 45-49 to its existing A recommendation for adults 50-75. That change followed an American Cancer Society recommendation to lower the recommended age for screening in 2018, so the concept of screening younger patients isn’t new.
What some people may not yet know is that roughly 10% of all colorectal cancers in the United States are being detected in people younger than 50. Just as alarming is the fact that less than one in three people in the 45-49 age group have been screened.
At the start of this century, colorectal cancer was the fourth-leading cause of cancer deaths in American men and women in that age group. It now ranks as the leading cause of cancer death for men younger than 50 and second for women.
How do we help patients appreciate the importance of screening? Many of our patients don’t realize they’re at risk, but the reality is that roughly one in 24 men and one in 26 women will be diagnosed with colorectal cancer in their lifetimes. Their odds are worse than they think.
Too many people assume that if a type of cancer doesn’t run in their family, they’re not at risk, but only about 10% of CRC cases are hereditary. Rates vary depending on multiple factors, including race, education, diet and exercise, alcohol and tobacco use, chronic conditions, and family history. I use a free, online risk assessment calculator to inform my patients about their individual risk levels. The process only takes a few minutes, and the results are eye-opening for many.
Black patients have a higher risk of developing and dying from colorectal cancer compared to other racial groups. They are also more likely to be diagnosed at a later stage and have lower five-year survival rates. The National Colorectal Cancer Roundtable has evidence-based resources aimed at increasing screening rates in a range of settings and populations.
Talking to patients about the need for screening is just the first step. Next, we need to discuss modalities. Colonoscopy is recommended for individuals with a personal or family history of colon cancer or polyps. That procedure can be a nonstarter for some patients, who might be reluctant to discuss the procedure, let alone utilize it as their first option. What they might not realize is that for many patients, there are alternatives.
There are a growing number of less invasive screening tools that are covered by many insurance plans. The fecal immunochemical test detects blood in stool, while Cologuard looks for abnormal DNA and blood in a stool sample. Both tests can be performed at home. Last year, the FDA approved Shield, a blood test that detected colorectal cancer more than 80% of the time during clinical trials, according to the agency.
Some patients may not be convinced to take action the first time screening is discussed. We can use personalized letters, other reminders and repeat visits to encourage screening at every opportunity, embracing the idea that there is more than one way to get it done.
A few years ago, my aunt was diagnosed with colorectal cancer that was detected during a screening colonoscopy. Fortunately, it was caught in an early stage and removed. She’s one of 1.5 million survivors of colorectal cancer in the United States.
We need to help patients understand that colorectal cancer is survivable, but early detection is the key.
Jason Domagalski, MD, FAAFP, is a family physician at the Clement J. Zablocki Veterans' Administration Medical Center in Milwaukee, Wisconsin.
Disclaimer
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