How to maximize screening for colon cancer?

Research informs care as Kaiser Permanente Washington, exceeding 80 percent screening rate, launches home-based ‘FIT First’ pilot.

Cancers of the colon and rectum, the fourth most commonly diagnosed cancers, are the second leading cause of cancer deaths in the United States. But this doesn’t need to be the case: By making early detection and treatment possible, screening average-risk people is effective at reducing deaths from colorectal cancer.

Kaiser Permanente Washington researchers are working with providers on several projects to help make such screening appropriately available to Kaiser Permanente members—and people everywhere—and therefore lower their risk.

Two alternatives

You might think that colonoscopy (inserting a tube with a video camera at its tip) is your only option for screening for colorectal cancer. But if your risk is average, you have a noninvasive option that’s simpler, faster, and easy to do at home: the fecal immunochemical test (FIT).

“Colorectal cancer screening is very effective at detecting cancer and saving lives,” says Beverly B. Green, MD, MPH, a senior investigator at Kaiser Permanente Washington Health Research Institute (KPWHRI) and a family medicine physician at Washington Permanente Medical Group. “But it can’t work if average-risk people age 50 to 75 don’t get screened regularly—yearly for FIT and every decade for colonoscopy.” After FIT, stool samples are mailed to a lab, and if testing shows blood, it needs to be followed up with a diagnostic colonoscopy.

“Many people find FIT to be a more convenient option than colonoscopy for colorectal cancer screening,” she adds. “Unlike FIT, colonoscopy requires following a low-fiber diet starting four days before the procedure, fasting for a day, sedation, time off work, and a driver to and from the procedure—and it also has a potential risk of bleeding and bowel tearing.” People with a personal or family history of colorectal cancer need to be screened with colonoscopy, not FIT. But the U.S. Preventive Services Task Force considers the two screening tests to be comparably effective for people of average risk.

80% Hall of Fame

Thanks in part to more use of FIT, rates of colorectal cancer screening have been on the rise nationally and at Kaiser Permanente in recent years. Now all Kaiser Permanente regions, including Kaiser Permanente Washington, are members of the National Colorectal Cancer Round Table 80% Hall of Fame, having screened at least 80 percent of patients for colorectal cancer. The Round Table is sponsored by the Centers for Disease Control and Prevention (CDC) and the American Cancer Society.

“But we’re always looking for ways to improve,” says John Dunn, MD, MPH, Kaiser Permanente Washington’s medical director of preventive care. “That’s why our clinics launched the FIT First pilot program with our Learning Health System program. This helps to ensure that our efforts are informed by research, including research done at Kaiser Permanente Washington.”

Dr. Dunn’s team discovered that many eligible patients are not aware of FIT, he explains. “So the FIT First pilot gives our providers a decision aid to introduce their patients to this convenient alternative to colonoscopy. Of course, the screening option that the patient chooses is up to them. We prioritize helping our patients to understand their options and make decisions based on their own values and preferences.”

The public may hear of a new form of FIT that is being advertised heavily, called “FIT-DNA.”–a FIT kit combined with a DNA test. Although it is more likely to detect colorectal cancer than FIT testing alone, it is also more likely to give an abnormal result when no serious problem is present: a false positive. “We don’t routinely use FIT-DNA here because the risk-benefit ratio doesn’t suggest any advantage over FIT or colonoscopy,” Dr. Dunn says.

Ongoing research

KPWHRI has an active portfolio of projects studying how best to screen people and follow up for colorectal cancer. Among Kaiser Permanente Washington patients who were overdue for screening, Dr. Green’s randomized controlled trial, Systems of Support to Increase Colorectal Cancer Screening (SOS), has significantly boosted screening, year after year—up to nine years now. SOS took a centralized, automated approach of mailing FIT kits to these people once a year.

“I always say that the best screening test is the one that gets done, and SOS was ‘agnostic’ about whether patients chose FIT or colonoscopy,” Dr. Green says. “But we found the increase in screening was due almost entirely to people using more FIT kits, rather than colonoscopy.”

In ongoing research, Dr. Green is working with Kaiser Permanente Northwest colleagues to improve screening rates in multiple safety net clinics and with Medicaid health plans in several states. FIT shows promise in helping to lower disparities in screening rates between patients in different ethnic, racial, and economic groups: Colorectal cancer tends to be more common among Blacks, but screening rates tend to be lower in this group. “We also actively collaborate with the Washington State Department of Health Breast, Cervical, and Colon Health program that provides free screening and complete follow up for the uninsured,” Dr. Green says.

Jessica Chubak, PhD, a KPWHRI senior investigator, and Aruna Kamineni, PhD, a KPWHRI assistant investigator, are helping to lead a research center within a large consortium called Population-based Research to Optimize Screening Process (PROSPR), which focuses on screening for colorectal (and cervical and lung) cancer. They’re working with colleagues at Kaiser Permanente Northern California and Southern California and collaborators outside of Kaiser Permanente on how to improve screening and reduce harms in groups that aren’t studied as often, such as people older than 75.

With continuing focus on personalized risk strategies, improving patient outcomes and experience of care, and optimizing health care delivery, no doubt research and care will continue to inform each other to improve cancer screening at Kaiser Permanente Washington.

By Rebecca Hughes