Screenings and outcomes
It is estimated that 1,918,030 people in the United States will be diagnosed with cancer in 2022 and 609,360 deaths from cancer are expected this year.1 Significant, but unequal, progress has been made against cancer over the past several decades. This is evidenced by a 32% decline in cancer death rates from a peak of 215 per 100,000 in 1991 to 146 per 100,000 in 2019.2 This decline is attributable largely to reductions in smoking and advances in early detection and treatment for some of the most common cancers.
Colorectal cancer (CRC) is the fourth most common type of cancer, with 151,030 new cases expected in the United States this year, and the second leading cause of cancer death, with 52,580 deaths expected this year.3 Additionally, the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) Program estimates that the five-year survival rate for colorectal cancer for the period of 2012-2018 was 65.1%.4
According to the American Cancer Society (ACS), similar to most cancers, the risk of CRC increases with age; the incidence rate doubles for each ascending five-year age group below the age of 50 and increases by an estimated rate of 30% after the age of 50. The rate of increase among people ages 50-54 is only 15%, which the ACS attributes to a higher rate of screening among that age group.5
Beyond genetic and lifestyle risk factors, research shows a correlation between access to CRC screening and patient outcomes. Analysis from the ACS shows that CRC death rate has dropped by 56% from 1970 to 2019, a decline of about 2% per year. This is attributable mostly to earlier detection as a result of screening and treatment advances.6 The United States Preventive Services Task Force (USPSTF) recommends screening for CRC in all adults ages 50-75 with an “A” rating and adults ages 45-49 with a “B” rating.7 The ACS recommends that as part of CRC screening, non-colonoscopy screening tests should be followed up with a timely colonoscopy, as delays in follow-up of abnormal results increase the risk of advanced CRC and CRC death.8 CRC screening, in line with guidelines, has increased significantly since 2000. Among Americans aged 50 and older, screening rates increased from 38% in 2000 to 59% in 2010.9 By 2018, the screening rate for U.S. adults ages 50-75 increased to nearly 69%.10 The screening rate among Federally Qualified Health Center (FQHC) patients ages 50-75 increased from 30.2% in 2012 to 45.6% in 2019.11 During this time, financial barriers to CRC screening were reduced, with the number of insured American increasing and the Patient Protection and Affordable Care Act (ACA) requiring the vast majority of insurance plans to cover all preventive health services with an A or B rating. Older, “grandfathered” insurance plans, as well as short-term limited duration insurance plans were among those not required to cover CRC screening services. Additionally, prior to 2022, some individuals faced potential surprise charges, which also created a sense of uncertainty and financial risk for some individuals.
It is well-documented that the COVID-19 pandemic strained the healthcare system in many ways. To mitigate the spread of disease and manage resources, restrictions on elective medical procedures were implemented in March of 2020. A biproduct of these restrictions was fewer people being screened for cancer and fewer people being diagnosed.
The percentage of FQHC patients ages 50-75 screened for CRC fell from 45.6% in 2019 to 40.1% in 2020, increasing to 41.9% in 2021. An analysis of cancer screening in Veterans Affairs facilities showed that colonoscopies decreased by 45% in 2020 compared to the average number of procedures performed in 2018 and 2019. Similarly, prostate biopsies, chest computed tomography scans and cystoscopies decreased by 29%, 10% and 21%, respectively. New cancer diagnoses decreased by 13% to 23%. For CRC specifically, 1979 fewer CRC cases (20%) were diagnosed in 2020 compared to baseline years 2018 through 2019.12
The impact of a delayed diagnosis can be significant. An evaluation of studies published between January-April 2020 showed that even just a four-week delay in treatment is associated with an increase in mortality across all common forms of cancer treatment, with longer delays being increasingly detrimental. Across three major treatment modalities – surgery, systemic treatment and radiotherapy – the study found that a treatment delay of four weeks is associated with an increase in the risk of death. For surgery, this is a 6-8% increase in the risk of death for every four-week delay. This impact is even more marked for some radiotherapy and systemic indications, with a 13% increased risk of death for adjuvant systemic treatment for colorectal cancer.13
Areas of Need
Simply put, adherence to recommended screening guidelines saves lives. Timely access to screening services, any necessary follow-up diagnostic testing, and treatment leads to better outcomes and lower healthcare costs. Unfortunately, patients need more than just time to catch up on cancer screenings and other routine preventive services. A point of access or initiation of screening services is a major area of need for patients.
President Joe Biden has championed the Cancer Moonshot and Cancer Moonshot 2.0, which includes goals of improving cancer screening, enhancing prevention, addressing inequities.14 President Biden issued a call to action on cancer screening. In May 2022, the president’s Cancer Cabinet roundtable held discussions which included a call to action on cancer screening and jumpstart progress on the 10 million screenings missed as a result of the pandemic. The Administration also wants to ensure that all Americans equitably benefit from the currently available tools to prevent, detect and diagnose cancer. As part of the May 2022 discussions, various private sector commitments were announced, including:
- Ralph Lauren Corporate Foundation collaboration with five major cancer centers to reduce disparities;
- Various employers helping employees access recommended screenings; and
- National Minority Quality Forum (NMQF) Cancer Stage Shifting Initiative (CSSI), with the mission to move from late stage to early-stage diagnosis and treatment in minority populations, with a special focus on colorectal cancer
Notably missing from Cancer Moonshot discussions is a focus on increasing workforce capacity or the benefits of utilizing primary care to help achieve the Moonshot’s goals.
There were challenges and shortages across the healthcare workforce that have worsened during the pandemic. Before the pandemic, the percentage of people in the United States with a primary care provider from 77% in 2002 to 75% in 2015.15 Patients were considered to have a primary care provider if they answered yes to four questions: “Do you have a usual source of care for new health problems? Do you have a usual source for preventive health care? Do you have a usual source for referrals? and, Do you have a usual source for ongoing health problems?”
This corresponds to a study that found a negative correlation between a loss of primary care clinicians and patient outcomes. An evaluation of a random sample of Medicare claims data from 359,470 fee-for-service beneficiaries with at least one primary care evaluation and management (E/M) visit between 2008-2017 found than 10.4% of primary care providers left the Medicare system during that time.16 This study found that in the year following beneficiaries’ primary care providers exiting Medicare, beneficiaries had 18.4% fewer primary care visits and 6.2% more specialty visits; these outcomes were found to have persisted for at least two years. Additionally, urgent care visits increased by 17.8% and emergency department visits increased 3.1%, with overall Medicare spending per beneficiary also increasing.17
The physician workforce shortage in the United States is growing and projected to exceed 139,000 by 2030.18 There are a number of widely documented factors contributing to the physician workforce shortage. These include burnout, which has been exacerbated by the COVID-19 pandemic, an aging population that also includes an aging physician workforce, caps on Medicare-funded graduate medical education that have not kept up with population growth or other workforce needs and, importantly, Medicare payment rates that have not received an inflationary update in more than two decades.
There is a longstanding recognition that patients benefit from having a medical home and a comprehensive physician-led healthcare team. Joint Principles of the Patient-Centered Medical Home are supported by the American Osteopathic Association and other healthcare organizations. They recognize that patients benefit from having a personal physician, receiving care from a physician directed medical practice, a whole person orientation, care that is coordinated or integrated across the healthcare system, quality and safety, enhanced access, and payment that aligns with care delivery. The National Academies of Sciences, Engineering, and Medicine (NASEM) published a report in May 2021, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care, which found that while primary care is the bedrock of a strong healthcare system, visits to primary care clinicians are declining, the workforce is shrinking, and many practices struggle to remain open.19
Unequal Disease Burden
CRC screening rates declined across all populations during the pandemic. However, it is essential to highlight that significant health disparities existed prior to March 2020. Underserved communities were disproportionately impacted by many of the challenges that resulted from the pandemic and have long been impacted by physician and other healthcare workforce shortages. Additionally, these communities are among those most likely to be impacted by future challenges to the healthcare system.
Prior to the COVID-19 pandemic, CRC rates were worse among certain racial and ethnic groups. CRC incidence and mortality “are highest in non-Hispanic blacks…, followed closely by American Indians and Alaska Natives (AIANs), and lowest in Asians/Pacific Islanders (APIs).”20 More specifically, for the years 2012-2016, “CRC incidence rates in blacks were about 20% higher than those in non-Hispanic whites (NHWs) and 50% higher than those in APIs. The disparity for mortality is twice that for incidence; CRC death rates in blacks are almost 40% higher than those in NHWs and double those in APIs.”21 The ACS recognizes that there are a number of factors that contribute to these disparities, the data reflects “differences in risk factor prevalence and health care access.”22
A 2018 study found that Alaska had the lowest county-level CRC screening prevalence in the nation.23 CRC screening at Indian Health Service (HIS) clinics is primarily performed through stool testing, which has a limited capacity for cancer prevention and requires timely follow-up with colonoscopy for positive tests. According to the ACS, AIANs are the only racial and ethnic group for which CRC mortality rates are not declining.24
To improve the way care is delivered in underserved communities, the healthcare workforce needs to be strengthened and augmented in a number of ways. The NASEM report calls for expanding and diversifying the primary care workforce, particularly in areas that are medically underserved and have a shortage of health professionals. It also calls for strengthening interprofessional teams to better align the workforce with the communities they serve.25
Ensuring the payment for healthcare services is sustainable, especially for smaller practices that care for vulnerable populations, is also essential. The NASEM report calls for payers to evaluate and disseminate payment models based on the ability of those models to promote the delivery of high-quality primary care, not on achieving short-term cost savings.26 However, policy changes must go further. Payment policies should include routine updates to account for the actual costs of healthcare delivery and ensure that practices can be stable and viable, especially in communities with existing healthcare workforce shortages.
Additionally, efforts to strengthen the physician workforce must also account for the growing debt that physicians have when they complete their training. It has been shown that 76 percent of medical school graduates have student loans, averaging approximately $190,000.27 Recognizing the importance of a physician-lead medical team, a number of states have implemented graduate medical education and loan repayment programs that have been effective in recruiting physicians to practice in specialties and geographic areas of need.28
Additionally, there should be further exploration of unique models of care that are demonstrated to be effective and can be replicated. One such example is the “Flu FIT” clinic model. The FluFIT initiative was a partnership among Penn Medicine, the Enon Tabernacle Baptist Church and the Einstein Healthcare Network.29 Out of 335 people who registered for the flu clinic, 192 (57.3%) were eligible for CRC screening; 93.8% of whom self-identified as Black. The individuals who were eligible for CRC screening were provided with a take-home fecal immunochemical test (FIT). Out of 192 people, 154 (80.3%) returned their tests. Out of the 154 individuals who returned their tests, 13 had positive test results and received letters referring them for colonoscopies.30
The FluFIT initiative is an example of an innovative way to reach people and facilitate CRC screening. It also demonstrates the limitations of unconventional models of care that are provided outside of the medical home or without coordination with a primary care practice. The article highlighting the FluFIT initiative does not indicate whether the 13 individuals received their follow-up colonoscopies.
CRC screening in accordance with evidence-based guidelines helps prevent cancer or catch it when it is most treatable. However, access to CRC screening is unequal and barriers exist for many Americans. For many access is impacted by geography, financial constraints or other logistical challenges. While there is no single solution, greater access to and integration with a physician-led healthcare team will improve access to screening services and result in better health outcomes.