By Richard C. Wender, MD
About a year ago, U.S. Assistant Secretary for Health Howard Koh, MD, invited a small group of people to his office to discuss the opportunity for the nation to start a full court press to end colorectal (colon) cancer as a major public health problem in the United States. The meeting idea came from a conversation on his back porch with his college friend Ron Vender, MD, who had just been elected President of the American College of Gastroenterology (ACG). Howard asked Ron how he could most effectively work with the ACG and, together, they decided that it was the right time to tackle colon cancer in a big way.
Dr. Koh invited leaders of the organizations that were at the center of public health efforts to increase colon cancer screening rates to attend the meeting. Screening is looking for cancer in people who have no symptoms of the disease. In the case of colon cancer, screening can find the disease at an early, more treatable stage, and it can also prevent it altogether. This is because colon cancer screening tests often find polyps, which can then be removed before they have a chance to become cancerous.
Leaders from the American Cancer Society and Centers for Disease Control and Prevention (CDC) were joined by leaders of several other vital governmental agencies, gastroenterologist organizations, and the National Colorectal Cancer Roundtable (NCCRT). The NCCRT is an organization co-founded 17 years ago by the American Cancer Society and CDC. Today, the NCCRT brings together close to 80 organizations with a single common goal: to increase colon cancer screening rates, our most effective way to fight the disease. The key to the NCCRT's success has been its commitment to joining diverse organizations as equal stakeholders, to do the kind of work that no one organization can accomplish alone. It's a great example of public health in action.
Colon cancer's cost
The people who attended that meeting in Dr. Koh's office hatched the idea to launch a bold initiative to reduce colon cancer deaths. The reasons could not be clearer and the timing could not be better. Colon cancer is the third leading cause of cancer related deaths in both men and women. In 2014, about 136,830 new cases of colon cancer will be diagnosed and about 50,310 deaths will occur. As substantial as these numbers are today, they would be much larger if the American Cancer Society and others had not recommended screening for colon cancer many years ago. Since that time, incidence and colon cancer death rates have been coming down steadily. In other words, we have the tools to dramatically reduce the human toll that colon cancer exacts every year.
How we can end colon cancer
First, everyone needs to know if they're at increased risk for colon cancer. A personal history of colon polyps, cancer, or inflammatory bowel disease places someone at higher-than-average risk. A family history of colon polyps or cancer also puts someone in a higher-than-average risk category. But the message that we need to communicate to the American public is that risk rises sharply as we age, so everyone aged 50 and over needs to be tested (or screened).
Next, everyone needs to know that there are screening options. The American Cancer Society recommends a number of different tests for colon cancer screening. Both colonoscopy every 10 years and a yearly fecal immunochemical test (FIT) or modern fecal occult blood test (FOBT), a tiny sample of stool collected from a bowel movement at home, will save about an equal number of lives. Patients get to choose the test they prefer after discussing the options with their personal primary care clinician.
And the time is right for a big coordinated national push to get more people tested. More people should now have access to insurance, giving more people the opportunity to get tested. Federally qualified health centers (FQHCs), a major source of primary care services for close to 20,000,000 low-income people, are now required to report colon cancer screening rates which will provide a big incentive for these critically important centers to focus on increasing colon cancer testing. In fact, the National Association of Community Health Centers (NACHC) was represented at the meeting with Dr. Koh and has joined forces with cancer organizations to realize our shared vision. The CDC has funded 25 states and 4 American Indian tribes to increase colon cancer screening rates, and we're learning a lot from those programs that can be applied throughout the country. The NCCRT is a trusted home for all of these organizations to join and plan together to achieve something great.
In November 2012, the NCCRT proposed to its members that we establish a goal of achieving 80% colon cancer screening rates by 2018. This proposal was unanimously and enthusiastically embraced - giving birth to the 80% by 2018 campaign. This will be a difficult goal to achieve but it is not out of reach. Already, 2 out of 3 adults in the US report that they have been screened as recommended, and 10 states have already surpassed the 70% screening rate threshold, led by Massachusetts at 76.3%. Certain high performing health care plans have already reached 80%. So you see: this goal is achievable if we put the right steps into place.
But it will take an all hands on deck, full court press. Among college graduates, 73.5% are up to date with screening and 80.6% have been tested at least once, but only 54.9% of individuals with less than a high school education have ever had a screening test, and less than 50% have had them as often as they're recommended. While we have to continue to work hard to increase screening across the board, we especially need to come up with newer and more effective strategies to reach lower income individuals. Helping people become insured and to connect with a regular source of primary care (doctor, nurse practitioner, or other health care professional) will make more difference than anything else we can do. This is going to test how we work with partners and systems to make a difference.
Good news. We're not in this alone. The enthusiasm generated by communicating our shared goal has been nothing short of extraordinary. The nation is ready -- in fact eager -- to do something important and satisfying together. We can take a major step to eliminating colon cancer as a major public health problem. We can increase colon cancer screening rates for everyone in the United States.
80% by 2018 ... I can see it.
Dr. Wender is chief cancer control officer for the American Cancer Society.