NIH State-of-the-Science Conference:
Enhancing Use and Quality of
Colorectal Cancer Screening
February 2–4, 2010
Bethesda, Maryland
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Background
Colorectal cancer is the second-leading cause of cancer-related deaths in the United States. Approximately 50,000 people in the United States are expected to die from colorectal cancer in 2009. Colonic polyps, abnormal growths of tissue on the inner lining of the colon, are relatively common findings in men and women 50 years and older. Most of these growths are not cancerous, but one type of polyp, known as an adenoma, can develop into colorectal cancer. Screening tests for colorectal cancer generally either seek to identify and remove adenomas or examine the stool for signs of early cancer in people who have no symptoms. A range of colorectal cancer screening tests are available in the United States. The U.S. Preventive Services Task Force currently recommends that average-risk adults aged 50 to 75 years undergo screening for colorectal cancer with annual fecal occult blood testing, sigmoidoscopy (internal examination of the lower part of the large intestine) every 5 years, or colonoscopy (internal examination of the entire large intestine) every 10 years. Additional tests that may be used for colorectal cancer screening include computed tomography (CT) colonography and fecal DNA testing.
Although colorectal cancer is an important cause of mortality in the United States, screening for this disease is currently underutilized among eligible individuals. Despite evidence supporting the value of screening, in 2005 only 50% of U.S. adults aged 50 and older had been screened according to guidelines. Rates of screening for colorectal cancer are consistently lower than those for other common cancers, particularly breast and cervical cancer. Reasons for this disparity are complex. Unlike most other preventive services, in colorectal cancer screening there are multiple test options from which to choose, and patients and providers may have varying preferences for or access to the tests. Successful completion of colorectal cancer screening requires effort on the part of the patient to obtain stool samples for testing or to clean the colon in preparation for endoscopic examination. Test options may also differ in cost and availability for a given community. Patient, provider, and healthcare system characteristics may each play a unique role in influencing the use and quality of colorectal cancer screening.
Adding to the complexity of this issue, colorectal cancer screening may be overused or misused in certain situations. Despite uncertainty regarding the benefit of removing small polyps, many people undergoing sigmoidoscopy or colonoscopy have all identified growths removed. This may put them at increased risk for possible complications from these procedures, which can include rectal bleeding or colonic perforation (a tear in the wall of the intestine that can cause a serious abdominal infection). In addition, follow-up testing of individuals who have previously had polyps removed may occur more frequently than available evidence supports, which again may put people at risk for complications and have both cost and capacity implications for the healthcare system.
To provide healthcare providers, patients, policy makers, and the general public with a comprehensive assessment of how colorectal cancer screening and surveillance are most appropriately implemented, monitored, and evaluated for average-risk populations in the United States, the National Cancer Institute and the Office of Medical Applications of Research of the National Institutes of Health will convene a State-of-the-Science Conference February 2–4, 2010, to assess the available scientific evidence related to the following questions:
- What are the recent trends in the use and quality of colorectal cancer screening?
- What factors influence the use of colorectal cancer screening?
- Which strategies are effective in increasing the appropriate use of colorectal cancer screening and follow-up?
- What are the current and projected capacities to deliver colorectal cancer screening and surveillance at the population level?
- What are the effective approaches for monitoring the use and quality of colorectal cancer screening?
- What research is needed to make the most progress and have the greatest public health impact in promoting the appropriate use of colorectal cancer screening?
National Cancer Institute
Office of Medical Applications of Research
of the National Institutes of Health
Co-sponsors
National Institute on Aging
National Institute of Diabetes and Digestive and Kidney Diseases
National Institute of Nursing Research
Office of Behavioral and Social Sciences Research
Partners
Centers for Medicare and Medicaid Services
Health Resources and Services Administration
Centers for Disease Control and Prevention
The Agency for Healthcare Research and Quality provided additional conference development support.
Tuesday, February 2, 2010
| 8:30 a.m. | Opening Remarks Robert T. Croyle, Ph.D. Director Division of Cancer Control and Population Sciences National Cancer Institute National Institutes of Health |
| 8:40 a.m. | Charge to the Panel Jennifer Miller Croswell, M.D., M.P.H. Acting Director Office of Medical Applications of Research Office of the Director National Institutes of Health |
| 8:50 a.m. | Conference Overview and Panel Activities Donald M. Steinwachs, Ph.D. Panel and Conference Chairperson Professor and Director Health Services Research and Development Center Department of Health Policy and Management Bloomberg School of Public Health The Johns Hopkins University |
| 9:00 a.m. | The Importance of Colorectal Cancer Screening and Its Public Health Impact David A. Lieberman, M.D. Professor of Medicine Chief, Division of Gastroenterology Oregon Health and Science University Veterans Affairs Medical Center |
| 9:20 a.m. | U.S. Preventive Services Task Force and Colorectal Cancer Screening: Current Recommendations and Supporting Evidence Mary Barton, M.D., M.P.P. Scientific Director, U.S. Preventive Services Task Force Center for Primary Care, Prevention, and Clinical Partnerships Agency for Healthcare Research and Quality |
| I. | What Are the Recent Trends in the Use and Quality of Colorectal Cancer Screening? |
| 9:40 a.m. | Trends in the Use and Quality of Colorectal Cancer Screening in the U.S. Carrie N. Klabunde, Ph.D. Epidemiologist Health Services and Economics Branch Applied Research Program Division of Cancer Control and Population Sciences National Cancer Institute National Institutes of Health |
| 10:00 a.m. | Why Disparities Matter in Colorectal Cancer Screening Electra D. Paskett, Ph.D., M.P.H. Marion N. Rowley Professor of Cancer Research College of Public Health The Ohio State University |
| 10:20 a.m. | Ensuring Quality in Colorectal Screening: Avoiding Misuse and Overuse David F. Ransohoff, M.D. Professor of Medicine Clinical Professor of Epidemiology Schools of Medicine and Public Health University of North Carolina at Chapel Hill |
| 10:40 a.m. | Evidence-Based Practice Center Presentation I TBA |
| 11:00 a.m. | Discussion |
| 11:40 a.m. | Lunch Panel Executive Session |
| II. | What Factors Influence the Use of Colorectal Cancer Screening? |
| 12:40 p.m. | Evidence-Based Practice Center Presentation II TBA |
| 1:00 p.m. | Patient Preferences, Patient-Physician Communication, and Shared Decision Making Department of Social and Behavioral Health, School of Medicine Virginia Commonwealth University |
| 1:20 p.m. | Patient and Physician Barriers to Colorectal Cancer Screening Steven Woolf, M.D., M.P.H. Professor of Medicine Departments of Family Medicine, Epidemiology, and Community Health Director, VCU Center for Human Needs Virginia Commonwealth University |
| 1:40 p.m. | Primary Care Practice and Health System Influences John Z. Ayanian, M.D., M.P.P. Professor, Medicine and Health Care Policy Harvard Medical School Professor, Health Policy and Management Harvard School of Public Health |
| 2:00 p.m. | Discussion |
| III. | Which Strategies Are Effective in Increasing the Appropriate Use of Colorectal Cancer Screening and Follow-Up? |
| 2:40 p.m. | Evidence-Based Practice Center Presentation III TBA |
| 3:00 p.m. | Intervention Strategies in Diverse Populations Roshan Bastani, Ph.D. Professor of Health Services Associate Dean for Research UCLA School of Public Health |
| 3:20 p.m. | Primary Care Practice-Based Interventions Allen J. Dietrich, M.D. Professor Department of Community and Family Medicine Associate Director for Population Sciences & James J. Carroll Professor in Oncology Dartmouth Medical School Norris Cotton Cancer Center Dartmouth Hitchcock Medical Center |
| 3:40 p.m. | Quality Improvement Initiatives and Programs Elizabeth Yano, Ph.D., M.S.P.H. Adjunct Professor of Health Services UCLA School of Public Health Senior Social Scientist and Co-Director VA Center for the Study of Healthcare Provider Behavior VA Greater Los Angeles Healthcare System |
| 4:00 p.m. | Discussion |
| 4:40 p.m. | Adjournment |
Wednesday, February 3, 2010
| IV. | What Are the Current and Projected Capacities to Deliver Colorectal Cancer Screening and Surveillance at the Population Level? |
| 8:30 a.m. | CT Colonography Capacity in U.S. Hospitals Megan McHugh, Ph.D. Director of Research, Health Research & Educational Trust American Hospital Association |
| 8:50 a.m. | CT Colonography: Training Issues, Quality Control, and Potential Certification C. Daniel Johnson, M.D. Professor of Radiology Mayo Clinic Arizona |
| 9:10 a.m. | Endoscopy Capacity Laura C. Seeff, M.D. Associate Director, Colorectal Cancer Programs Centers for Disease Control and Prevention |
| 9:30 a.m. | National Estimates of Resource Requirements for Delivering Colorectal Cancer Screening Ann G. Zauber, Ph.D. Associate Attending Biostatistician Department of Epidemiology and Biostatistics Memorial Sloan-Kettering Cancer Center |
| 9:50 a.m. | Evidence-Based Practice Center Presentation IV TBA |
| 10:10 a.m. | Discussion |
| V. | What are the Effective Approaches for Monitoring the Use and Quality of Colorectal Cancer Screening? |
| 11:00 a.m. | Achieving Population-based Performance Measurement for Colorectal Cancer Screening in the United States Eric C. Schneider, M.D., M.Sc. Senior Scientist and Director RAND Boston Associate Professor Department of Health Policy and Management Harvard School of Public Health |
| 11:20 a.m. | Implementing and Monitoring Colorectal Cancer Screening Performance Improvement in an Integrated Healthcare System T.R. Levin, M.D. Research Scientist Director of Colorectal Cancer Screening Kaiser Permanente Northern California |
| 11:40 a.m. | Implementing and Monitoring Colorectal Cancer Screening Performance in the National Health Service Julietta Patnick, CBE, FFPH Director National Health Service Cancer Screening Programmes |
| 12:00 p.m. | Discussion |
| 12:30 p.m. | Adjournment |
Thursday, February 4, 2010
| 9:00 a.m. | Presentation of the Draft Consensus Statement |
| 9:30 a.m. | Public Discussion |
| 11:00 a.m. | Panel Meets in Executive Session Adjournment |
| 2:00 p.m. | Press Telebriefing |
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