The American Gastroenterological Association (AGA) released position statements on the prevention of colorectal cancer (CRC) through the widespread implementation of screening programs. The full report, published in Gastroenterology, comprised 8 guiding principles focused on improving CRC screening uptake and accessibility.
Statement #1: The AGA supports a national approach to CRC screening.
There is no national approach to CRC screening in the United States, the AGA Executive Committee on the Screening Continuum explained. Outreach is infrequently performed, with most patients receiving a screening referral through their health care provider. As a result, patients without access to health care have significantly lower CRC screening rates. The AGA thus recommends a systematic outreach program in which all age-eligible patients are offered screening and clinical support.
Statement #2: Increasing CRC screening rates will reduce CRC incidence and mortality.
This statement is based on data from many observational prospective studies and randomized clinical trials. Specifically, CRC incidence, mortality, and burden of care are significantly reduced in individuals aged 50 years and older with exposure to CRC screening procedures. Further research suggests that extending the age eligibility of CRC screening to 45 to 49 years may increase these benefits. The AGA estimated that colonoscopy-based surveillance programs can prevent up to 75% of CRC cases and up to 83% of CRC deaths. Fecal immunochemical test (FIT)-based screening programs have similar benefits.
Statement #3: Screening programs should include outreach and education programs and offer both colonoscopy and noninvasive screening options.
Offering more than 1 screening option improves participation, per data from studies on multiple screening metrics. Noninvasive options are often more acceptable to patients for multiple reasons, including scheduling, transportation, and mistrust in the medical system. Further, study data indicate that outreach/education programs can significantly increase screening uptake and improve health equity. To include as many patients as possible in screening programs, the AGA advocated for the widespread availability of FIT tests and other noninvasive options.
Statement #4: The full cost of screening should be covered by payers without cost sharing.
Cost is a significant barrier to screening participation. While the Affordable Care Act eliminated co-payments for preventative services in 2010, cost-sharing remains common for CRC screening, with an estimated 48.9% of patients with private insurance and 77.9% of patients with Medicare paying at least some portion of their screening cost. Currently, Medicare and Medicaid apply cost-sharing to the follow-up colonoscopies conducted after a positive noninvasive test. These added costs further entrench inequities in CRC outcomes, particularly along socioeconomic lines.
Statement #5: Screening with colonoscopy should be covered by payers without cost-sharing. Covered costs must include the bowel preparation, facility and professional fees, anesthesia, and pathology.
The AGA elaborated on Statement #4 by emphasizing that the colonoscopy and all associated fees should be covered by insurance payers. This includes costs associated with polyp removal, which can often incur fees related to processing in pathology. As polyp removal and assessment is an essential component of screening, the AGA wrote, it should not be subject to cost sharing. All payers’ screening programs should also implement quality metrics to assess bowel preparation level, examination completeness, and adenoma detection rate.
Statement #6: Noninvasive colorectal screening should be considered a program with multiple steps, each of which are covered by payers without cost-sharing. This includes follow-up colonoscopies, if necessary.
The success of screening programs depends on the completion of all steps. In addition to fully covering colonoscopies, payers should also cover all steps of noninvasive screening processes, including any follow-up procedures, the AGA noted.
Statement #7: The screening “continuum” should expand to include follow-up visits for patients with high-risk adenomas (HRAs) or advanced sessile serrated lesions (SSLs).
Research indicates that patients with HRAs or advanced SSLs at baseline colonoscopy are at high risk of developing CRC in subsequent years. As such, for this subset of patients, the AGA advocated for incorporating follow-up colonoscopies into the screening care continuum. Specifically, intensive surveillance colonoscopy at 3 years postbaseline can significantly reduce incidence and mortality. The AGA defines high-risk adenomas as any adenoma of 10 mm or larger or with villous histology or high-grade dysplasia. Advanced sessile serrated lesions are defined as a lesion 10 mm or larger or with cytological dysplasia or a traditional serrated adenoma.
Statement #8: Taken together, the AGA’s position statements support the implementation of a nationwide CRC screening program focused on ensuring high-quality screening and eliminating barriers to access.
The AGA seeks to establish a coalition with other stakeholders to realize this goal. While CRC screening rates have improved over the past 20 years, they still hover at 60% to 70% of age-eligible adults. These rates are far below those observed for other cancer types, such as breast and cervical cancers. Concerted efforts to improve screening accessibility will have a substantial impact on CRC prevalence and mortality in the years to come.
Disclosure: Several study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Lieberman D, Ladabaum U, Brill JV, et al. Reducing the burden of colorectal cancer: AGA position statements. Gastroenterology. Published online June 14, 2022. doi:10.1053/j.gastro.2022.05.011