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Kelly McCormick
August 31, 2021

Colorectal cancer screenings save lives by detecting cancerous and precancerous polyps in populations with the highest risk – older adults. Gastroenterologists have shaped their practices around providing colorectal cancer screenings to patients over the age of 50. However, a growing number of younger adults are developing colorectal cancer; under the old recommendations, younger patients may not be receiving the colon cancer screenings they need. To address this, the U.S. Preventive Services Task Force (USPSTF) has recently updated their guidelines on colorectal screenings to include younger patients; this change may reshape the GI landscape.

With an estimated 52,980 projected to die from the disease in 2021, colorectal cancer is the third leading cause of cancer deaths for both men and women. Clinicians most frequently diagnose the condition among patients aged 65 to 74 years. However, more than 10 percent of new cases of colorectal cancer occur in people younger than 50. Incidence of colorectal cancer, and adenocarcinoma in particular, in adults aged 40 to 49 years has jumped by nearly 15 percent from 2000-2002 to 2014-2016. While not numerically large, the increase in colorectal cancer in young adults is greatly concerning and not well understood. This is because the increase happened too quickly to be a genetic issue. While researchers work to explain the early onset, doctors and healthcare organizations are taking action to screen younger patients for this largely-preventable disease.

The number of colonoscopies is already on the rise

Analysis from iData Research found that doctors now perform 75 million endoscopies each year, and more than 19 million of these are colonoscopies. The number of colonoscopies and sigmoidoscopies has increased in the past two decades, from 28.25 percent of adults in the United States undergoing the procedure in 2000 to 61.22 percent in 2018.

Several factors are driving the growth in colonoscopy procedures, including media campaigns to increase public awareness of colorectal cancer. There is also an aging population who hopes to avoid colorectal cancer through screening. Recommendations by USPSTF are also a major driving factor, as most private insurance plans are required to cover preventive services that receive an A or B grade from the Task Force without a copay, although payors and policymakers still make final coverage decisions.

Screening age guidelines

The updates to the USPSTF guidelines on colorectal cancer screenings, which drops the recommended age for screening from 50 to 45, will also increase access to these screenings. In fact, the guideline changes will allow 15 million additional people to get the preventive colorectal cancer screening, and most will undergo this screening at no cost. It is important to note that not all payers have reduced their coverage age to reflect the guideline changes.

The updated guidelines are widely embraced by the major U.S. gastroenterology societies, including AGA, ACG and ASGE, as well as individual gastroenterologists and GI clinics due to the life-saving potential the expanded recommendation offers. However, drastically increasing the number of colonoscopies may overwhelm clinics. In particular, those already struggling to keep up with a backlog of overdue screening created by COVID-19 and the economic downturn that preceded the pandemic. The surfeit of average-risk patients needing colonoscopy will ratchet up pressure on endoscopy schedules, particularly on those clinics and institutions already struggling to meet demand. Added pressure to schedules will undoubtedly result in increased wait times, delayed diagnoses, and even decreased compliance as patients develop cold feet while waiting for their procedure.

Recommendations for Expanding Colonoscopy

Colonoscopy is often considered the “bread and butter” of a GI practice. However, too much of a good thing might choke an unprepared gastroenterology clinic. Gastroenterologists can take steps to avoid a backlog of patients.

Create or add to staff dedicated to colonoscopy

A well-rounded colonoscopy team includes staff dedicated to scheduling the procedure. It also includes those providing patient information, and managing workups, intake forms and patient records.

Implement a triage

Establishing colonoscopy triage priorities can ensure that the patients at highest risk receive screening promptly. From highest to lowest, colonoscopy triage prioritizes:

  1. Symptomatic patients with rectal bleeding and/or anemia
  2. Patients with positive FOBT
  3. Symptomatic patients with no evidence of obstruction or bleeding
  4. Patients with a family history of colorectal neoplasia
  5. Asymptomatic men and women aged 45 to 75 who have never undergone colonoscopy

Offer alternatives for patients at average risk

Clinics inundated with colonoscopy requests may benefit from developing a tiered approach to recommending colonoscopy, one that is based on assessing each patient’s individual risk for developing colorectal cancer. Some clinics may find value in screening average-risk patients with fecal immunochemical testing or stool DNA. They may choose to reserve colonoscopy for only those patients at higher risk. Others might suggest virtual CT colonography (CTC), also known as virtual colonoscopy, which the American Cancer Society has already to its list of test options for colorectal cancer screening for patients at average risk. These screening methods are not optimal because they do not allow for the removal of suspicious polyps. However, they can provide patients at average risk with the screening they need.

Identify and address factors likely to slow patient throughput

Several factors can slow throughput, which is the number of patients completing colonoscopy within a given period. Patients known to have difficulty with colonoscopy, have a history of diverticular disease or pelvic surgery or radiation, are over the age of 75 or obese, or have known comorbidities can slow throughput, for example. No shows and equipment failures can also negatively affect patient throughput.

Increasing throughput may involve scheduling patients in groups then taking patients on a first-come-first serve basis, keeping procedure times to a minimum, asking patients to send in their paperwork earlier and having ancillary staff available to process it, and calling patients to confirm appointment times and answering questions.

Beef up the business office

Not all insurance providers have adjusted their plans to reflect the updated recommendations. Therefore, some business offices could get busier trying to help patients sort out billing issues – and sort them out for themselves. Healthcare organizations are encouraging payers to update their policies quickly. However, it may take some time for insurance companies to update their policies. Adding temporary staff to the Billing & Insurance office can help GI clinics avoid a backlog of paperwork and payments.

Use a “Direct Endoscopy Referral System” for eligible patients

Direct endoscopy referral system (DERS), sometimes called “open access,” allows nurse practitioners and other care providers to medically clear and refer patients directly for colonoscopy. The DERS procedure can vary. It is dependent on whether the patient is an external referral or comes from within a hospital system. Therefore, the process may seem a little daunting at first. Most patients are eligible for direct endoscopy referral, however, so DERS can help most clinics keep the patient pipeline flowing.

As colorectal cancer continues to affect an increasingly younger population, the new USPSTF screening recommendations could potentially save thousands of lives. It could also help increase patient throughput in already-busy endoscopy suites. GI doctors that prepare for the influx of patients can grow their practices, reach more patients, and save more lives.