Friday, February 28, 2014

Engaging patients in screening for colon cancer

Colon cancer runs in families. If you have a relative with colon cancer, your chances of getting the disease are markedly higher than if you don't. The good news is that if you get a screening test periodically, the disease can be found early, treated relatively easily, and you can go about your business. The bad news is that we don't do enough screening, especially of first-degree relatives and especially in rural areas where the long drive to colonoscopy is a barrier.
Anita Kinney, a nurse and epidemiologist in Utah, led a teem of researchers from five states in testing whether telephone outreach could get more high-risk patients screened. They found patients at elevated risk of cancer by recruiting the relatives of diagnosed patients. They either got a mailed brochure or a 40 minute telephone call with a genetic counselor plus a follow-up letter (with a copy to their primary provider). This was a carefully designed and executed randomized controlled trial with 481 subjects, so the improvement in colonoscopy from 16% to 25% is not only statistically significant (P<0.001), but unlikely due to bias or confounding. Interestingly, the effect of the telephone intervention was about the same in rural, urban, high income, and low income groups.
Although this is an impressive and clinically important effect, this intervention is a bit costly. The authors don't provide details, but these counselors are highly-trained and sophisticated providers and it takes a lot of their time to handle each case. I have to agree with the authors that this intervention should probably be part of a stepped strategy with the genetic counseling reserved for those who don't get screened after less expensive methods are tried first, especially since they had such a nice response from their brochure.
Now the challenge will be how to integrate this proven intervention into an ongoing delivery model, and that means, an ongoing business model. Who will pay for the outreach and the colonoscopy, especially if the index patient has different coverage than their relatives?

Kinney AY, Boonyasiriwat W, Walters ST, Pappas LM, Stroup AM, Schwartz MD, Edwards SL, Rogers A, Kohlmann WK, Boucher KM, Vernon SW, Simmons RG, Lowery JT, Flores K, Wiggins CL, Hill DA, Burt RW, Williams MS, Higginbotham JC. Telehealth Personalized Cancer Risk Communication to Motivate Colonoscopy in Relatives of Patients WithColorectal Cancer: The Family CARE Randomized Controlled Trial. J Clin Oncol. 2014 Mar 1;32(7):654-62. doi: 10.1200/JCO.2013.51.6765. Epub 2014 Jan 21.

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