Reigniting Colorectal Cancer Screening as Communities Face and Respond to the COVID-19 Pandemic: A Playbook

This resource provides an action-oriented playbook to be adopted throughout the COVID-19 pandemic and aims to align NCCRT members, 80% pledged partners, and colorectal cancer screening advocates across the nation to work together to reignite our screening efforts appropriately, safely, and equally for all communities.

The COVID-19 pandemic has challenged efforts to address inadequate screening and inequities in colorectal cancer outcomes, hindering the progress toward our 80% in Every Community goals. In the early stages of the COVID-19 pandemic, leading agencies, such as the Centers for Medicare & Medicaid Services (CMS) and the American Cancer Society, made recommendations to delay all non-urgent procedures. Colonoscopies to detect colorectal cancer have been delayed or cancelled and patient fears about contracting COVID-19 have led to further reductions in screening. This drop has raised concern that COVID-19 related screening delays will lead to missed and advanced stage colorectal cancer diagnoses and to excess deaths from colorectal cancer. Moreover, this burden will likely not be evenly distributed as screening disparities may be exacerbated in communities and populations that are disadvantaged by both old and new challenges in the COVID-19 era.

The colorectal cancer fighting community stands prepared and well-positioned to respond to and overcome the difficult task ahead, and this document offers the latest (as of June 2020) data, research, and clinical guidelines available related to colorectal cancer screening and COVID-19. 

Aligning Statements include: 

  1. Despite the challenges we face during the pandemic, colorectal cancer remains a public health priority, and we must provide the public with safe opportunities to prevent and detect colorectal polyps and cancer.
  2. Colonoscopy remains safe, is a good option for screening, and is quickly reopening around the country, but identifying patients who should receive higher priority for colonoscopic screening is a critical step.
  3. During a time when availability of elective screening colonoscopy may be limited by the COVID-19 pandemic, colorectal cancer screening can be safely offered through at-home stool-based tests.
  4. Gaining momentum and reigniting screening activities and public messaging will be highly dependent upon local regulatory requirements, public health priorities, and policy change.

Throughout the pandemic, individuals have options to screen for colorectal cancer. There are many safe, effective, and evidence-based screening tests available, including colonoscopy and non-colonoscopy options (e.g., stool-based tests, stool-DNA tests, and CT colonography). In addition to the information included in the Playbook specific to stool-based testing and colonoscopy, CT colonography also serves as an important option for patients. Learn more in an editorial published in Abdominal Radiology (July 2020), “CT Colonography’s role in the COVID-19 pandemic: a safe(r), socially distanced total colon examination.” 

We gratefully acknowledge the contributions of the following individuals and organizations. Thank you to our authors Durado Brooks, Rachel Issaka, Steven Itzkowitz, Michael Sapienza, Ma Somsouk, Richard Wender, Caleb Levell, and Emily Bell. We also extend a special note of gratitude to our committed partners, NCCRT Steering Committee members, and subject matter experts that have contributed to both reviewing and advising on this document, but also for their participation in ongoing discussions aimed at uniting and guiding the colorectal cancer community throughout the COVID-19 pandemic. And finally, we recognize the efforts of the Colorectal Cancer Alliance to provide support, in-kind staff, and continued commitment in coordinating a national response to improving colorectal cancer screening rates during the COVID-19 era. 

Clinician’s Reference: Stool-Based Tests for Colorectal Cancer Screening

This newly revised resource is designed to introduce (or reintroduce) clinicians to the value of stool-based testing for colorectal cancer. It explains the different types of stool-based tests available—Fecal Immunochemical Tests (FIT), High-Sensitivity Fecal Occult Blood Tests (HS-gFOBT) and FIT-DNA testing—and provides guidance on implementing high quality stool-based screening programs. The resource now includes information on sensitivity and specificity for many of the most commonly used tests.

We would like to thank the following individuals, many from the NCCRT Professional Education and Practice Implementation Task Group, for reviewing past and current versions of this resource and contributing to this work: James Allison, Kim Andrews, Barry Berger, Durado Brooks, Gloria Coronado, Debbie Kirkland, Theodore Levin, Dorothy Lane, Laura Makaroff, Marion Nadel, Kerstin Ohlander, Mike Potter, Robert Smith, and Richard Wender. We’d also like to thank the Comprehensive Cancer Control Program National Partners for providing funding support.

Colorectal Cancer Screening: Recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer

The US Multi-Society Task Force on Colorectal Cancer Screening, comprised of representatives from the American Society for Gastrointestinal Endoscopy, American College of Gastroenterology and American Gastroenterological Association, develops recommendations for the prevention and early detection of colorectal cancer. Recommendations are based on scientific evidence, practical considerations, and cost.
The latest set of recommendations, summarized in this press release, recommends screening begin at age 50 for average risk individuals, with screening starting at age 45 for African-Americans. The recommendations rank screening tests into three “tiers” according to the strength of the recommendation. The recommendations also provide guidance for screening individuals with a family history of the disease.

The press release links to joint publications of these recommendations in GastroenterologyThe American Journal of Gastroenterology and GIE: Gastrointestinal Endoscopy.

Evaluation: The US Multi-Society Task Force is made up of representatives from the American Society for Gastrointestinal Endoscopy, the American College of Gastroenterology, and the American Gastroenterological Association. Recommendations for screening are re-evaluated periodically as new evidence emerges and as shifts occur in health care delivery and access.

Permissions: Made publicly available online by the American Society for Gastrointestinal Endoscopy.

Publication date: June 2017

Post date: September 15, 2017

Contact: Follow instructions in the press release to reach out to media contacts at each of the three societies.

What Can Primary Care Physicians Do To Advance 80% By 2018?

Learn how primary care physicians can be part of the national effort to make sure 80% of adults ages 50 and older are regularly screened for colorectal cancer by 2018.

Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement

The US Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for people at average risk and with no signs or symptoms of the specific disease or condition under evaluation. Recommendations are assigned a letter grade (A, B, C, or D grade or I statement) based on the strength of the evidence and the balance of benefits and harms of a preventive service. Costs of services are not considered in the evaluation.

In 2016, the USPSTF released a new “A” grade Final Recommendation Statement for colorectal cancer screening, which recommends screening for colorectal cancer starting at age 50 and continuing until age 75 years with one of several screening strategies. One of the primary differences from the 2008 recommendation is the addition of computed tomography (CT) colonography and multitargeted stool DNA (FIT-DNA) to the list of screening strategies.

Evaluation: The USPSTF is comprised of volunteer members who are nationally recognized experts in prevention, evidence-based medicine, and primary care. The USPSTF bases its recommendations on the strength of the evidence and the balance of benefits and harms of a preventive service. This recommendation statement was also published in the peer-reviewed journal JAMA.

Permissions: Made publicly available online by the US Preventive Services Task Force.

Publication date: June 2016

Post date: September 15, 2017

Contact: Submit comments, questions, and suggestions via web form.

The Importance of Waiving Cost-sharing for Follow-up Colonoscopies: Action Steps for Health Plans

The Affordable Care Act (ACA) eliminates cost-sharing for United States Preventive Services Task Force (USPSTF) – recommended preventative services for individuals who are privately insured, including screening for colorectal cancer by high sensitivity stool test or colonoscopy for adults ages 50 and 75.* Some health plans, however, apply cost-sharing to colonoscopies that follow a positive stool test. This creates a financial incentive for patients to select the more costly and invasive colonoscopy as their initial test. Additionally, this cost-sharing creates a financial disincentive that may lead patients to forego the follow-up test that they need.

This Issue Brief gives an overview of this issue and makes a request to health plans to waive cost-sharing for members when colonoscopy is ordered as follow-up to a positive stool test or other colorectal cancer screening test, just as cost-sharing is waived for colonoscopy when it is selected as the first-line screening exam.

Learn more in Colorectal Cancer Screening Best Practices Handbook for Health Plans, a compilation of best practices, case studies, templates and tools.

*The ACA preventive services requirements do not apply to “grandfathered” health plans that were in existence prior to March 23, 2010, as long as such plans continue to meet certain standards for grandfathered plans.

Strategy Paper on Expanding Colorectal Cancer Screening at Community Health Centers

The NCCRT issued a strategy paper entitled, “Strategies for expanding colorectal cancer screening at community health centers ,” which has been published in CA: A Cancer Journal for Clinicians.  The Strategy Paper emerged from the Summit on Increasing Colorectal Cancer Screening in the Community Health Center setting that the NCCRT hosted in June 2013.

How to Increase Colorectal Cancer Screening Rates in Practice: A Primary Care Clinician’s  Evidenced-Based Toolbox and Guide

The CRC Clinician’s Guide and slide set is a practical guide for primary care clinicians containing evidenced-based tools, sample templates and strategies that can help practices improve their screening performance. A printable slide set is available for download. For PowerPoint version please contact us.

An interactive, online version of CRC Clinician’s Guide has been launched to offer an interactive, web-based version of the CRC Evidence Based Toolkit and Guide that can walk physicians through the contents of the Guide in an interactive, online format. Also available is a CA Journal article, “How to Increase Colorectal Cancer Screening Rates in Practice,” which provides a quick overview of the evidence in the Guide, and a CRC Clinician’s Guide brochure, which is a quick one-page overview of the Guide that can be emailed or downloaded and printed.

Colorectal Cancer Screening Clinician’s Guide: Cancer Screening Action Plan. This shorter version of the Colorectal Cancer Screening Clinician’s Toolbox and Guide was designed for busy clinicians after collecting extensive feedback from physicians on the original Guide. The most important material from the full Guide was condensed into a step by step tool that still offers an expansive collection of the most relevant charts, templates and sample materials that clinicians can put to use.

To access this new tool click here.

Options for Increasing Colorectal Cancer Screening Rates in Community Health Centers. In addition, researchers from the University of North Carolina Lineberger Comprehensive Cancer Center, have recently adapted the CRC Clinician’s Guide for use in the Community Health Center setting.

To access this specialized tool click here.

American Cancer Society Recommendations for Colorectal Cancer Early Detection

The American Cancer Society creates guidelines for the prevention and early detection of  cancer, including colorectal cancer, as well as guidelines for screening and surveillance for individuals at increased or high risk of the disease.

The ACS’s 2008 recommendations were issued in a joint guideline, Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. They recommend adults at average risk for the disease begin screening starting at age 50 with a menu of screening options. The recommendations provide benefits and limitations associated with each test to aid in making an informed decision. The webpage also includes additional links to tools and resources for patients and clinicians.

Evaluation: The guidelines were developed in collaboration with experts from the American Cancer Society, the US Multi Society Task Force on Colorectal Cancer, and the American College of Radiology. Learn more in the Guidelines Development, Methods, And Framework section of the joint guideline. This recommendation statement was also published in the peer-reviewed journal CA: A Cancer Journal for Clinicians.

Permissions: Made publicly available online by the American Cancer Society.

Publication date: 2008

Post date: September 15, 2017

Contact: Submit comments, questions, and suggestions via web form.