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. 

Summary Report on Links of Care Pilot to Increase Colorectal Cancer Screening for Underserved Patients

The newly released report, Report on a Pilot Project to Increase Colorectal Cancer Screening Rates and Ensure Access to Specialty Care for Underserved Patients, provides an overview of the Links of Care pilot project (2015-2017), which implemented evidence-based strategies to increase screening rates and timely access to specialists after abnormal screenings in three Federally Qualified Health Centers (FQHCs). Participating FQHCs successfully increased CRC screening rates by 8-28 percentage points, secured low- or no-cost colonoscopies from specialty care providers, and implemented patient navigation to ensure timely follow-up to diagnostic services. The report outlines key facilitators to success.

Congratulations to the evaluators and authors that contributed to this publication, Lesley Watson, Kara Riehman, Mary Doroshenk, Rentonia Williams, Vonda Evans, Lynn Basilio, Maryanne Goss, and Roshan Paudel, as well as the numerous individuals that contributed to the pilot projects’ success.

The NCCRT Resources Center also includes two webinars that feature findings from the Links of Care pilot projects, including a 2017 webinar and a 2015 webinar

Please email caleb.levell@cancer.org for a print-ready version. 

Beyond Thankful: 80% by 2018

Our story of audacity, commitment, and unity

The 80% by 2018 Beyond Thankful report tells the story of our collective ambition, commitment, and unity during the course of this campaign. We hope it not only inspires a sense of accomplishment, but also expresses our absolute gratitude for the enthusiasm, innovation, and hard work that you put into making this campaign a success. The 80% by 2018 effort brought out the best in us and we have no intention of letting this spirit of goodwill fade as we launch 80% in Every Community

Thank you to the NCCRT Steering Committee, the Public Awareness and Social Media Task Group, and the project advisory group that oversaw the development of this report. Advisory group members included: Dennis Ahnen, April Barry, Durado Brooks, Anne Carlson, Paige Cucchi, Brian Davis, David Greenwald, Laura Habighorst, Nikki Hayes, Steven Itzkowitz, Kinetra Joseph, Dorothy Lane, Michael Potter, Marta Sanchez, Paul Schroy, Robert Smith, and Andrew Wortmann. Finally, a special thank you to 1000 Feathers for leading the design, development, and editing of the report. 

Cancer Center Summit:  A Strategic Look at Cancer Centers and Colorectal Cancer Screening – October 2, 2017

On October 2nd, 2017, in Washington, DC, the American Cancer Society (ACS) and the National Colorectal Cancer Roundtable (NCCRT) hosted a Cancer Center Summit: A Strategic Look at Cancer Centers and Colorectal Cancer Screening. The purpose of the meeting was to convene representatives from key national and local organizations, including leaders from the National Cancer Institute (NCI), the Centers for Disease Control and Prevention (CDC), and several NCI-designated cancer centers to explore how to leverage the expertise and community presence of cancer centers in the effort to increase CRC screening rates.  The meeting sought to understand cancer center barriers to focusing on CRC screening as a priority issue; identify strategies to overcome barriers so that cancer centers can leverage their role in the community to achieve higher CRC screening rates; and begin the process of developing a strategic plan to spur cancer center action in this area.  The summary meeting report, which includes case studies of NCI-designated Cancer Centers that excel in advancing CRC screening efforts, is attached. 

This report was only made possible by the work of numerous individuals. Many thanks to the meeting co-chairs, Robert Croyle, Richard Wender, and Lisa Richardson, for their leadership and guidance; to the meeting presenters/facilitators, Ernest Hawk, Electra Paskett, Karen Kim, Robin Vanderpool, Ronald Myers, Lynn Butterly, Caleb Levell, Mary Doroshenk, Katie Bathje, Ken Lin Tai, Suzanne Lagarde, Holly Guerrero, LeeAnn Bailey, Cindy Vinson, Sarah Shafir, and Michael Potter, who each reviewed their individual sections for accuracy; and to Michael Potter, Dorothy Lane, Electra Paskett, Ernest Hawk, and Todd Lucas for their review and edit of the full report.

Meeting Report: Increasing Colorectal Cancer Screening for American Indians and Alaska Natives

This post meeting report summarizes the presentations, discussions, and strategic planning that took place during the American Cancer Society and NCCRT co-sponsored meeting to discuss increasing colorectal cancer screening in American Indian and Alaska Native (AI/AN) communities that took place on April 25th, 2016 in Traverse City, Michigan. The report provides an overview of the burden of colorectal cancer among AI/AN, summarizes meeting presentations and discussions, and presents the participants’ collaborative “framework for change” tool that identifies goals, priority tactics, barriers, and potential communities of solution and roles.

Learn more by viewing the webinar replay and slide deck from the November 28, 2017 webinar that explored the opportunities and barriers related to delivering quality colorectal cancer screening and follow-up care in health care settings serving AI/AN communities.

Colorectal Cancer Initiatives in Medicaid Agencies – A National Review

Screening rates vary by population and geography; however, one segment known to be less likely screened for colorectal cancer (CRC) is the Medicaid population. Due to the Patient Protection and Affordable Care Act (ACA), many states have expanded their Medicaid program to individuals under age 65 who are under 138% of the federal poverty level. This expansion is increasing the number of individuals eligible for Medicaid who fall within the recommended guidelines for CRC screening, and thus providing a significant opportunity to improve CRC screening rates in participating states. Some states that did not officially expand Medicaid also have begun offering CRC screening to more uninsured and low income individuals.

The NCCRT Policy Action Task Group worked with a researcher at George Washington University to conduct a state by state assessment of CRC control activity among Medicaid programs. The report found a wide range of CRC control activity among Medicaid agencies, ranging from no activity to ten states with “Extensive” CRC activity, including data collection, partnership, measurement and tracking, and implementation of evidence-based interventions.

Study on Medicaid Expansion and Access

A study released by the American Cancer Society Cancer Action Network (ACS CAN) and the NCCRT estimates that in 2017 over 2.7 million low-income men and women aged 50-64 will remain uninsured and continue to lack access to an affordable health care coverage option, including colorectal cancer screening services.

The report, Health Reform and the Implications for Cancer Screening, provides national and state-specific estimates of the number of uninsured men and women in 2017 based on three scenarios: Medicaid expansion decisions as of April 2015, no state Medicaid expansions, and if all states expand Medicaid. Read the ACS CAN report summary.

Many thanks to our partners at ACS CAN for developing the report, and to NCCRT’s Policy Action Task Group members Barry Berger, Joel Brill, Heather Dacus and Holly Wolf for generously sharing their expertise in the review process.

Improving Northern Plains American Indian Colorectal Cancer Screening (INPACS) Report

The American Indian Cancer Foundation’s Improving Northern Plains American Indian Colorectal Cancer Screening (INPACS) project recruited 54 Indian Health Services (IHS), tribal health, and urban health clinics within MN, WI, ND, SD, NE, MT, and WY to better understand successes and challenges for colorectal cancer screening and to collaboratively develop strategies to improve cancer screening rates.

About 96,000 American Indians between ages 50 and 74 reside in the Northern Plains, where the incidence of colorectal cancer is 53% higher for American Indians compared to non-Hispanic Whites. Although rates are improving, less than half of Northern Plain American Indians ages 50 years and older are up to date with colorectal cancer screening.

Data for this report was collected by INPACS staff during visits to each participating site. Multiple components of the project comprehensively assessed quality assurance measures at both the provider-level and the systems-level such as colorectal cancer policies and clinic systems for provider and patient reminders.

A clear, overarching finding of this project is that system-level strategies are needed to impact colorectal cancer screening rates in clinics across Indian Country. A provider who recommends screening is the most influential factor in patients completing colorectal cancer screening. The report also discusses clinic policies on screening, clinic reminder systems, communication systems, highlights from provider discussions, and lessons learned from the INPACS project.

Evaluation: The INPACS project used surveys and one-on-one discussions to assess clinic colorectal cancer screening practices. The project focused on evaluating the use of evidence-based practices, such as patient and provider reminders, described in in NCCRT’s “How to Increase Colorectal Cancer Screening Rates in Practice: A Primary Care Clinician’s Evidence-Based Toolbox & Guide.”

Permissions: Made publicly available online through the American Indian Cancer Foundation.

Publication date: May 2013

Post date: October 2, 2017

Contact: Send comments, questions, and suggestions to Anne Walaszek at awalaszek@aicaf.org or info@aicaf.org.

Report on Use of Electronic Medical Records to Facilitate Colorectal Cancer Screening in Community Health Centers

The NCCRT joined with the American Cancer Society and the National Association of Community Health Centers to issue a report entitled, “Use of Electronic Medical Records to Facilitate Colorectal Cancer Screening in Community Health Centers.”  The purpose of this study was to gather insights from individuals who use electronic medical records (EMRs) in community health centers about the use of EMRs to facilitate colorectal cancer screening, including for those with a family history of the disease. To meet this goal, the NCCRT commissioned Aeffect Inc. to conduct a series of qualitative interviews with clinicians and technical staff in community health centers (CHCs) across the country. This report provides important recommendations about the barriers, opportunities, and next steps needed to enhance effective use of EMRs in community health centers.

Coverage of Medicaid Preventive Services for Adults – A National Review

The NCCRT partnered with ACS CAN and the American Heart Association to commission researchers at George Washington University to determine state by state Medicaid coverage around USPSTF-recommended preventive services, including colorectal cancer screening.

While some research has been published examining Medicaid coverage of select preventive services, there has not been a comprehensive look at state-level Medicaid coverage of preventive services for adults. This study is intended to provide a better understanding of Medicaid coverage of preventive services for adults in the current state programs and inform state policy makers as they consider the level of preventive benefits and services to offer should they expand Medicaid in 2014.

The report was also the basis of a Health Affairs article that was published in July of 2013.  The article abstract can be accessed here.