Colorectal Cancer Screening

Measure Description 

Name	Description	Numerator	Denominator	Source	Reference
Colorectal Cancer Screening	Percentage of adults 50-80 years of age who had an appropriate screening for colorectal cancer	Patients in the denominator who received one or more screenings for colorectal cancer	All patients 51 to 80 years of age during the measurement year	NCQA/NQF PQRS/PCPI	National Committee for Quality Assurance

Part 1: Introduction

Part 2: Characteristics for Success: Colorectal Cancer Screening

Part 3: Implementation of Clinical Quality Measure: Colorectal Cancer Screening

Part 4: Improvement Strategies: Colorectal Cancer Screening

Part 5: Holding the Gains and Spreading Improvement

Part 6: Supporting Information

Part 1: Introduction 

Colon cancer is a common and lethal disease and the second leading cause of cancer death. ⁽¹⁾ Consider the following:

• Colorectal cancer is the third most common cancer found in men and women.⁽²⁾
• The risk of colorectal cancer begins to increase after the age of 40 years and rises sharply at the ages of 50 to 55 years; the risk doubles with each succeeding decade, and continues to rise exponentially.
• Despite advances in surgical techniques and adjuvant therapy, there has been only a modest improvement in survival for patients who present with advanced neoplasms. ^(4,5)
• One out of every three adults over the age of 65 has colon polyps – these polyps can sometimes progress to colon cancer.⁽⁶⁾

Colorectal screening procedures have an important role in preventing colorectal cancer. Screening can detect precancerous polyps and removal can be done before the polyps become cancerous. Screening also identifies cancer early in the course of the disease when treatment is more effective and the chance of recovery is higher. When screening identifies a colorectal tumor in its early stages, the cost of treatment is often much less expensive than if the tumor is detected later in the course of disease.⁽⁷⁾ Screening also has a potentially significant impact on preventing mortality and morbidity with estimates of up to 60 percent of deaths from colorectal cancer prevented if everyone age 50 and older were screened regularly and treated appropriately.(8) Eighty percent of colorectal cancer may be preventable through removal of colon polyps during endoscopic colorectal screening.⁽⁶⁾

Although colorectal cancer screening continues to yield some improvement, significant challenges remain. Screening rates for colorectal cancer lag behind other cancer screening rates, even though research shows that screening with fecal occult blood testing (FOBT), sigmoidoscopy, or colonoscopy effectively detects early-state cancer and polyps.⁽⁹⁾ Unfortunately, screening rates for colorectal cancer indicate fewer than half of men and women over age 50 are screened at the recommended intervals.⁽¹⁰⁾ Screening rates are higher in adults who are insured, better educated, non-Hispanic, or have a usual source of medical care.⁽¹¹⁾

Although the challenge is daunting, it is clear that experts do know what good colon cancer screening looks like and are continually increasing public knowledge about colon cancer screening. The scientific literature, centers of excellence in colon cancer screening, and the experience of health care organizations are consistent in pointing to common themes in screening for colon cancer. Effective primary and secondary preventive approaches must be developed to reduce the morbidity and mortality from colorectal cancer.

Measuring performance allows an organization to document how effectively care is provided and lays the foundation for improvement. 

Identifying patients aged 50 to 80 years for appropriate colon cancer screening allows an organization the opportunity to focus on systems which support appropriate preventive care in patients with average risk of colon cancer. Patients with risk factors, such as inflammatory bowel disease, prior history of polyps or colorectal cancer, and genetic predisposition, usually warrant screening for colorectal cancer at an earlier age. Consider the characteristics of a good performance measure and the Institute of Medicine (IOM) framework, Envisioning the National Healthcare Quality Report :

• Relevance: Does the performance measure relate to a frequently-occurring condition or have a great impact on patients at an organization’s facility?
• Measurability: Can the performance measure realistically and efficiently be quantified given the facility’s finite resources?
• Accuracy: Is the performance measure based on accepted guidelines or developed through formal group decision-making methods?
• Feasibility: Can the performance rate associated with the performance measure realistically be improved given the limitations of the clinical services and patient population?

To ensure that a performance measure has these characteristics, it is often based on, or aligned with, current evidence-based guidelines and proven measures.

The Colorectal Cancer Screening measure aligns with measures endorsed by the National Committee for Quality Assurance (NCQA) and similar performance metrics used by HRSA grantees and programs. The measure also aligns with those adapted by the Office of Regional Operations (ORO). Similar measures also exist in the national measure set for Healthy People 2020. [PDF | 407KB]

Clinical Quality Measure: Colorectal Cancer Screening

Measure Description 

Name	Description	Numerator	Denominator	Source	Reference
Colorectal Cancer Screening	Percentage of adults 50-80 years of age who had an appropriate screening for colorectal cancer	Patients in the denominator who received one or more screenings for colorectal cancer	All patients 51 to 80 years of age during the measurement year	NCQA/NQF PQRS/PCPI	National Committee for Quality Assurance

As with all performance measures, there are essential inclusions, exclusions, and clarifications that are required to ensure that an organization collects and reports data in the same way. This allows an organization using the measure to compare itself with others. Detailed specifications for the measure, with descriptions of inclusion and exclusion criteria, are found in the section, Part 3: Data Infrastructure: Colorectal Cancer Screening.
Improvement Experience: Colorectal Cancer Screening

As previously mentioned, the Colorectal Cancer Screening measure was chosen to align with existing national measures. The data demonstrating the experience with these measures is discussed briefly in this section.

In 2005, the Centers for Disease Control and Prevention (CDC) funded five colorectal cancer screening demonstration projects. The scope of the projects included colorectal cancer screening in adults ages 50 and older. The activities of the demonstration projects included grass roots efforts to increase awareness, screening, treatment, follow-up, and policy activation. Through these efforts, the cancer demonstration projects were able to increase the number of free colorectal cancer screenings offered; identify multiple community partners to provide secondary diagnostics and treatment, and influence State and county policy. ⁽¹²⁾

Despite some improvements over time, colorectal cancer screening rates remain low. As indicated in Figure 1.1, colorectal cancer test use has shown a slight increase, especially between the years 1987 to 1992, 1998 to 2000, and 2003 to 2005. Since 1987, colorectal cancer test use has been rising in Whites. The rise of cancer test use in Blacks was attributed to overall significant increases between the years of 1987 to 1992 and 1998 to 2000. After a large rise of cancer test use among Hispanics occurred between the years of 1987 to 1992, the trend has been stable.

In 2005, 25 percent of people aged 50 and older had a home FOBT within the past two years. This includes 18 percent of Hispanics, 24 percent of Blacks, and 26 percent of Whites. Among Asian women interviewed in California, 22 percent had a home FOBT within the past 2 years. In 2005, 50 percent of people aged 50 years and older had a colorectal endoscopy. This included 32 percent of Hispanics, 43 percent of Blacks, and 53 percent of Whites. Among Asian women interviewed in California, 53 percent had a colorectal endoscopy. In 2005, 59 percent of people aged 50 years and older had used a colorectal cancer test. This included 40 percent of Hispanics, 52 percent of Blacks, and 61 percent of Whites. Among Asian women interviewed in California, 60 percent had used a colorectal cancer test. ⁽¹³⁾

In the United States, the burden of disease is distributed unequally among the poor and ethnic minorities. This is due to no or insufficient insurance, cultural influences, previous bad experiences that lead to mistrust in the health care system, logistical barriers, such as, lack of transportation or child care services, language or cultural differences with health care providers, and limited knowledge about health care issues. Because these barriers exist, patients may not receive preventive health care services or may delay care until they are very ill. Therefore, minorities and people with low incomes tend to present to clinics with advanced-stage disease. For example, Figure 1.2 shows that Blacks had the highest incidence rate for colorectal cancer; American Indian/Alaska Natives had the second highest incidence of colorectal cancer, followed by Whites, Asian/Pacific Islanders, and Hispanics.

Incidence source: Surveillance, Epidemiology, and End Results (SEER) Program, National Cancer Institute (NCI) 1975–1991 = SEER 9; 1992–2005 = SEER 13.
*Rates are per 100,000 and are age-adjusted to the 2000 U.S. standard population (19 age groups - Census P25-1130).
†Rates for American Indians/Alaska Natives are based on the CHSDA (Contract Health Service Delivery Area) counties.
‡Hispanics are not mutually exclusive from whites, blacks, Asians/Pacific Islanders, and American Indians/Alaska Natives. Incidence data for Hispanics are based on NHIA and exclude cases from the Alaska Native Registry. ⁽¹⁴⁾

Additionally, the Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of the United States’ managed health care plans and a growing number of Preferred Provider Option (PPO) plans to measure performance on important dimensions of care and service including colorectal cancer screening. The colorectal cancer screening measure estimates the percentage of adults 50 to 80 years of age who have had appropriate screening for colorectal cancer with any of the four following tests:

• FOBT during the measurement year
• Flexible sigmoidoscopy during the measurement year or during the four years prior
• Double contrast barium enema during the measurement year or during the four years prior
• Colonoscopy during the measurement year or during the nine years prior

While screening rates show a slight improvement as indicated in Figure 1.3, the 2009 State of Healthcare Quality report, inclusive of HEDIS data, clearly reflects that if screening for colon cancer were universal, around 18,800 lives would be saved every year ⁽¹⁵⁾.

Being diagnosed at a later stage significantly decreases the five-year survival rate from 93 percent for stage I colon cancer to 8 percent for a stage IV tumor.⁽¹⁶⁾ Putting systems in place to track Colorectal Cancer Screening helps an organization to better understand how effectively it is able to provide preventive care for its patients. Systematically identifying and screening patients for colorectal cancer during the age ranges of increasing incidence will prevent cancer in many. Even for those who do develop colorectal cancer, there is a significant impact on morbidity and mortality by early detection and appropriate treatment.