Colorectal cancer (CRC) screening is recommended to start at age 50 for most average risk individuals but may begin earlier if a provider sees increased risk factors present. There are multiple methods for screening and these vary greatly in invasiveness. Visual examinations with high sensitivity can be done at a healthcare facility including colonoscopy, CT, barium enema and sigmoidoscopy; colonoscopy is generally accepted as the screening method of choice for individuals at higher risk of CRC. Lower sensitivity, non-invasive stool testing can be done in a clinical laboratory with one non-invasive test that can be completed in the comfort of the patient’s home. Two lower sensitivity tests, fecal immunochemical test (FIT) and high-sensitivity guaiac-based fecal occult blood test (gFOBT), are done annually and require multiple stool samples be brought to the provider or laboratory. Some recently published literature indicates that FIT analysis shows higher sensitivity than gFOBT and also requires fewer samples than gFOBT. The last non-invasive stool test available is called a fecal immunochemical DNA test done at home. The stool sample is collected at home and the patient can directly mail the completed kit to the assigned laboratory. Each of the visual examinations are examining the colon and rectum for concerning polyps which may develop into cancerous lesions. The basis for the non-invasive testing is analysis of stool samples for the presence of blood. Polyps can bleed into the intestine which can be undetectable to the naked eye but present when analyzed with testing designed to detect those trace amounts of hidden blood.
One of the struggles with screening for CRC is the general unease with the process of screening and possible embarrassment of the more invasive procedures. However, CRC progression is unique because of the ability of current medicine to detect the presence of polyps before cancerous growth develops. According to the National Cancer Society Colorectal Cancer Facts & Figures for 2017-2019, it is estimated that nearly 100,000 new cases of colon cancer and nearly 40,000 new cases of rectal cancer will be diagnosed in the United States alone. 50,000+ individuals in the US reportedly die of CRC annually. Age increases the risk of CRC development which is why screening is recommended at age 50. There have been reductions in CRC incidences over time in part due to altering behaviors associated with CRC risk (e.g. decrease in smoking) and a progressive uptick in screening rates.
In a new study published in the Annals of Internal Medicine, one group created a digital intervention for CRC screening promotion and patient engagement in their health. The intervention was a developed application for apple mobile devices (iPad) that allowed patients to evaluate a CRC screening decision tree, order their own screening tests, and provided follow up messages to the patient. One of the authors, Dr. Murphy, noted, “Giving patients a choice of screening tests is important. Not just in personal preference but also for financial reasons or time constraints required for more invasive screening tests”. Positive results on non-invasive screening test options indicates the need for a colonoscopy to follow up. Generally, colonoscopy is recommended for all patients needing screening rather than some of the less invasive testing options and the authors noted that this could be harmful if patients cannot afford the more expensive visual screening methods. Patients may believe that they simply cannot be screened if not given an option of a non-invasive stool test. The results showed that of the patients assigned to the digital intervention group, 30% completed a screening test compared to 15% of the control group. Of note, there were multiple patients within the intervention group that had positive screening tests and went on to have a follow up colonoscopy.
While this topic deserves additional research and investigation, the goal was explore novel avenues to get more patients to utilize CRC screening in order to: first, identify early stages of CRC in more patients as a result of screening; and two, decrease the number of people diagnosed with CRC by increasing engagement and compliance with CRC screening through the use of an iPad app.
Sources: Annals of Internal Medicine, National Cancer Institute, U.S. Preventive Services, National Cancer Society CRC Figures, Clinical Gastroenterology and Hepatology
