Workgroup V: professional education and advocacy. UICC International Workshop on Facilitating Screening for Colorectal Cancer, Oslo, Norway (29 and 30 June 2002)

P. Rozen1, M. Pignone2, M. Crespi3, D. Criblez4, S. A. El-Badawy5, R. Leicester6, S. Otto7, C. Pox8, M. Richards9, D. Smith10,*, S. Spann11, G. P. Young12 and R. Smith13

1 Tel Aviv Medical Center, Tel Aviv, Israel; 2 University of North Carolina, Chapel Hill, Chapel Hill, NC, USA; 3 UEGF-PAC, Rome, Italy; 4 Professional Organisation of Swiss Gastroenterologists, Lucerne, Switzerland; 5 National Cancer Institute, Cairo, Egypt; 6 St. George's Hospital, London, UK; 7 National Institute of Oncology, Budapest, Hungary; 8 Medizinische Universitätsklinik, Bochum, Germany; 9 St. Thomas' Hospital, London, UK; 10 American Cancer Society, Washington, DC, USA; 11 Baylor College of Medicine, Houston, TX, USA; 12 Flinders Medical Centre, Adelaide, Australia; 13 American Cancer Society, Atlanta, GA, USA

* Correspondence to: Dr R. Smith, American Cancer Society, 1599 Clifton Road NE, Atlanta, GA 30329, USA. Tel: +1-404-329-7610; Email: robert.smith{at}cancer.org


    Introduction
 Top
 Introduction
 Health professionals' roles in...
 Barriers to effective screening...
 Specific recommendations for...
 Summary of key issues
 References
 
Colorectal cancer is an important cause of morbidity and mortality throughout the developed and industrializing/westernizing world [1Go]. Etiological causes include the ‘Western’ or industrialized world lifestyle, innate genetic susceptibility and the interaction between the two. The biological progress to clinical cancer is stepwise, over a period of time. This gives us a ‘window of opportunity’ to identify and treat the precancerous adenomatous polyps or early-stage cancer, before it is beyond medical treatment (Figure 1). Strong evidence now indicates that screening for colorectal cancer can decrease colorectal cancer incidence and mortality [2Go, 3Go]. Many countries are now considering, or pilot testing, organized programs of colorectal cancer screening [4Go]. Others have begun opportunistic screening [5Go].



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Figure 1. Line A depicts the natural history of disease in the absence of a screening test. Line B depicts lead-time bias. Although the diagnosis of disease is made earlier with the screening test because of the lead time, the ultimate outcome of disease (morbidity/mortality) has not changed. Line C depicts the benefits of a good screening test. Early detection, in time, through screening, changes the outcome by preventing or postponing morbidity/mortality. Reproduced with permission from Rozen et al. [17Go].

 
Implementation of colorectal cancer screening on a broad scale requires a substantial amount of initial planning and resource allocation, including defining roles for different health professionals, identifying barriers to implementation, and providing education, training and tools to facilitate success.

The workgroup consisted of 12 members from nine countries and included primary care physicians, gastroenterologists, surgeons, oncologists, health policy makers and cancer advocates, and reports its findings as follows.


    Health professionals' roles in implementing screening
 Top
 Introduction
 Health professionals' roles in...
 Barriers to effective screening...
 Specific recommendations for...
 Summary of key issues
 References
 
Educating and training in colorectal cancer screening
This needs to be directed at several different groups including: primary care physicians, general surgeons, oncologists, gynecologists, gastroenterologists and other endoscopists; paramedical staff including nurses and clerical staff; policy makers; advocacy groups; and political leaders (Table 1).


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Table 1. Professional education and advocacy of CRC screening

 
Primary care providers. The key roles for primary care providers (and including general surgeons, oncologists and gynecologists who often are referred to for advice or are in a position to volunteer it) include: informing patients about colorectal cancer, the benefits of screening and the tests available and encouraging them to have screening; identifying high-risk patients who need special screening; integrating colorectal cancer screening with other preventive and curative care activities; and, in some cases, performing screening, keeping records of results, and assuring that follow-up tests are ordered and completed. Primary care providers should also advocate for screening with policy makers and politicians [6Go].

Gastroenterologists and gastrointestinal surgeons. Gastrointestinal specialists also have several key roles in colorectal cancer screening. They perform screening examinations and are responsible for maintaining reports of the results and ensuring that patients receive the proper follow-up care after screening examinations. Along with primary care physicians, they are responsible for recognizing high-risk patients and providing appropriate testing. They should act as advocates for screening and may also educate primary care physicians about screening [7Go].

Paramedical staff. These include the nurses and administrative staff who work with the physician promoting and/or performing screening. Nurses educate patients about the screening procedures and are often responsible for maintaining a safe, supportive and effective screening environment. In many cases, the paramedical staff also play a major role in maintaining screening databases and integrating screening with other clinical activities.

Advocacy organizations, policy makers and political leaders. These also have key roles in colorectal cancer screening. Each of these groups has responsibility for advocating for sufficient resources to be available so as to conduct screening effectively and efficiently. To do so, they must assure that insurance coverage is available for high-risk patients and balance average-risk colorectal cancer screening costs with other health and health-care needs. They must also work with health-care provider organizations to assure that high-quality care is available; this may require developing regulations or standards for screening and follow-up tests and therapy. In many countries, promotion of cancer prevention and sometimes performance of screening is done by a national anticancer society. The responsible laypersons should be actively enrolled into colon cancer screening projects and therefore need to be fully aware of screening methodologies and results of their performance.


    Barriers to effective screening and overcoming them
 Top
 Introduction
 Health professionals' roles in...
 Barriers to effective screening...
 Specific recommendations for...
 Summary of key issues
 References
 
Well-structured health systems must understand barriers to effective screening and develop strategies for overcoming them. Barriers to effective screening can be classified as those of the patient, provider or health-care system.

Patient barriers
Patient barriers (Table 2) include: a lack of knowledge or awareness about colorectal cancer or the availability of screening tests; embarrassment about screening or fear of screening with a negative attitude based on previous unpleasant experience (such as rigid sigmoidoscopy); cost of screening and/or lack of medical coverage for its performance; competing health and other demands, and the beliefs that ‘I feel fine so I don't need a test’ or a fatalistic attitude ‘I don't want to know if I have cancer since there is nothing I can do about it’.


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Table 2. Patient barriers to CRC screening

 
Provider barriers
Provider barriers (Table 3) include: an inadequate or incorrect knowledge about the benefit and performance of screening; a lack of training or experience in performing or discussing screening; the belief that patients do not want or will not accept screening; forgetting to offer screening and follow-up tests; competing demands during the office visit which often include acute medical problems and other preventive examinations or demands; and the perception that reimbursement for screening is inadequate [6Go–10Go].


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Table 3. Provider barriers to CRC screening

 
Health-care system barriers
Health-care system barriers (Table 4) include: a lack of knowledge about and performance of non-endoscopic screening using fecal occult blood testing (FOBT); a lack of easily available trained endoscopists and equipment for endoscopy; lack of health medical organization or national screening policy guidelines; unavailability of reminder and other data management systems; poor reimbursement for preventive medicine; and lack of economic or political incentives for insurers and governments to adopt screening [6Go].


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Table 4. System barriers to CRC screening

 

    Specific recommendations for promoting screening implementation
 Top
 Introduction
 Health professionals' roles in...
 Barriers to effective screening...
 Specific recommendations for...
 Summary of key issues
 References
 
Develop and disseminate structured educational programs for members of the public, providers, health-care systems and policy makers/political leaders
Effective educational programs should be directed to each of the important actors.

For members of the public, educational efforts should focus on awareness of colorectal cancer as an important health issue and the availability of effective screening methods. Members of the public should be encouraged to discuss screening with their health-care providers. Screening programs for persons without regular health-care providers may also be effective. For persons considering screening, materials should provide information on the potential benefits and adverse effects, how to prepare for screening and what constitutes appropriate follow-up care. The US Centers for Disease Control ‘Screen for Life’ campaign materials (available at www.cdc.gov), are a good example in this area. Prominent public personalities can promote screening and act as role models. For example, Pope John Paul II and Senator Hillary Rodham Clinton have agreed to be, respectively, Patron and Supporter of the International Digestive Cancer Alliance for the Worldwide Promotion of Prevention and Screening of Digestive Cancers.

Provider education should focus on skill building and overcoming barriers to successful screening. Some of the key features of educational programs are described in Table 1. An example of provider educational materials is the US Centers for Disease Control and Prevention's ‘A Call to Action Prevention and Early Detection of Colorectal Cancer’ slide set, available at www.cdc.gov. Other such educational materials have been prepared in various national languages and should be easily available and updated [4Go]. For endoscopists and clinicians, colorectal screening educational materials are now being prepared in detail for an OMED/OMGE (World Organizations of Gastroenterology and Gastrointestinal Endoscopy) website (www.gastro-pro.org).

Health-care system administrators, policy makers and politicians should receive information about the large potential benefits and favorable cost-effectiveness of colorectal cancer screening [11Go, 12Go].

Develop evidence-based standards for quality throughout the screening process
Quality standards should assure accurate preparation and development of FOBT, whether office-developed slides or central laboratory-developed tests are used [13Go] (Table 5). Accurate, safe, painless, rapid and affordable endoscopic screening should be available [14Go, 15Go]. Attaining quality requires structured training with ongoing updates and reinforcement, periodic assessment of competence and outcome audits [9Go] (Tables 6 and 7Tables 6 and 7). Videotapes on the commonly used guaiac FOBT preparation and development are available, and are also on www.gastro-pro.org [7Go]. Several endoscopy centers have developed and implemented systematic approaches to training and quality assurance, including the use of simulators for teaching [8Go–10Go, 16Go] (see also www.simbionix.com).


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Table 5. Fecal occult blood testing (FOBT) and other screening tests for CRC

 

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Table 6. Endoscopic screening: sigmoidoscopy and colonoscopy

 

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Table 7. Endoscopic screening sigmoidoscopy and colonoscopy

 
Develop and disseminate inexpensive, easy to use, data management systems
Data management systems should include the ability to record and update patient risk and demographic data, test ordered, their completion, results and follow-up examinations, and should be able to provide reminders when the next test is due [6Go]. Ideally, such systems would provide information to providers and also be accessible to the patient, especially as they may move to another medical service or provider. Maintenance of data privacy is essential so as to prevent untoward use of this information.

Advocate screening
Advocacy should be addressed by meetings and personal interaction with policy leaders and policy makers, so as to promote colorectal cancer screening in the preventive health policy and to provide adequate resources for its performance. Some nations may wish to develop a specific national screening policy that advocates use of one or more effective screening tests; others may wish to present a wider range of options that can be tailored to specific circumstances. However, it is important not to confuse the target audience with conflicting and/or too many alternative recommendations.

Promote colorectal cancer screening as part of comprehensive clinical preventive care
Preventive health visits are associated with higher rates of colorectal cancer screening. This includes screening for common disorders; physical examination, blood pressure, breast/gynecological and prostate examination; urine, blood sugar and lipids; mammography and colorectal cancer screening (for example, health care provided at some places of work [12Go]).

Currently, only about 20% of patients in the USA have a preventive care visit in each year. Increasing this rate could provide additional opportunities for screening.


    Summary of key issues
 Top
 Introduction
 Health professionals' roles in...
 Barriers to effective screening...
 Specific recommendations for...
 Summary of key issues
 References
 
In order to perform screening effectively, countries planning to implement colorectal cancer screening need to:

  1. identify roles for different types of health-care professionals;
  2. develop tools for overcoming barriers to effective colorectal screening;
  3. ensure that screening is adequately reimbursed so that the costs of the program are not prohibitive and that providers of screening do not have economic disincentives that would discourage screening;
  4. develop comprehensive quality assurance programs for individuals and centers engaged in colorectal cancer screening;
  5. make available data management and follow-up systems that are feasible for use in primary care practice and endoscopy centers; and
  6. provide training opportunities to health professionals and advocates to ensure that they have adequate knowledge and skills for screening and its promotion.


    Acknowledgements
 
Portions of this report appear in ‘Business Briefing: Global Health Care 2003’, published by Business Briefings Ltd (BBL), London, UK.


    References
 Top
 Introduction
 Health professionals' roles in...
 Barriers to effective screening...
 Specific recommendations for...
 Summary of key issues
 References
 
1. Spann S, Rozen P, Levin B, Young G. Colorectal cancer: How big is the problem, why prevent it and how might it present? In Rozen P, Young G, Levin B, Spann S (eds): Colorectal Cancer in Clinical Practice: Prevention, Early Detection and Management. London: Martin Dunitz 2002; 1–13.

2. Pignone M, Rich M, Berg A et al. Screening for colorectal cancer: systematic review for the US Preventive Services Task Force. Ann Intern Med 2002; 137: 132–141.[Abstract/Free Full Text]

3. Smith RA, Cokkinides V, von Eschenbach AC et al. American Cancer Society guidelines for the early detection of cancer. CA Cancer J Clin 2002; 52: 8–22.[Abstract/Free Full Text]

4. Rozen P, Winawer SJ, Waye JD. Prospects for the worldwide control of colorectal cancer through screening. Gastrointest Endosc 2002; 55: 755–759.[CrossRef][ISI][Medline]

5. Centers for Disease Control and Prevention. Colorectal cancer test use among persons >50 years–United States, 2001, 52. MMWR 2003; 193–196.

6. Spann S, Rozen P, Levin B, Young G. The pros and cons of population-based colorectal cancer preventive strategies. In Rozen P, Young G, Levin B, Spann S (eds): Colorectal Cancer in Clinical Practice: Prevention Early Detection and Management. London: Martin Dunitz 2002; 115–129.

7. Young G, Rozen P, Levin B. How should we screen for early colorectal neoplasia? In Rozen P, Young G, Levin B, Spann S (eds): Colorectal Cancer in Clinical Practice: Prevention, Early Detection and Management. London: Martin Dunitz 2002; 77–99.

8. Rex DK, Bond JH, Winawer S et al. U.S. Multi-Society Task Force on colorectal cancer. Am J Gastroenterol 2002; 97: 1296–1308.[CrossRef][ISI][Medline]

9. Waye JD, Leicester RJ. Teaching endoscopy in the new millennium. Gastrointest Endosc 2001; 54: 671–673.[CrossRef][ISI][Medline]

10. Schroy PC 3rd, Heeren T, Bliss CM et al. On-site screening sigmoidoscopy promotes long-term utilization but fails as a venue for training primary care endoscopists. Gastroenterology 2002; 122: 1226–1234.[CrossRef][ISI][Medline]

11. Pignone M, Saha S, Hoerger T, Mandelblatt J. Cost-effectiveness analyses of colorectal cancer screening: A systematic review for the US Preventive Services Tasks Force. Ann Intern Med 2002; 137: 96–104.[Abstract/Free Full Text]

12. Tatsumi Y, Nishida H, Rozen P. An occupational GI cancer-screening program. Gastrointest Endosc 2001; 54: 801–803.[CrossRef][ISI][Medline]

13. Young GP, St John DJ, Winawer SJ, Rozen P. Choice of fecal occult blood tests for screening: recommendations based on performance characteristics in population studies: a WHO (World Health Organization) and OMED (World Organization for Digestive Endoscopy) report. Am J Gastroenterol 2002; 97: 2499–2507.[CrossRef][ISI][Medline]

14. Larsen IK, Grotmol T, Bretthauer M et al. Continuous evaluation of patient satisfaction in endoscopy centres. Scand J Gastroenterol 2002; 7: 850–855.

15. Bretthauer M, Hoff G, Thiis-Evensen E et al. Carbon dioxide insufflation reduces discomfort due to flexible sigmoidoscopy in colorectal cancer screening. Scand J Gastroenterol 2002; 37: 1103–1107.[CrossRef][ISI][Medline]

16. Sedlack RE, Kolars JC. Validation of a computer-based colonoscopy simulator. Gastrointest Endosc 2003; 57: 214–218.[ISI][Medline]

17. Rozen P, Young G, Levin B, Spann S (eds). Colorectal Cancer in Clinical Practice: Prevention Early Detection and Management. London: Martin Dunitz 2002.





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