Spotlight: Colorectal Cancer Research in HSR&D

March 2014

According to the American Cancer Society (ACS), colorectal cancer (CRC)—cancer in the colon or the rectum—is the third most common cancer diagnosed in the United States, and the second-leading cause of cancer-related mortality.¹ However, when detected early, it is also one of the most treatable cancers.

Within VA, screening Veterans for CRC is a priority. The methods VA providers use to conduct CRC screenings include:

• A fecal occult blood test (FOBT). This test detects blood that is not visible in a stool sample.
• A flexible sigmoidoscopy examination (FS). This procedure allows physicians to visually inspect the interior walls of the rectum and the lower part of the colon using a thin, flexible, lighted tube called a sigmoidoscope.
• A colonoscopy. This procedure allows physicians to visually inspect the interior walls of the rectum and the entire colon using a thin, flexible, lighted tube called a colonoscope.
• A double-contrast barium enema (DCBE). In this procedure, x-rays of the colon and rectum are taken after air—and liquid containing barium—are put into the rectum. The barium compound helps an outline of the colon and rectum show up on an x-ray.

Risk and Screening Schedules

As with many screening and preventive tests, VA providers review a variety of factors to determine a Veteran's risk for CRC, and develop the appropriate screening schedule based on that risk. VA defines CRC risk in two ways—average risk and high risk. Average risk is considered being over age 50, and high risk is considered having a family history of CRC in first-degree relatives (parent, sibling, or child), and those with a personal history of polyps or inflammatory bowel disease. ²

• For Veterans at average risk for CRC, the screening options include:
• Home FOBT test alone every year,
• Flexible sigmoidoscopy alone every 5 years,
• Home FOBT every year combined with FS every 5 years,
• DCBE every 5 years, and
• Colonoscopy alone every 10 years.

However, for Veterans at high risk for CRC, screening methods and frequency may vary as determined by a patient's primary care provider, but can include a colonoscopy as early as age 40. ³

To support VA's CRC prevention and treatment goals, investigators within VA's Health Services Research & Development (HSR&D) Service conduct research that contributes to quality improvement, delivery of care, and access to services. Some of these studies include:

• Automated Point of-Care Surveillance of Outpatient Delays in Cancer Diagnosis . This study, scheduled to conclude in 2017, is part of the VA HSR&D Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) initiative, "Improving Quality and Safety through Better Communication in PACTs." Investigators will evaluate the accuracy of a "real-time" automated surveillance system to identify Veterans at risk for missed or delayed cancer diagnosis, including colorectal cancer, within the VA's Patient Aligned Care Teams (PACTs). Investigators will build on previous work and will develop and test an innovative, automated surveillance intervention to improve timely diagnosis and follow-up of five common cancers in primary care practice (colorectal, prostate, lung, hepatocellular, and breast). The study will include facilities within Veterans Integrated Service Network (VISN) 12, and has three specific aims: 1) Develop and test algorithms to "trigger" those patient records that lack a documented follow-up action after pre-defined diagnostic clues for cancer; 2) Conduct interviews, analysis, and usability testing to ensure that the intervention fits in with real-world clinical practice; and 3) Conduct a randomized controlled trial with VISN 12 PACTs to compare the intervention with usual care. Study outcomes will focus on the average number of days from diagnostic clue to follow-up action (e.g., time to colonoscopy after a positive hemoccult), as well as the proportion of Veterans receiving appropriate and timely follow-up care.

• Home-Based Colorectal Cancer Screening Significantly Improves Screening Rates among Overdue Veterans in a Rural State .The overall colorectal cancer (CRC) screening rate among VA healthcare users is high (80%) when compared to the non-VA population (63%), yet one in five VA healthcare users remains unscreened. Previous research has suggested that a variety of challenges including rural residency and distance from a VA clinic are barriers to screening. Fecal occult blood tests (FOBTs) are often referred to as "at-home tests" because they are typically sent home with a patient and returned by mail. The fecal immunochemical test (FIT) is a type of FOBT that has superior sensitivity/specificity and better compliance because only one sample is required as opposed to three for traditional FOBT. In this study, investigators sought to determine whether a simple one-step mailing of a FIT accompanied by educational materials would improve screening rates in Veterans who were overdue (n=500) compared to Veterans who received educational materials only (n=499), and to Veterans in a usual care group (n=500) who received no mailings.

Findings show that mailing FITs and educational materials to Veterans overdue for CRC screening resulted in significantly higher screening rates than usual care or educational materials alone. At six months, 21% of Veterans in the FIT group had received CRC screening by any method compared to 6% in the educational materials-only group and 6% in the usual care group. Among respondents eligible for FIT, 90% completed and returned a FIT. Further, investigators learned that the most frequently reported reasons for not having a colonoscopy included: concerns about pain (39%); the procedure was not recommended by a provider (37%); confusion about screening options (35%); and preference for at-home testing (34%). The overwhelming reason for not having at-home testing was because providers did not recommend it (62%).

Improving Colonoscopy Quality through Education. Although there are several approaches to colorectal cancer screening (CRC), colonoscopy is the only test that allows for the identification and removal of polyps from the entire colon. A successful colonoscopy requires that patients effectively evacuate their bowels through a combination of dietary restrictions and the use of medications; however, inadequate bowel preparation is common and is linked to poor colonoscopy results. Completed in 2012, investigators at the West Los Angeles VA Medical (WLAVA) Center and the Durham VA (DVA) conducted a three-phase study: Phase 1 focused on developing the educational booklet on colonoscopy preparation; Phase II involved a randomized controlled trial that compared Veterans who received the booklet to Veterans who received usual care, with the main outcome being the quality of bowel preparation at the time of colonoscopy; and Phase III repeated the trial across two Veteran populations (WLAVA and DVA). Study results showed that Veterans who received the booklet had significantly improved bowel preparation quality vs. Veterans who received usual care.

The study has had wide impact and has resulted in the distribution of the booklet to all Veterans scheduled for colonoscopy at the WLAVA. In addition, UCLA Medical Center has converted the booklet for use with their patients. Moreover, the booklet is being used in centers across the globe, and has been translated into Turkish, among other languages.

To learn more about colorectal cancer, visit the links located in the Resources Box, at right.

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References

1. American Cancer Society (http://www.cancer.org/Cancer/ColonandRectumCancer/DetailedGuide/colorectal-cancer-key-statistics)
2. VHA screening guidelines for CRC (http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1530)
3. ibid

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