1. Greenwald, Beverly PhD, RN, FNP, CNS, CGRN

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Cancer is anticipated to exceed heart disease as the major cause of deaths within the next few years. Fortunately, there has been a reduction in cancer deaths in the United States over the past 2 decades due to improved cancer prevention and control and improved medical practices. The lifetime risk of developing cancer is 43% for men and 38% for women. Colorectal cancer (CRC) is the third leading cause of cancer deaths in both men and women. The top three cancers for men (prostate, lung and bronchus, and CRC) and women (breast, lung and bronchus, and CRC) account for about one half of all cases for each gender. Approximately 132,700 new cases of CRC will be diagnosed in 2015 and there will be an estimated 49,700 deaths from this preventable disease (Siegel, Miller, & Jemal, 2015).


The success in reducing CRC deaths since the mid-1980s has been attributed to a reduction of smoking and improved uptake of CRC screening. One third of cancers are caused by exposure to tobacco products. Colorectal cancers had a particularly rapid decline from 2008 to 2011 due to the increased numbers of colonoscopies (which can actually prevent cancer by removing precancerous lesions). The colonoscopy has increased as a screening choice among adults aged 50-75 years from 19.1% in 2000 to 54.5% in 2013 (Siegel et al., 2015).


The colonoscopy is considered the "Gold Standard" for CRC screening and is the only screening test by which precancerous lesions can be removed to prevent CRC. The positive identification of blood loss or suspicious lesions on other screening tests should be followed by a colonoscopy. The recommendation for average-risk persons is to start screening at the age of 50 years. The American Cancer Society's additional screening options include an annual guaiac-based fecal occult blood test or fecal immunochemical test (FIT), stool DNA test every 3 years, flexible sigmoidoscopy every 5 years (with or without the annual guaiac-based fecal occult blood test or FIT), double-contrast barium enema every 5 years, or computed tomography colonography every 5 years (Smith et al., 2015). The best screening test is the one the patient will actually have done and is determined by consultation between the provider and the patient. Provider recommendation is the single most influential factor in persuading individuals to be screened for CRC. Insurance coverage is another major predictor of whether patients will get screened (Sarfaty, Peterson, & Wender, 2008).


In spite of the variety of CRC screening options, people remain unscreened for CRC. The Centers for Disease Control and Prevention (CDC) reports state-to-state variation in screening compliance ranging from 54.1% to 75.2% (CDC, 2010). Overall, about one of three (or more than 20 million people) remain unscreened. The Affordable Care Act will assist better screening rates through better access to health coverage, healthcare, and preventive services like CRC screening tests. These screening tests will be available at no additional cost (CDC, 2013b). Access to a provider will enable the requisite conversation about CRC screening and choosing a covered screening test. These contributions will provide momentum to the recent statistics that show CRC incidence rates have dropped 30% in the past 10 years. The incidence rates for people older than 65 years have dropped most dramatically because of higher screening rates due to universal insurance coverage (National Colorectal Cancer Roundtable [NCCR], 2014b).


The American Cancer Society and the CDC cofounded the NCCR, which proposes the ambitious goal of having 80% of adults screened for CRC by 2018: the "80% by 2018" initiative. This initiative was launched in March 2014, with the hopes of getting organizations to commit to help with eliminating CRC as a major public health problem (NCCR, 2014a).


The NCCR provides suggestions and resources on their website to remedy the problem that not enough people are getting screened for CRC (NCCR, 2014c). One problem is that people are not aware of the need for testing or the screening intervals for follow-up testing. The NCCR recommends that both office nurses and providers promote the CRC testing of the patient's choice, even at routine check-ups or ill visits. Health systems can automatically mail the FOBT or FIT kits and ensure that any abnormal tests are followed by colonoscopy. Patient reminder systems can be used to notify patients at appropriate screening intervals. On a larger scale, state and local public health services can track and explore ways to improve screening rates. Public health workers can focus their efforts on communities with lower screening rates. Medicaid programs, Medicare quality improvement organizations, and primary care associations can help people get tested. Federal contributions to this cause include the Affordable Care Act provision for no-cost coverage of CRC screening tests and improved tracking of patients at the Veterans Administration system. One Healthy People 2020 health indicator for preventive services is CRC screening (CDC, 2013a). A community of resources at multiple levels can remedy this CRC screening problem.


Ultimately, the "80% by 2018" goal is to channel the energy and momentum of community partners to promote patients, providers, community health centers, and health systems commit to eliminating CRC as a public health problem. This collective commitment provides the opportunity to save thousands of lives each year from CRC, one of the most preventable and treatable cancers (NCCR, 2014a). Each organization may benefit from asking, "How are our team and community doing on this endeavor?"




Centers for Disease Control and Prevention. (2010). Colorectal cancer screening rates. Retrieved from[Context Link]


Centers for Disease Control and Prevention. (2013a). Colorectal cancer tests save lives: The best test is the test that gets done. Retrieved from[Context Link]


Centers for Disease Control and Prevention. (2013b). Colorectal cancer screening rates remain low. Retrieved from[Context Link]


National Colorectal Cancer Roundtable. (2014a). New American Cancer Society data show that investing colorectal cancer screening pays off. Retrieved from[Context Link]


National Colorectal Cancer Roundtable. (2014b). Organizations working together to advance colorectal cancer control efforts. Retrieved from[Context Link]


National Colorectal Cancer Roundtable. (2014c). Tools and resources: 80% by 2018 press kit. Retrieved from[Context Link]


Sarfaty M., Peterson K., Wender R. (2008). How to increase colorectal cancer screening rates in practice: A primary care clinician's evidence-based toolbox and guide 2008. Retrieved from[Context Link]


Siegel R. L., Miller K. D., Jemal A. (2015). Cancer statistics, 2015. CA: A Cancer Journal for Clinicians, 65(1), 5-29. doi:10.3322/caac.21254. [Context Link]


Smith R. A., Manassaram-Baptiste D., Brooks D., Dooroshenk M., Fedewa S., Saslow D., Wender R. (2015). Cancer screening in the United States, 2015: A review of current American Cancer Society guidelines and current issues in cancer screening. CA: A Cancer Journal for Clinicians, 65(1), 31-54. doi:10.3322/caac.21261. [Context Link]