At-Home Colon Cancer Screening on the Rise
Interviewee: Dr. Vinod Kurupath
Reviewed By: Dr. Archana Nair
In the past two decades, colon cancer has become the second-leading cause of cancer deaths in the United States, with an astounding increase in the subset of millennials and younger adults testing positive. Like other cancers, many are misinformed on how to adopt preventive habits into their lifestyles, which is especially concerning considering its prevalence in the younger demographic of our population. In the midst of these statistics, at-home colorectal cancer tests, approved by the FDA in 2014, have become an integral part of the initiative to fight colon cancer. These tests, often known as Cologuard, are essentially stool-sampling kits patients can use themselves. This test works by screening for blood in the stool as well as any sequences in DNA that can cause polyps, an early indication of colon cancer. With the pandemic making medical care for at-risk patient populations less accessible, at-home cancer tests are becoming more widely adopted in health systems across the United States. In particular, colonoscopies are being replaced by at-home colon cancer screening tests. While at-home colorectal cancer tests raise concerns about effectiveness and incorporation in special circumstances, their impact on expanding colon cancer screenings to more low-risk patients as well as making preventative digestive care more accessible to individuals throughout the country is critical.
Colonoscopies
Colonoscopies are the gold standard colon cancer screening method. During a colonoscopy, a long, flexible tube with a camera attached to the end is inserted into the rectum. The flexibility of this tube allows doctors to navigate through the curves of the colon and remove polyps, abnormal tissue growths associated with colon cancer. Since these precancerous polyps, also known as adenomas, take over three to ten years to develop into cancerous polyps, a colonoscopy screening every five years is sufficient. Although colonoscopies have the highest sensitivity and specificity for detecting colon cancer, they are invasive and require bowel preparation, a procedure in which patients need to take prescribed laxatives and make dietary changes in order to prepare for the colonoscopy.
Gastroenterologist Dr. Vinod Kurupath says that although he would refer a colonoscopy to a patient if they are able and willing to have one, he “would use a stool for Cologuard in high-risk patients, elderly people over 75, or people with significant comorbidities, who may not be able to finish a colonoscopy prep.”
At-Home Screening
There are many options for at-home screening, including FIT, a fecal immunochemical test. This test detects occult, or hidden blood, in the stool using antibodies. As CRC (colorectal cancer) patients have sensitive blood vessels that can be damaged by the passage of the stool, they can bleed into the colon or rectum. Using a stick or brush, a small amount of stool is obtained and sent to the lab to check for microscopic amounts of blood. Since this blood suggests polyp formation, if the test comes back positive, patients will have to have a colonoscopy to remove the polyps as a preventative measure. Another alternative is the FIT-DNA test, or as we discussed, the Cologuard, which checks for trace amounts of blood and specific DNA sequences in the stool that may show a chance of polyp formation. This test requires patients to collect an entire bowel movement to send to the lab.
Pros and Cons
Ill Populations
Although FIT tests have to be conducted more often, bowel prep, dietary restrictions, laxatives, and sedation are unnecessary. This is especially important in elderly and unwell patients. A study conducted by Dr. Joan L. Warren of the U. S. National Cancer Institute found that patients with a history of stroke, chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, or multiple chronic conditions had a higher risk for bleeding and colon perforation during the colonoscopy. In addition, pregnant patients and patients nearing the end of their lives are strongly advised not to undergo the procedure. In this population, colon cancer screening is still critical, and at-home alternatives are a great option.
Rural and Underserved Communities
At-home screening tests are key in improving screening rates in populations where health care is not readily available. A colorectal cancer screening program has been implemented in an urban, ethnically diverse population in CommunityHealth, a free clinic in Chicago, Illinois with the help of low cost at-home screening methods. The study resulted in 2418 were screened for colon cancer, 90% having never had been screened before; in total, 69 adenomas were removed. Furthermore, a study published in The Journal of Rural Health accumulated 345 participants from eight rural counties in Kentucky and provided them with at-home colorectal cancer screening kits. 82% of the participants completed the test and returned their samples to the clinic, demonstrating that when provided with the resources and information, rural inhabitants are willing and able to take care of their health. With the pandemic spotlighting at-home screening, an at-home screening model is key to improving screening rate, especially in low resource communities.
Cons
Accuracy
The FIT screening method is 79% accurate at detecting cancer, but has a 5% false positive rate, which would lead to patients getting a colonoscopy. Since Cologuard utilizes a multitarget DNA stool technology, the accuracy rate is much higher, at 92%. However, 14% of tests taken result in a false positive.
Dr. Kurupath says that it is important to remember that “Colon cancer screening is to check for polyps so that you can prevent them from getting colon cancer,” and Cologuard is only 42% effective at detecting large polyps.
Cost Considerations
The Affordable Care Act mandated that insurance plans cover all CRC screening, including colonoscopies and at-home tests. Fortunately, at-home screening tests are covered by Medicare and most private health insurance plans. Without insurance, the FIT costs around $20, while Cologuard costs around $600. However, colonoscopies ordered after an at-home test and diagnostic colonoscopies (the status of a colonoscopy is changed from screening to diagnostic once a polyp is found) are not covered by insurance.
Screening During the Pandemic
At-home screening tests are especially important in increasing screening rates.
Dr. Kurupath states that, “The goal from the American College of Gastroenterology is to at least have as many people screened as possible.”
Hospitals around the country are taking steps to allow for colon cancer screening through the pandemic. Drive-by FluFIT clinics in which patients can receive a FIT test and get their flu vaccination have been implemented to increase screening rate even through the COVID-19 pandemic. With colorectal cancer screening rates in the United States leveling out at a little over 55% of the population, mailed FIT tests are a significant step in equalizing the accessibility of the test to far more people. A study conducted at the Kaiser Permanente Center for Integrative Medicine in Northern California cited, “about 61% of those mailed a FIT responded to automated outreach with a pre-letter, FIT kit, automated call and reminder postcard, yielding an overall screening rate of 70%,” well above the national average. With younger populations becoming more and more affected with colorectal cancer, it is essential to focus whatever resources hospitals can utilize on getting as many individuals screened as possible.
Bottom Line
Overall, at-home colorectal screening kits represent a tremendous step towards equalizing and optimizing screening in patients of all forms. Like any medical innovation, much is to be developed and investigated about the cost and accuracy of these tests, as well as how efficiently these tests can sustain themselves in hospital administration and the homes of different patients. However, the increased patient reliance of these tests in the last few years represent an overall public awareness of the effectiveness of different modes of screening, especially for individuals who may not be eligible for or choose not to undergo certain invasive procedures.
Dr. Kurupath, like other health professionals, speculates that, “in the next five to ten years, everybody in the population, high-risk and low risk patients, may get a Cologuard and then a colonoscopy.”
While they may be subject to doubts and uncertainties in the present, at-home colorectal screening tests can become a key part in revolutionizing the future of at-home preventative care, making healthcare more accessible to a wide range of patients.