Expanded Lung and Colorectal Cancer Screening – Ensuring Fairness and Safety Under New Guidelines
In 2021, the United States Task Force on Preventive Services (USPSTF) has recommended a major expansion of the populations that should undergo routine screening for lung or colorectal cancer. Both recommendations are evidence-based and, if implemented effectively, they are very likely to save lives. The changes were made in an attempt to reduce inequalities in early cancer detection rates among women and people who identify as black, indigenous or Latin. The guidelines, however, were published without sufficient attention being paid to how they would be implemented. Efforts to deploy complex and highly personalized screening methods using the patchwork approach typical of the U.S. healthcare system could backfire, unless healthcare organizations, payers, and policymakers invest in it. preventive care infrastructure.
We believe that regulatory and policy solutions are needed to avoid the unintended consequences associated with these large increases in cancer screening eligibility. To combat systemic racism and promote safety in ambulatory care, health systems could collect and report data on disparities in preventive care, and they could design and deploy safety nets to ensure rapid follow-up afterwards. abnormal screening results. In addition, we need policies that explicitly support equity and safety in preventive care.
When added to an already inequitable healthcare delivery system, a substantial increase in the volume of preventive screening could exacerbate inequalities in access based on race and other factors and lead to missed or delayed cancer diagnoses. due to inadequate monitoring. Twenty million people between the ages of 45 and 49 are newly eligible for routine colorectal cancer screening under the guidelines. Another 6.4 million people are newly eligible for lung cancer screening. The recommended age to start screening for lung cancer in current and former smokers has been increased from 55 to 50, and the recommended number of pack-years of smoking history before screening has been increased from 30 to 20 , which almost doubles the eligible adult population.1
Even before these changes, the preventive care system was not functioning well. According to previous USPSTF screening guidelines, only 5% of eligible people were screened for lung cancer and 69% of adults were up to date for colorectal cancer screening. Eligible populations now include younger people, who historically have had lower preventive screening rates, are more racially and ethnically diverse, and are more likely to be underinsured than older people. Inequalities in screening rates, cancer incidence and mortality have persisted for decades, in part because health systems have failed to invest in preventing systemic racism in the delivery of routine preventive care and failing to do so. do not have functional systems to ensure constant monitoring of test results. indicating a moderate or high risk of cancer.2 Determined action will be required to overcome these challenges in order to achieve the goals of the USPSTF’s expanded guidelines.
We believe the first step is for health systems to create equity dashboards that report data on disparities in screening rates by race and ethnicity, sexual orientation, and gender identity. gender and language. Because we can’t improve what we don’t measure, equity dashboards that track key processes and outcome measures should be part of standard performance management tools deployed across the health system. American. Our perspective could then shift from caring for only the individual patients who present in our offices to a more complete understanding of the health of our populations, so that we can begin to systematically remove barriers faced by our patients and promote facilitators. that our patients need. . Such an approach is essential to harness the potential of the new guidelines, and it will be necessary to begin to address systemic racism and other inequalities in our health systems. Of course, reliable equity dashboards will only be possible if health systems consistently ask patients to share key demographics. This will require proactive education and outreach in close partnership with the community, as evidenced by the âWe Ask Because We Careâ campaigns deployed by many U.S. health care systems over the past decade.
Plans to address inequalities in preventive care could be mandated by the Joint Commission, the National Committee for Quality Assurance and other accreditation bodies. Health care systems will then need to focus on solutions to advance equity, such as employing preventive care navigators, providing after-hours screening and diagnostic services to improve performance. access, support to community testing sites and the large-scale deployment of programs offering home testing methods. , such as fecal immunochemical tests or fecal DNA tests for colorectal cancer. By setting explicit goals for equitable access to preventive care and tracking improvements, we can avoid exacerbating health disparities and start leveraging USPSTF guidelines to correct long-standing inequalities.
As health care systems reap the financial rewards of performing the various diagnostic assessments and surveillance tests that frequently follow screening, they could also be mandated to invest in a comprehensive safety net program for cancer screening. Such a program could include records and workflows to ensure that tracking of abnormal test results is done in a timely and highly reliable manner for all patients. Very few colorectal cancer screening programs in the United States have a very reliable system to track all patients who do not follow up after an abnormal screening result. Although accredited lung cancer screening facilities that charge for Medicare are required to submit data to the Centers for Medicare and Medicaid Services using a registry, it is not necessary that the registry then be used for come full circle and follow up. An ideal safety net program for cancer screening would track all patients for various prevention services, regardless of their insurance status.
The goal of implementing fair and safe cancer screening across the entire population will be elusive without payment and regulatory reform. Several types of reforms would be beneficial. First, payers could recognize the role of health hubs as essential members of the care team. Once Navigators are funded, either through an adjustment to the fee structure or through a primary care sub-cap model, they could engage with the most marginalized patients in their community. to remove social barriers to care, facilitate shared decision-making, and order and schedule appropriate tests. Mariners would also maintain cancer screening safety net registries and provide patient education.
Second, the United States does not have the kind of well-organized national screening program that has been adopted in many European countries.3 To fill this gap, the federal and state governments could enter into collaborative agreements with healthcare organizations to establish interoperable preventive care and safety net registries that would enable preventive screening records of departing patients. a health system or a geographic region. to another to be easily accessible to any clinician they see. Third, requiring employers to provide paid time off for preventive care is critical to ensuring adoption among the younger populations that are included in the USPSTF’s expanded guidelines.4
Fourth, Congress could pass legislation requiring commercial and government payers to immediately cover services that receive grade A or B recommendations from the USPSTF. The current one-year lag before commercial payers begin reimbursing providers for recommended services delays the need for screening and could therefore delay the diagnosis of new cancers. Finally, the expansion of Medicaid under the Affordable Care Act has resulted in a substantial improvement in the delivery of preventive care. We believe every effort should be made to get the 12 states that have not yet extended Medicaid to do so.5
Expansion of screening eligibility for lung cancer and colorectal cancer outlined by the USPSTF represents an opportunity for the United States to promote health equity, create safety net registries to ensure follow-up adequate post-screening and implement regulatory and payments reform that facilitates rapid adoption. of these guidelines and others on preventive care. Since we are building on fragile foundations, all political and regulatory levers should be activated to encourage the American health care system to invest in a more equitable and safer approach to preventive care.