Ineffective Use of Fecal Blood Testing as a Lone Method for Colorectal Cancer Screening: Cancer Screening Is Only Useful When in Compliance With Recommendations

Abstract

Introduction: In a culture which leans towards procedural screening for colorectal cancer, it is easy to disregard less invasive methods. There is a subset of patients who defer endoscopic exam either due to embarrassment, fear, or they are deemed medically inappropriate for routine screening. Use of fecal blood testing as a screen for colorectal cancer is recommended annually as an alternative to endoscopic examination. Gastroenterologists have limited interaction with the general patient population as compared with primary care physicians, thus the task of most cancer screening falls to primary care. To ensure that this subset of patients is being screened appropriately, we undertook the task of investigating compliance of fecal blood testing as a lone cancer screening within our healthcare system. Methods: On a retrospective review of 8,187 patient medical records from January 1, 2002 through December 31, 2012, selected from the primary care cohort as being average risk of colorectal cancer based on the American Gastrointestinal Association 2012 guidelines. The entry point for the study was an adult of age 50 or older within the study period, and who were using fecal blood testing as their primary screening method for colorectal cancer. Patients undergoing other means of screening by endoscopic examination, barium enema, or computerized tomography (CT) colonography were excluded. Patient records were reviewed over this period for annual compliance. Results: The mean age of patients included was 67.1 years; 55% of these were females. Out of 8,187 patients undergoing fecal blood testing, only 672 (8.2%) were appropriately undergoing annual testing as a sole method for colorectal cancer screening over the 10-year study period; 7,147 (87.3%) patients did not undergo a consecutive fecal blood test on an annual basis and underwent no alterative means of screening. Surprisingly, 368 (4.5%) patients were undergoing both annual fecal blood testing and endoscopic examination by colonoscopy. Conclusion: We have found that compliance with annual fecal blood testing as a colorectal cancer screen is quite low throughout our healthcare system. It is unclear where the care gap lies; on the side of the physician not requesting appropriate testing, or with the patient not completing the requested testing. Interestingly, a subgroup of patients had an overutilization of screening by both concomitant colonoscopy and annual fecal blood testing. Despite the use of electronic medical records with proven care benchmarks and quality care alerts, there still exists a care gap and in some cases a redundancy of care which requires further review. Implementation of care standards within the electronic medical record may assist in closing this care gap.