Colorectal Cancer Screening Demonstration Program

Although colorectal cancer screening has been shown to decrease incidence and deaths from this disease, use of colorectal cancer screening tests has been lower than use of other well accepted preventive services. As of 2006, 61% of the U.S. population has been screened for colorectal cancer as recommended, with those without health insurance least likely to get screened. To explore the feasibility of implementing a national screening program for the underserved population and to learn which settings and program models may be most feasible and cost-effective, CDC established a three-year colorectal cancer screening demonstration program (CRCSDP).

Program Planning

CDC convened two stakeholder meetings in 2004 to consider possible program designs, identify eligibility criteria for program applicants and clients receiving services, and determine which services would be reimbursed in the program. Meeting attendees included health scientists, economists, epidemiologists, and program and communications experts from CDC, as well as health scientists from other federal health agencies; representatives from screening programs from U.S. states and other countries; and clinical experts.

Recommendations

The following recommendations were made regarding the design of the CRCSDP—

• Eligible applicants could come from any non-profit medical entity offering services to low-income people who are underinsured for colorectal cancer, including—
  • State or county health departments.
  • Hospital systems.
  • CDC's National Breast and Cervical Cancer Early Detection Program.
  • Other organizations.
• Eligible applicants must show collaboration with their local CDC-funded Comprehensive Cancer Control Program.
• Since the U.S. Preventive Services Task Force (USPSTF) recommends four screening tests, with no test considered "best," applicants could choose which screening test(s) to offer as long as—
  • The selected test(s) is/are recommended by USPSTF guidelines, and
  • The applicant had measured the capacity to offer the selected test(s).
• Screening tests would be reimbursed at the Medicare rate.
• The program would focus primarily on average-risk persons aged 50 years or older.
• Patients with colorectal cancer symptoms or certain high-risk conditions would not receive services within the program.
• Treatment resources would be identified prior to programs applying to part of the demonstration effort.
• Priority would be given to programs ready to begin screening within six months.

Tools

CDC consulted with experts across the country to develop tools for the CRCSDP.

• CRCSDP Policy Manual [PDF-201KB]
• Readiness Checklist [PDF-63KB]
• Colorectal Cancer Screening Algorithm [PDF-32KB]

Program Launch

A Request for Application was published in the Federal Register in May 2005. Reviewers for the applications were from CDC and other federal health agencies. Cooperative agreement awards between CDC and five programs were made for August 2005 through August 2008. CDC awarded $2.1 million for year one activities, and $2.6 million annually for years two and three.

The demonstration program sites were—

• Baltimore City Colon Cancer Screening Program (Maryland Department of Health and Mental Hygiene).
• Missouri Screen for Life (Missouri Department of Health and Senior Services).
• Nebraska Colon Cancer Screening Program (Nebraska Department of Health and Human Services).
• Project SCOPE (Stony Brook University Medical Center/SUNY, New York).
• Washington Colon Health Program (Public Health - Seattle and King County, Seattle, WA).

Providing high-quality clinical services was critically important to the demonstration program. CDC provided guidance to CRCSDP sites to ensure that high-quality services were delivered. Programs and their participating endoscopists are encouraged to follow the standardized colonoscopy reporting system. Current guidelines for surveillance following polypectomy or cancer resection also were followed. Sites collected data elements to enable them to assess the quality of endoscopic services.

Program Evaluation

An in-depth evaluation of the CRCSDP was being conducted to support decision making about future colorectal cancer screening efforts. The evaluation included three methods—

1. A longitudinal, multiple case study [PDF-20KB] conducted over the course of the project to understand and describe program implementation better.
2. A description of the economic analyses [PDF-25KB] to assess costs.
3. The collection and analysis of client-level screening and diagnostic data [PDF-3MB] for program monitoring and to measure program outcomes.

Publications

Some non-clinical activities may incur substantial costs in Colorectal cancer screening programs. A evaluation and assessment of these costs are highlighted in "Clinical and Programmatic Costs of Implementing Colorectal Cancer Screening: Evaluation of Five Programs."

The April 2008 issue of Preventing Chronic Disease contains four studies that detail the process and cost to design CDC's Colorectal Cancer Screening Demonstration Program—

• "Start-Up of the Colorectal Cancer Screening Demonstration Program."
• "Facilitators and Challenges to Start-Up of the Colorectal Cancer Screening Demonstration Program."
• "Cost of Starting Colorectal Cancer Screening Programs: Results from Five Federally Funded Demonstration Programs."
• "Development of a Federally Funded Demonstration Colorectal Cancer Screening Program."