Effective Practices to Improve Equitable Cancer Screening

This is the third post in a blog series on the National Comprehensive Cancer Network (NCCN) Policy Summit: Reducing the Cancer Burden through Prevention and Early Detection.
According to Nikia Clark, community relations coordinator of Community Outreach and Engagement at Roswell Park Comprehensive Cancer Center, cancer screening is not an easy task. It’s a challenge that requires key partnerships and effective communication with communities. In the NCCN Policy Summit session “A Modern Take on Early Detection: Overcoming Real World Challenges to Accelerate Effective, Accessible, and Equitable Cancer Screening,” speakers like Clark discussed effective practices to equitable cancer screening and strategies to overcome common challenges.

Building Community Partnerships

To create equitable and impactful cancer screening programs, Clark shared that healthcare providers need to offer effective education and make people understand why screening is so important. Additionally, Clark’s team at Roswell Park is going the extra mile, including educating people in their preferred language and hiring advocates who have experience with screening (e.g., they’ve gone through a colonoscopy themselves) and who identify with the communities they are trying to reach.
Additionally, the panel featured Lisa Schlager, vice president of Public Policy at Facing Our Risk of Cancer Empowered—an organization dedicated to improving the lives of individuals who face hereditary breast, ovarian, pancreatic, prostate, colorectal, and endometrial cancers through education, support, advocacy, and research. “Our goal is to help people look at their family history and determine if and when they need to begin screening for that cancer,” Schlager said. In particular, Facing Our Risk of Cancer Empowered is advocating for certain individuals to begin mammograms at 20 years to 30 years old (with current guidelines recommending annual screening starting at 40 years old) and colonoscopies at 40 years to 45 years old (with current guidelines recommending annual screening starting at 45 years old) if determined to be at risk. But ensuring equitable access to and coverage of these services for individuals with a hereditary risk for these cancers are equally a challenge.
According to Schlager, and others during the day’s event, national cancer screening guidelines and recommendations “absolutely have to be different for these subsets.” And while the NCCN might have specific guidelines tailored to hereditary cancer populations, other organizations do not nor are their guidelines equally recognized in practices across the United States.
“We need to decentralize and democratize screening to increase access,” said Philip E. Castle, PhD, MPH, director of the Division of Cancer Prevention and Senior Investigator, Division of Cancer Epidemiology and Genetics at the National Cancer Institute (NCI). The answer: self-collection.

At-Home Testing

Dr. Castle believes that “self-collection is the future.” This is because more people are willing to do these tests if they can complete it in the comfort of their own home and on their own time. For example, instead of willingly scheduling a colonoscopy with their provider, people may be more willing to mail in their stool using tests like Cologuard®. But the challenge of improving cancer screening rates nationally remains, as these numbers were deeply impacted by the COVID-19 pandemic.
Chyke Doubeni, MBBS, MPH, chief health equity officer at The Ohio State University Wexner Medical Center, attributes at-home testing as a silver-lining to the pandemic and the nation’s depleted screening rates. “The key here is that people are more open to non-invasive, at-home testing,” he said. And because we do not know just yet the long-term impact the COVID-19 pandemic will have on cancer screening, including if these impacts are worsening health disparities already seen among particular communities, at-home testing could be an answer to improving access and screening rates. In turn, these improvements could lead to earlier diagnoses and better patient outcomes.

Finding the Balance

Many panelists agreed that cancer screening is not simply a single test. Screening is now considered by oncology professionals to be a process that should include any follow-up tests and other services like imaging, necessary to confirm a cancer diagnosis. Therefore, a change in the reimbursement mindset is needed to ensure individuals have full coverage for these services when determined necessary by providers to make a final diagnosis.
At the same time, oncologists and the broader healthcare system alike want to ensure an appropriate level of screening and avoid utilizing unnecessary healthcare services. This is where prior authorizations—a hot topic in healthcare—can help strike the right balance. According to Dr. Eric Gratias, MD, FAAP, chief medical officer at eviCore Healthcare, prior authorizations are a service-level decision for approving healthcare services, including cancer screenings. While prior authorizations may be overused by payers as an automated utilization management tool, if used properly they could assist healthcare providers in finding this balance by not rendering services to individuals who would not benefit from them in the long term.
Yet “the decision to screen or not comes down to the ratio of benefits versus risks,” Dr. Gratias concluded. “We’re [screening] a lot [of] people who are never going to get cancer throughout their lives.” Therefore, screening for cancer, especially as at-home tests gain popularity, requires a keen eye for those who will truly benefit from these services without causing harm or overutilization of healthcare services in the long term. And because this balance cannot be perfectly defined with an algorithm and current data sets, more work is needed to tailor cancer screening guidelines and recommendations for each cancer and specific populations, while properly identifying those who would benefit from such services.