Health Policy

Colon Cancer Screening in the Elderly

In the past decade, the incidence of mortality from colon cancer has substantially decreased primarily in patients aged 65 years and above. By large, although this can be associated with better treatment and reduced risk factors, screening has been the biggest contributor to the positive outcome. The concept of screening has been recommended for people with average risks beginning at the age of 50 years. Nevertheless, the efficiency of screening has not been studied exhaustively or the potential hazards associated with the procedure. As Wilson (2010) notes, there has been a significant number of controversies surrounding cancer screening in the seniors. Recommendations are only available based on detection rates and do not address the impact of co-morbidities, life expectancy, or functional status. A precise estimate of the benefits against the harm of the screening procedures is critical in this case to aid in an informed decision-making process. For instance, during the procedure, the doctor or nurse practitioner usually inserts a colonoscopy into the back passage of the patient and pumps air into the bowel to expand it for a better view of the colon. The practitioner will then pass the colonoscopy through the patient’s colon as the images are recorded on a monitor connected to the device. Although the procedure has been effective in early detection of cancer, it is sometimes hard to perform and may bring certain complications to the patient such as tear or damage to the bowel, requiring an operation to repair it. Moreover, Wong, as Germaine & Howard (2011) claim, screening is also associated with higher risks of death and decreased life expectancy especially to people with co-existing morbidities and chronic diseases such as cardiovascular diseases. In this context, the most feasible and advisable option is adopting the fecal occult blood test, which is used to search for the presence of tiny amounts of blood in the stool that could signal the presence of cancer.

Fecal Occult Blood Test

The fecal occult blood test has been recommended by the American Cancer Society (n.d) as one of the best alternatives to search for hidden blood in the stool. The idea behind the adoption of this test takes into consideration the fact that blood vessels to a great colorectal polyp are fragile and can easily suffer damage from the stool. Usually, the damaged vessels bleed into the colon, but not enough to be detected in the stool. By use of a chemical reaction, the fecal occult blood test detects blood in the stool. Unfortunately, the test cannot tell whether the source of the blood is from the colon or other parts of the digestive system. Nevertheless, in case the fecal occult blood test comes out positive, then the colonoscopy test can be used to uncover the reason behind the bleeding. While the procedure only aids in detecting early signs of cancer without being conclusive, it has significantly improved cancer screening for the elderly. Virtually, fecal occult blood testing is categorized into guaiac and immunochemical FOBT. Bleeding from cancer may be intermittent and not detectable in a single sample, thus according to a report by the Medical Advisory Secretariat (2009), the test involves collecting specimens from consecutive bowel movements. A positive FOBT test is usually followed by a colonoscopy test to examine the colon to rule out the case of cancer.

Current Characteristics

Unlike the colonoscopy test, the fecal occult blood test can be done every year. The test uses a kit and patients can do it in the privacy of their homes and even carry more than one sample stool test. It is assumed that a single rectal exam done at the doctor’s office is not enough for proper screening of cancer. The test kit is available from a clinical facility or the pharmacies, and the issuing practitioner usually instructs the patients on usage. After testing at least three samples of the stool, the kit is returned to the clinical for testing. Before the procedure, it is advisable to avoid some foods and drugs such as non-steroid anti-inflammatory drugs seven days prior testing. Vitamin C exceeding 250mg daily from supplements such as citrus fruits or juices should be avoided for three days before undertaking the test. Foods such as red meat, which include beef, liver, or lamb, should also be avoided three days before testing. These foods have been linked with the interference of the test results making it appear as if there was blood present in the stool when there was none. Contrary to the colonoscopy test, most people find this test easier because it lacks drugs or diet restrictions and no risks associated with it. 

Impact of the Recommendation on Stakeholders

After lung and prostate cancer, colorectal cancer is the other type of cancer with a high prevalence in both men and women. Every year, thousands of patients are diagnosed with colon cancer, and a substantial number of these people die from the disease, making it among the major leading cause of death in the globe. However, with an appropriate fecal occult blood test, which is a population-based screening program, cancer can be detected early enough for proper diagnosis and intervention to prevent the incidence of increased mortality. 

From the Consumers Perspective

Existing literature reviews indicate that the test allows screening for people at average risk. Along with that, the program is cost effective, non-invasive, accessible, and high patient compatibility. With the implementation of the policy, the wellness of the individuals, families, groups, and the community is assured. In return, the particular outcome variable translates to the effectiveness of the nursing practice (Fawcett & Russell, 2011). Effectiveness, in this case, is the extent to which the health policy will improve the health of the individual, family, group, or the community.

From the perspective of a nursing professional

Implementation of the health policy will focus on improving efficiency in the administrative practices of healthcare delivery. Efficiency in this context is viewed from the perspective of delivery of the highest quality value of care within limited resources and technology. As Fawcett & Russell note, efficiency viewed from an economic side means that nurses deliver quality nursing care at the lowest cost possible. Thus, the health policy will be expected to address the level of personnel, the technology used, and cost in a bid to attain the highest level of efficiency in nursing practice processes.

From the perspective of other health professionals

According to Fawcett & Russell, the view is broader in that it incorporates various subsystems within care delivery system. Such include medicine, nursing, physical therapy, the pharmacy among other subsystems within the specific heath care system. The implementation of the policy will focus on improving the efficiency and effectiveness of the health professional practices. In this case, the effectiveness refers to the percentage of colorectal cancer problems identified, the rate of medical intervention delivered, the efficiency of intervention, and response to treatment.

From the Perspective of Other Stakeholders

By 2009, the cost for Medicare patient on colon cancer treatment for one year was estimated to be between U.S. $26,196 and $30,738 (Luo, Bradley & Dahman, 2010). Depending on the rate of inflation, this cost has substantially gone up. What this means, the society is burdened with high expenditures on cancer intervention for patients under especially those under Medicare. The amount is even higher for patients who pay out-of-pocket or with private insurance. Early detection of cancer means that the disease can be managed early enough to avoid additional costs as a result of complications that emanate from advanced cases of cancer. As it is, the health professional has a responsibility towards the society. According to Fawcett & Russell, the meaning of health considers the fair distribution of care to the global community to relieve the burden of disease inequities. Thus, with the policy allowing early detection of the disease, this will eliminate the imbalance of economic burden of the treatment of the disease.

Current Solutions

The current standard of screening of patient is to prevent cancer. Currently, for the purposes of screening, patients are divided into various categories from average risk, increased to high-risk groups. For the average-risk individuals, the U.S. Multi-Society Task Force recommends colonoscopy for every ten years, with a flexibility of 5 years in between (United Healthcare Services, 2015). However, with the fecal occult blood test, cancer screening is performed every year with 2 to 3-day sample collection. In case the test detects the presence of blood in the stool, the doctors recommend for a colonoscopy test to verify whether the blood is a sign of cancer or not.

Status in the Health Policy Arena

From accumulated evidence, it is clear that fecal occult blood test has a positive mortality effect on colon cancer. According to Pitkäniemi, Seppä & Hakama (2015), the average reduction rate for colorectal cancer was estimated to be 12 percent down from 21 percent. Pitkaniemi et al. even suggest a bigger reduction in the rate of colon mortality after screening. Some areas where the policy has been successful include Canada, where colorectal cancer is one of the most preventable diseases, yet it has been part of the leading causes of death. Given the increased rate of morbidity and mortality in mental health individuals, Canadians hypothesized that the adoption of fecal occult blood test would remove the potential barrier to CRC screening for people with a mental health condition, a policy that has been successful so far (Hategekimana, Karamouzian & Karamouzian, 2016). In the United States, the fecal occult blood test policy was effective from January 21, 2017, although there is no substantial evidence of its success.

Colon cancer is a worrying problem in the United States and all over the world. Early detection of the disease reduces mortality. Introducing the fecal occult blood test in cancer screening is by far cost effective as compared to colonoscopy. Combining both fecal occult blood tests with flexible colonoscopy is more likely to yield improved results and better management of colorectal cancer in seniors. However, whether the policy will be successful largely depends on the available resources and commitment of the relevant stakeholders to oversee its success.

References

American Cancer Society. (n.d). Colorectal Cancer Screening Tests. Retrieved from: https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/screening-tests-used.html

Fawcett, J., & Russell, G. (2001). A Conceptual Model of Nursing and Health Policy. Policy, Politics, & Nursing Practice, 2(2), pp.108-116.

Hategekimana, C., Karamouzian, M., & Karamouzian, M. (2016). Self-perceived mental health status and uptake of fecal occult blood test for colorectal cancer screening in Canada: A cross-sectional study. International Journal of Health Policy and Management, 5(6), pp.365-371.

Luo, Z., Bradley, C. J., Dahman, B. A., & Gardiner, J. C. (2010). Colon cancer treatment costs for Medicare and dually eligible beneficiaries. Health Care Financing Review, 31(1), pp. 35-50.

Medical Advisory Secretariat. (2009). Fecal Occult Blood Test for Colorectal Cancer Screening. Ontario Health Technology Assessment Series, 9(10), pp. 1-40.

Pitkäniemi, J., Seppä, K., Hakama, M., Malminiemi, O., Palva, T., Vuoristo, M.-S., Järvinen, H., … Malila, N. (2015). Effectiveness of screening for colorectal cancer with a faecal occult-blood test, in Finland. Bmj Open Gastroenterology, 2(1), pp.1-7.

United Healthcare Services. (2015). Fecal Occult Blood Test. Retrieved from: https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Laboratory%20Benefit%20Management%20Program/Fecal_Occult_Blood_Test.pdf

Wilson, J. A. (2010). Colon cancer screening in the elderly: when do we stop? Transactions of the American Clinical and Climatological Association, 121, pp.94-103.

Wong, Germaine, Howard, Kirsten, Chapman, Jeremy R, Tong, Allison, Bourke, Michael J, Hayen, Andrew, MacAskill, Petra, … Craig, Jonathan C. (2011). Test performance of faecal occult blood testing for the detection of bowel cancer in people with chronic kidney disease (DETECT) protocol. BMC public health, 11(516), pp. 1-7.