From 2005 through 2009, the Centers for Disease Control and Prevention (CDC) administered and funded a 4-year Colorectal Cancer Screening Demonstration Program (CRCSDP) for low-income, underinsured, or uninsured men and women aged 50 years to 64 years in 5 sites in the United States. This initiative, which focused on the second leading cause of cancer deaths in US adults, was put into place to reduce the burden of colorectal cancer in vulnerable populations, including those who are low-income and uninsured, for whom the incidence and mortality rates of colorectal cancer are disproportionately high.[2, 3] While there is substantial evidence that colorectal cancer incidence and mortality are reduced through regular screening, the CDC had not yet established a colorectal cancer screening program before this demonstration effort. Although screening rates have increased in recent years, disparities still exist, with certain populations, including uninsured persons, less likely to be screened.[4, 5] The establishment of the CRCSDP was a critical step toward addressing this screening disparity. The overall goal of the program was to assess the feasibility of establishing a federally funded, comprehensive, colorectal cancer screening program for an underserved population and to describe key outcomes that could guide future organized colorectal cancer screening. To determine overall program feasibility, the CDC conducted an evaluation of the CRCSDP, including an assessment of patient characteristics and clinical outcomes, an examination of program and clinical costs, and a multiple case study of program implementation.
The evaluation of the CRCSDP start-up period was documented in 4 articles published in a single issue of Preventing Chronic Disease in 2008.[1, 6-8] The start-up period, which ranged from 9 months to 11 months across all 5 sites and was defined as the period of time between initial program funding and the initiation of screening, highlighted some key overall findings[1, 6-8]:
- A critical facilitator in program start-up was the existence of an infrastructure on which to build and a framework through which to integrate with other chronic disease programs, including experienced staff, preexisting partnerships, and provider networks.
- New programs were most effectively established by integrating into existing service delivery systems with collaboration and support from a multidisciplinary staff team, a medical advisory board, local partners, cancer coalitions, and the National Comprehensive Cancer Control Program grantees in the participating states.
- Nonclinical activities, including the development and use of data collection and tracking systems, generated substantial costs.
- In-kind program site contributions were a key component of the overall program budget.
The collection of 13 articles that follow in this dedicated supplement to Cancer complement the previously published articles on program start-up and document the full experience and evaluation of the CRCSDP implementation. These articles include 3 that describe clinical and quality outcomes; 2 articles that describe programmatic and clinical costs; 3 that were based on a multiple case study, using qualitative methods to describe the overall implementation experience of this initiative; and 4 articles written by and about individual program sites.
The overall clinical outcomes article discusses key findings from the clinical evaluation of all 5 sites, which include patterns in program uptake and test choice, challenges in the implementation of fecal occult blood testing (FOBT) screening programs, and comparative test performance of FOBTs versus colonoscopies performed during the 4-year demonstration program, and documents a polyp and adenoma detection rate that is more than 10 times higher when using colonoscopy compared with FOBT. Nadel et al evaluate quality indicators and conclude that although some measures of colonoscopy quality were achieved, including cecal intubation and adenoma detection rates, increased attention to standardized colonoscopy reporting is needed. This article identifies the need for improvements in recommendations for rescreening and surveillance intervals and reinforces the importance of monitoring of quality indicators to improve screening quality. Castro et al describe the colonoscopy complication rate associated with this program, which was low. Lane et al, in an article from the Suffolk County, New York site, demonstrate a feasible method for an academic medical center to provide quality screening colonoscopy for medically underserved populations. Patient adherence to colonoscopy was efficiently facilitated thorough use of a preventive medicine clinician and a patient navigator. Cost is addressed in articles by Subramanian et al and Tangka et al.[13, 14] These 2 articles describe clinical costs by test type and by test indication and program costs by program component, and indicate that programs reaching large numbers of people were able to achieve economies of scale. Rohan et al demonstrate how the clinical complexity of colorectal cancer screening makes program implementation particularly challenging, and requires a high degree of teamwork and collaboration, thoughtful integration into existing systems, and local-level wisdom. Phillips-Angeles et al demonstrate that fostering partnerships was critical to the success of their program and to the long-term sustainability of a colon health program for Washington State. Cavanagh et al, in a second article concerning the Suffolk County program, highlight the importance of clinical case management and patient navigation in removing barriers to colonoscopy screening and providing individualized support to patients. Villanueva et al, from the Baltimore City site, describe the facilitators and challenges they encountered in establishing a colorectal cancer screening program in an urban environment. They illustrate the complexities involved in collaborating across multiple health care institutions, many of which had never collaborated previously. Boehm et al demonstrate that removing financial barriers was necessary but not sufficient to recruit patients into the CRCSDP. They describe recruitment challenges the sites faced and delineate how these sites overcame these challenges. Glover-Kudon et al use a novel approach to describe the process of program maturation, aligning the “life cycle” of the program to corresponding stages of human psychosocial development. The final article in the supplement uses the program evaluation and experiences described in the previous articles to confirm the feasibility of this program.
The comprehensive, multimethods evaluation conducted alongside the program and documented in these reports produced many important lessons regarding the design, start-up, and implementation of colorectal cancer screening in this high-need population, and paved the way for the CDC to establish a larger, population-based colorectal cancer control initiative, broadly aligned with expectations of the Patient Protection and Affordable Care Act through its population-based emphasis on using a health systems approach to increase colorectal cancer screening.