Introduction
The learning of a phenomenon requires the exploration of a variety of sources of information. The human personnel can be a source of specific information on certain aspect. For instance, interviewing a professional can help gather information on certain key aspects of the profession or a subject matter related to the profession. The interest in this paper is in the guidelines for the screening of colorectal cancer as a policy issue. To complement the secondary sources of information, this paper benefits from information gathered from an interview performed on the sixth day of July, 2016.
The interviewee was Alison White. Ms. White is a board certified Advanced Family Nurse Practitioner prepared at the doctorate level, the degree with which she graduated in 2011. Ms. White has ten years of experience in the medical field, with the last five years spent in primary care. This gives her authority and familiarity on matters of health policies and Medicare guidelines, including policies on colorectal cancer screening. In her previous engagement with an HMO agency, her roles involved dealing with Medicare/Medicaid guideline regulations and compliance.
At present, Ms. White as a nurse practitioner in a primary care clinic. As a health care provider, her patients are mostly adults. Among her roles is the implementation of the screening protocols for colorectal cancer as preventive measures aimed at ensuring a reduction in the incidence rate of colorectal cancer and other preventable diseases. Her roles also include the diagnosis and development of treatment regimens for patients who have acute illnesses and chronic diseases. As the resident nurse practitioner, she is tasked with overseeing the compliance with the screening protocols for various diseases.
While there is sufficient secondary information on the health policies on colorectal cancer, the performance of this interview was necessary because it offered an opportunity to acquire and experienced opinion and advanced information on the guidelines and compliance of colorectal cancer screening. This includes specific information on fecal occult blood testing and colonoscopy of sigmoidoscopy. There is need to obtain primary information from the healthcare providers on the policy issue because it helps them use the guidelines in the early detection of colorectal cancer among patients aged between 50 and 75 years.
Description of Policy Issue
The updates on the recommendations that were made by the US Preventive Services Task Force with regards to the screening of colorectal cancer is based on the recognition of the increasing incidence of colorectal cancer and the mortalities that result from the disease. For instance, US Preventive Services Task Force (2016) considered that the incidence of colorectal cancer as evidenced by new diagnosis in 2016 will be at 134000. Of this number of people, the mortalities will amount to 49,000. These statistics elevate the screening of colorectal cancer to an issue of importance; one that warrants the review of previous policy guidelines and recommendations.
The Review of Evidence
The update of the policy guidelines that were drawn in 2008 by US Preventive Services Task Force (2016) benefited from the review of evidence to determine the effectiveness of the various screening strategies recommended in the updated policy guidelines, the frequency of screening, and the benefits and harms of early detection of colorectal cancer. Some of the screening procedures for which evidence of effectiveness was considered include flexible sigmoidoscopy, guaiac-based fecal occult blood test, computed tomography colonography, multitargeted stool DNA test, fecal immunochemical test, methylated SEPT9DNA test, and colonoscopy.
Stool-Based Tests
The stool-based tests in the above list of tests considered in the review of evidence include guaiac-based fecal occult blood test, fecal immunochemical test, and multitargeted stool DNA test. Lin, Piper & Perdue (2016) found through a randomized clinical trial that the use of guaiac-based fecal occult blood test is effective in the reduction of deaths that result from colorectal cancer. However, when compared to guaiac-based fecal occult blood test, the fecal immunochemical test were shown that have increased sensitivity in the detection of colorectal cancer (Lin, Piper & Perdue, 2016). Certain variants of the fecal immunochemical test have the highest level of sensitivity and specificity, hence making them appropriately recommended strategies for the screening of colorectal cancer (Lin, Piper & Perdue, 2016).
Direct Visualization Tests
The direct visualization tests include those test through which the physicians can view the tissues in the colon such as the flexible sigmoidoscopy, computed tomography colonography, and the colonoscopy. Lin, Piper & Perdue (2016) found in a randomized clinical trial that the use of the flexible sigmoidoscopy leads to a reduction in the mortalities related to colorectal cancer. The researchers found that when combined with the fecal immunochemical test, the flexible sigmoidoscopy was more effective than when it was employed solely. The use of the colonoscopy procedure was also shown to reduce the mortalities related to colorectal cancer (15). The use of the computed tomography colonography is associated with overdiagnosis which leads to overtreatment.
Serology Tests
The methylated SEPT9DNA test is the only serological test that was considered in the review of evidence. The test was associated with a low sensitivity rate of 48% when used in the detection of colorectal cancer.
Harms Associated with Screening for Colorectal Cancer
There has been limited compliance with the screening for colorectal cancer. The analysis of evidence has shown that the low compliance is attributed to among other factors, low health literacy (Daly, Xu & Levy, 2014). This relates to the lack of knowledge regarding the severity of colorectal cancer. Even if this knowledge gap was to be bridged through appropriate interventions as recommended by Smith & Blumenthal (2013), Garcua, Buylla Nivolas-Perez & Quintero (2014) find that negative attitudes that people associate with the screening for cancer still serve as potent barriers for the compliance with the screening protocols.
It is for this reason that the direct and indirect harms that resulted from the screening strategies considered for the policy guideline updates. For instance, the harms related with endoscopy strategies include electrolyte imbalance and dehydration due to the preliminary preparations of the bowel, the cardiovascular events that result from the sedation, and the colonic perforations, infections, and bleeding that might result from the endoscopy procedures.
Benefits of Early Detection and Treatment
US Preventive Services Task Force (2016) found that the early detection was effective in the reduction of the mortalities related to colorectal cancer. For instance, Lin, Piper & Perdue (2016) showed that an annual screening for colorectal cancer resulted in a 32% reduction in the mortalities related to colorectal cancer even when screening approaches with low sensitivities are used. Other harms are related to the sensitivity and specificity of the screening approaches used. False positives can result in anxiety and the treatment for wrong conditions. The repeated use of computed tomography colonography can also result in cancer that is induced by the continued exposure to radiation.
Summary of Recommendations
Based on the review of evidence, the following are the updated recommendations for the screening of colorectal cancer.
Presentation of Policy Analysis
Problem Definition
The increase in the incidence rate and prevalence rate of colorectal cancer has coincided with the increase in mortalities related with colorectal cancer. There is need to stem the increase in the prevalence of colorectal cancer by reducing the incidence rate by applying preventive and early detection measures.
Evidence Assembly
The number of people projected to be diagnosed with colorectal cancer in 2016 is estimated at 134,000. Further predictions show that most of the diagnosed adults are between the ages of 65 and 74 years. The projected mortalities related to colorectal cancer in 2016 amount to 49,000.
Alternative Consideration
The alternative to the policy is the reliance on the treatment in the place of the prevention measures that the policy proposes. This alternative results in the loss of the benefits of an up to 32% reduction in the mortalities related to colorectal cancer. The alternative also results in a loss of between 188 and 227 life years that are gained in every 1000 individuals who are screened for colorectal cancer over the recommended time periods.
Criterial Selection
The determination of the recommendations was based on the analysis of evidence-based clinical trials that reported empirical evidence on the effectiveness of the use of various screening strategies for early detection and treatment of colorectal cancer, the gain in life-years, and the reduction in the mortalities that are related to the disease.
Outcome Projection
The project outcome of the endeavor was to make improvements to the policy guidelines that were published in 2008. Through the updates on the previous guidelines, the US Preventive Services Task Force (2016) hoped to help the clinicians make decisions on patient situations, the benefits and harms, and the effectiveness of various screening strategies.
Trade-off Confrontation
For the benefits promised due to the use of the recommended screening strategies, there are harms to the patients that clinicians need to consider. These harms include the discomfort to the patients due to the invasive nature of some procedures, the risk of developing cancer induced by the exposure to the radiation, and the physical injury of the patients in endoscopic procedures.
Decision-making
The decision to proceed with the recommendations despite the harms related to the implementation of the policy guidelines is because there is a substantial net benefit when the harms are pitted against the benefits of the recommendations.
Dissemination
There is need for the clinicians to use the updated guidelines during decision-making when dealing with patients with colorectal cancer or community members in the targeted age group. The publishing of the contents of the recommendations in popular medical journals will help reach clinicians as recommended by Schroy, Mylvaganam & Davidson (2014).
Conclusion
The concern regarding the prevalence rates of colorectal cancer is justifiable considering the mortalities that are related to the disease. The synthesis of evidence has shown that early detection of colorectal cancer can lead to the successful treatment of the disease. It is for this reason that screening protocols have been developed. The policy that was analyzed in the paper was the updated guidelines on colorectal cancer. The projection of the number of people diagnosed with the disease and the resultant mortalities necessitated the review of the previous guidelines. Periodic screening has been shown to increase the life-gain in years and the reduction of mortalities. However, there are harms to be considered that relate to the various screening strategies. Nonetheless, the net benefits compared to the harms are significant enough to justify the recommendation to use the screening strategies starting at the age of 50 years and ending at 75 years.
References
Church, T., Wandell, M., Lofton-Day, C. (2014). PRESEPT Clinical Study Steering Committee, Investigators and Study Team. Prospective evaluation of methylated SEPT9 in plasma for detection of asymptomatic colorectal cancer. Gut. 63(2):317-325.
Daly, J. M., Xu, Y., & Levy, B. B.T. (2014). Colon polyp model use for educating about colorectal cancer screening in Iowa Research Network. Journal of Cancer Education: The Official Journal of the American Association for Cancer education 29 (2): 401-406. doi: 10.1007/s13187-014-0637-7.
Garcua, A., Buylla N., Nivolas-Perez, D. and Quintero, E. (2014). Public Awareness of Colorectal Cancer Screening: Knowledge, Attitudes, and Interventions for Increasing Screening Uptake. International Scholarly Research Notices: Oncology. http://dx.doi.org/10.1155/2014/425787
Lin, J., Piper, M. and Perdue, L. (2016). Screening for Colorectal Cancer: A Systematic Review for the US Preventive Services Task Force: Evidence Synthesis No. 135. Rockville, MD: Agency for Healthcare Research and Quality; 2016. AHRQ publication 14-05203-EF-1.
Nishihara, R., Wu, K, Lochhead, P, (2013). Long-term colorectal-cancer incidence and mortality after lower endoscopy. New England Journal of Medicine. 369(12):1095-1105.
Schroy, P. C., Mylvaganam, S., & Davidson, P. (2014). Provider perspectives on the utility of a colorectal cancer screening decision aid for facilitating shared decision making. Health Expectations, 17(1), 27-35. doi:10.1111/j.1369-7625.2011.00730.x
Smith, S. A., & Blumenthal, D. S. (2013). Efficacy to effectiveness transition of an Educational Program to Increase Colorectal Cancer Screening (EPICS): study protocol of a cluster randomized controlled trial. Implementation Science, 8(1), 1-11. doi:10.1186/1748-5908-8-86.
US Preventive Services Task Force. (2016). Screening for Colorectal Cancer US Preventive Services Task Force Recommendation Statement. The Journal of the American Medical Association. 315(23):2564-2575.
