Tuesday, February 5, 2019

Brief Blog: Medicare Still Defines High Risk Colon Cancer Syndromes Without Genetics (Party Like It's 1897...)

One of the most important, frequent, and best understood cancer risk syndromes is Lynch Syndrome, which causes elevated risk of colon cancer (here, herehere).  Adequate screening for Lynch Syndrome is considered a public health issue.

Medicare defines inheritance of high risk for colon cancer, however, without any reference to genetics or Lynch syndrome. 

That means, for example, in a family with Lynch syndrome or familial polyposis and four offspring, Medicare blindly classes all four offspring as high risk for colon cancer, regardless of the fact that genetics will "de-select" two of them as not having inherited the relevant dominant gene.

Medicare's benefit system for colon cancer screening (ranging from FIT to colonoscopy to Cologuard) is here.   The regulations, from 1997, defining "high risk Medicare beneficiaries" are here.  Given the lack of genetics, they could as well date from 1897.

It's like they never heard of Gregor Mendel, or Watson & Crick.
Medicare defines High Risk for colon cancer screening as:
  • A close relative has had colorectal cancer OR an adenomatous polyp;
  • A family history of FAP (familial adenomatous polyposis);
  • A family history of hereditary nonpolyposis colorectal cancer;
  • A personal history of adenomatous polyp or colorectal cancer;
  • IBD (Crohn's or ulcerative colitis).
Note that Medicare considers a personal history of Stage 1 or 2 colorectal cancer a justification for annual colonscopy ($1000 plus each year) but (in a current scandal) not a justification for one time only Lynch panel screening (about $700).


For a 2019 article on low- or high-intensivity CRC screening in adenoma patients, Meester et al. in Annals of Internal Medicine, here.


For a flurry of articles circa October 1, 2019.  Study with modeling suggests that screening with FIT, sigmoidoscopy, and colonoscopy all actually have comparable 15-year benefits.  Here.  Euro guidelines suggest use risk-based modeling and nix screening for persons with no elevated risk.  Here.   Study suggests incorporating genetic modeling in risk modeling (the point of this blog).  Here.  CMS-funded model suggests that ColoGuard is very non-cost-effective.  Here.