Sunday, October 6, 2019

Very Brief Blog: Journal Watch: Flurry of Colon Screening Articles

Last winter, I noticed that Medicare has a special policy for frequent colonoscopy benefits, and it covers everything except genetics. 

If you have a family history of colon cancer or polyps, or a family history of familial polyposis, or family history of non hereditary colorectal cancer, Medicare will be happy to give you annual rather than per-ten-years colonoscopy.

But wait.  If you simply don't have the gene that runs in your family, you still get the Medicare benefit because you have a "family history;" as far as genetics, Medicare doesn't care. 

If you are gene-positive and therefore at high risk, but an orphan, you don't get a benefit, unless you can get an adoption agency to release records that your mom died of colon cancer.  CMS chugs on exactly as if Mendel never lived.  (Blog here).

Six Current Publications Related to CRC Prevention Policy

In the last few weeks, a flurry of research articles potentially relevant to colon screening policy and practices.

I'll rattle them off here and readers with further interests can use the links to go further.

1) Outcomes With Higher or Lower Intensity Screening

In September 2019, in Annals of Internal Medicine, Meester et al. studied the benefits of high-intensity screening, here.  Higher intensity screening had benefits, though small, and was cost-effective, though on the high side (<$100,000/QALY).  Comes with an op ed by Weinberg & Schoen on advising patients (here), and a "patient page" here.

Weinberg cites recent studies that up to 50-60% of patients have at least one tiny polyp on screening, thus qualifying for more intense screening (Weinberg citing Rex; and see Pilonis).

2) Outcomes With FIT, Colonoscopy, Sigmoidoscopy: Similar

In October 2019, in BMJ, Buskermolen et al. studied the differential outcomes expected, by modeling, assuming patients used either FIT, or sigmoidoscopy, or colonoscopy.   The conclusion: all were OK, and it didn't matter much.   Here.

3) European Guidelines: "Risk" More Important than "Age"  

In October 2019, a European guideline appeared in BMJ, Helsingen et al., recommending that CRC screening decisions be based on risk, not on age.

This would be quite different than US, where USPSTF and AHRQ recommendations are primarily based on age and definitely don't consider genomics (in or out) for either mammography or colon screening.  Article here, trade press at 360Dx here.

4) Towards Using Genetics in Population Health Recommendations for CRC Screening

In October 2019, in Cancer Epidemiology, Biomarkers, Prevention, McGeoch et al. published a systematic review of risk prediction models for CRC incorporating genetic variants.

They conclude that, "Public health modeling studies suggest that, if determined by risk models, the range of starting ages for screening would be several years greater than using family history alone."

See similarly Jeon 2018, here.

5) Cologuard: CMS Funds Cost-effectiveness Study

In September 2019, there was a media splash when a CMS-funded study appeared ascribing low cost-effectiveness to the Cologuard test.   See PLOS One, Naber et al., here.   Trade press here.  A STAT Op Ed on Cologuard here.   (My blog here.  I agree there are some errors, like lowballing the CMS cost of colonscopy.)

If this had appeared, say, in JAMA, there would be some letters pointing out errors, easily pegged to the article and easily found, co-listed in PubMed, etc.  Not so at PLOS One.

6) 2018 News Meets 2019 News: CRC Screening at Age 45 not 50

In late 2018, American Cancer Society new guidelines that CRC screening should start at 45, not 50.  Here

New tie-in this fall:  In September 2019, FDA approved Cologuard for patients 45-50,  here.


How CMS Makes New Preventive Benefits 

CMS can make new preventive benefits through an NCD if they are first endorsed by USPSTF.

Separately, for exactly two cancers, prostate and CRC, CMS can make screening benefits by acting on its own (without USPSTF) if it wants to.   For a discussion of the underlying patchwork of laws, here.



Essay comparing making new laws to making sausages.  Here.  Probably could adapt to "making new Medicare CRC preventive screening benefits."

But that's in keeping with the spirit of the original sausage metaphor.  The idea "Don't watch how sausage is made," from Bismarck, stated in full: "Don't watch how either law or sausages are made." Or colorectal cancer preventive screening benefits.

Original online here.

Essay, on the original Bismarck quote,"The less the people know about how either laws or sausage are made, the better they will sleep."  ("Je weniger die Leute wissen, wie Würste und Gesetze gemacht werden, desto besser schlafen sie!“)