Launching a CT colorectal cancer screening program: 4 barriers and how to overcome them

CT for colorectal cancer screening is at an “inflection point” following the Centers for Medicare & Medicaid Services’ recent decision to cover the exam. However, barriers to widespread adoption remain, which radiologists and other stakeholders must address.

That’s according to a new analysis from members of the specialty, published Wednesday in the American Journal of Roentgenology. Despite “extensive” supporting data, utilization of CTC as an alternative to colonoscopy remains sparse. Widespread deployment of the exam could help to bolster adherence rates while cutting back on cancer incidence, experts charge. 

“CTC screening has followed a tortuous and extended path toward acceptance due to factors unrelated to the test’s diagnostic performance,” David H. Kim, MD, with the Department of Radiology at the University of Wisconsin’s school of medicine, and colleagues wrote March 12. “Now, with the CMS approval of reimbursement for screening CTC examinations, CTC is poised to be incorporated into large-scale screening efforts in the United States.”

Kim and co-authors cited four common barriers to CTC adoption in the U.S., with potential solutions to overcome these obstacles.

“Addressing these challenges will be key to promoting future CTC integration,” the authors emphasized.  

1. Need for primary care acceptance: PCPs represent patients’ main access point to CT colorectal cancer screening, and they must be convinced the test is comparable to, or offers advantages over, other options. 

In the past, primary care physicians have steered patients to other options such as colonoscopy, due to the lack of coverage. 

“This perception will hopefully change given the recent CMS approval decision on top of the previously noted large longstanding body of supporting literature,” the authors advised. “Outreach, education, and reinforcement will be key to broaden PCPs’ … CTC adoption. In addition to efforts by individual radiologists, intersociety collaboration will likely be required.” 

2. Incidental extracolonic findings: Along with reimbursement, PCPs also have stated concerns about the incidental findings that come with CTC, Kim and colleagues noted. These may require further tests and procedures, which can increase patient anxiety and the burden on their PCPs. 

But experts caution that incidental findings only occur in about 6% to 8% of cases. Plus, sometimes, these findings could prove to be important. For instance, abdominal aortic aneurysms and extracolonic cancers are found incidentally in about 2% to 3% of cases. Standardization via the CT Colonography Reporting and Data System (C-RADS) can help maintain consistency, the authors added. 

“In the authors’ experience, the key to changing providers’ perception regarding extracolonic findings is not necessarily to emphasize a positive benefit-risk ratio but to minimize the cognitive burden added to the provider’s care of the patient,” Kim et al. advised. “Besides the fear that the recommendation is missed or incorrectly evaluated, incidental extracolonic findings yield additional work for the PCP to determine if and what additional tests are needed. Messaging within the electronic record, incorporating specific recommendations on how to best evaluate the finding, is an easy and well-received method to decrease the demands placed on the PCP. The inclusion of an option to call the radiologist directly for additional discussion furthers positive sentiment.” 

3. Radiologist reservations: Members of the specialty have been hesitant to recommend CTC, which has hindered its widespread use. Along with reimbursement, the perceived time investment for interpretation and worries about greater risk of error also impact CTC implementation. 

Specific CTC knowledge is needed to be able to detect and differentiate true soft-tissue polyps, the authors advised. 

“Training is critical to substantially increasing the number of qualified CTC readers, as discussed later,” Kim et al. wrote. “Whether gained expertise and reimbursement will shift radiologist interest toward greater CTC involvement, or ongoing time investment and fear of missed lesions will continue to dampen interest, remains to be seen.” 

4. Widespread standardized training: Building off the previous item, there is a need for training of radiologists on the interpretation of CTC exams. However, there is widespread variability in recommendations related to these educational endeavors. 

Kim and co-authors call for standardization in CTC schooling to help pave the way for colorectal cancer screening programs. 

“To date, much training has traditionally been accomplished by on-the-job exposure within a department or through commercially available short courses,” the authors wrote. “However, development of structured curricula is vital to reduce variation in practice and skills acquisition for radiologists. Recommended best practice principles in CTC interpretation training include: an expert CTC faculty; a structured syllabus with clinically relevant content, addressing the differentiation of neoplastic and non-neoplastic abnormalities, as well as identification [of] flat and small polyps; emphasis on pitfalls and common errors; and individualized training with feedback.”

In a corresponding editorial, radiologist Marc J. Gollub, MD, called CMS’ acceptance of CT for colorectal cancer screening a “landmark public health victory.” He noted that about 41% of eligible individuals do not undergo screening for the disease, presenting opportunity for members of the specialty. 

“So, let us radiologists—along with our primary and subspecialty care colleagues—rise to the occasion and offer modern screening as described in the article and this commentary, to benefit not only individual patients but the larger eligible population by helping to reduce CRC incidence with this newly reimbursable CTC option,” wrote Gollub, a gastrointestinal cancer specialist with Memorial Sloan Kettering in New York.