ACR Bulletin

Covering topics relevant to the practice of radiology

A Health Equity Hurdle: Access to Affordable CT Colonography

Even though colorectal cancers are expected to claim 52,000 lives in the U.S. this year, preventive screening is not always available to vulnerable populations. This second in an ACR Bulletin series showcases physician-led efforts to close gaps in awareness, access and outcomes.

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The best test is the one that gets done, but we are far from achieving optimal screening rates for colorectal cancer.

—Judy Yee, MD, FACR
August 31, 2023

This article is the second in a five-part series and examines the role of CTC and other types of screening for the underserved. The first article in the series, Exploring Radiology’s Role in Advancing Health Equity: Access to Uterine Fibroid Treatments, was posted in August on the Bulletin website.

Efforts to eradicate disparities in delivering critical imaging services continue to gain momentum as systemic problems loom large over the house of medicine. Current healthcare inequities in radiology can result in lower quality of care, poor patient outcomes and higher costs to patients and providers.

Marginalized populations often face barriers to treatment — including education and outreach, access to healthcare services and a host of social determinants that plague underserved communities. Initiatives that establish health equity coalitions and build from innovative institutional efforts to ensure health equity on a national united front are helping to put equitable healthcare services within reach.

The ACR is part of the Radiology Health Equity Coalition (RHEC), a group of 11 organizations that joined forces in 2021 to positively impact health equity for women, people of color and rural populations. To paint a picture of how radiologists and physicians from other specialties are moving the needle, the ACR Bulletin is interviewing changemakers who are advancing equitable care.

CTC for Underserved Populations

Excluding skin cancers, colorectal cancer (CRC) is the third-most-common cancer diagnosed in both men and women in the U.S. It is the second-most-common cause of cancer deaths when numbers for men and women are combined, according to the American Cancer Society. But screening for colorectal issues can be complicated because the options are not always available or affordable for everyone.

The three main colon health testing options are a colonoscopy, a CT colonography (CTC) or an at-home stool test. CTC, known as a virtual colonoscopy, is an effective and non-invasive diagnostic tool that uses an advanced CT scan to generate a 3D image of the colon and surrounding organs so radiologists can spot potential abnormalities. It requires home bowel preparation, and patients can resume normal activities following the scan. CTC may also be a more viable option for patients who cannot or do not wish to be sedated because of pre-existing medical conditions or who are on anticoagulation therapy.

The lack of Medicare coverage for screening CTC is a major barrier and makes no sense. Of all the colorectal cancer screening tests supported by the U.S. Preventive Services Task Force (USPSTF) and the ACS, CTC is the only one that is not currently approved by CMS.

—Judy Yee, MD, FACR

However, research published in the American Journal of Roentgenology shows the likelihood of undergoing CRC screening tests — including undergoing diagnostic CTC, a CMS-covered test with similar physical access as screening CTC — is a function of race, ethnicity, income and urbanicity. The less-invasive screening approach is often not accessible for low-income patients because Medicare does not cover screening CTC. That means instead of being screened for signs of pre-cancer, the testing methods available often wind up being too little or too late to catch cancer before it takes hold.

“For colon screening, the trend at our site and nationally has been an increased use of stool testing (FIT testing), which does not require a trip to the hospital,” says Judy Yee, MD, FACR, professor and university chair of radiology at Montefiore Medical Center, the teaching hospital of the Albert Einstein College of Medicine. Yee is an abdominal and gastrointestinal radiologist, a passionate advocate for screening CTC and chair of the ACR Colon Cancer Committee.

“However, stool tests (FIT and DNA tests) are best for identifying cancers, not precursor polyps,” Yee says. “CTC can find a precursor polyp, which can be resected using colonoscopy, and cancer may be prevented. CTC and colonoscopy are structural tests that have high accuracy in identifying polyps before they become malignant — and that is really the goal of this screening for best patient outcomes.”

Screening in Marginalized Communities

The 2023 American Cancer Society’s (ACS) estimates for colorectal cancers in the U.S. are 106,970 new cases of colon cancer and 46,050 new cases of rectal cancer — with more than 52,000 deaths anticipated as a result by year’s end. In people younger than 50, colorectal cancer rates have been increasing by 1% to 2% each year since the mid-1990s. Native American and Alaska Native people have the highest rates of colorectal cancer in the U.S., followed by Black and Latino men and women.

“We provide services for the underserved population in the Bronx, home to 1.4 million residents, with approximately 55% of them Hispanic and 35% Black,” Yee says. “Around 85% of healthcare costs for our Bronx patients are paid by government payers — Medicare and Medicaid — and there is a high burden of chronic diseases in the community.”

Because of the diverse population it serves, Montefiore Medical Center is committed to looking for ways to meet the needs of its patients beyond the limitations of CMS coverage.

“As an institution, there has been an inherent mission to provide outstanding equitable care to our patients. We are proud of having diverse trainees and faculty to help mirror the gender and race/ethnicity of patients in our communities,” Yee says.

“We are not yet formally working with the RHEC, but completely support the coalition and its aim,” Yee says. “I am on the board of directors of the New York State Radiological Society (NYSRS) and New York was the first state to join the RHEC. I am also on the board of directors of the Society of Chairs of Academic Radiology Departments (SCARD), which is also a member of RHEC.”

There is a need to improve patients’ trust in the healthcare system, Yee says. “This begins with the interactions they have from first access to follow-up care.”

Being visible in your community is one way to demonstrate your commitment to improving equal access to healthcare education and services. “In radiology, we hold and participate in community events throughout the year targeted toward Bronx patients,” Yee says. “For example, we hold events on stroke awareness, lung cancer screening access and colorectal cancer education — and have multidisciplinary participation. We offer free breast cancer screenings annually — so patients do not need health insurance to participate — and provide outpatient imaging care during evening and weekend hours for patients who may not be able to take time off on regular workdays.”

Yee says her institution also has community workforce programs in place to help recruit local community members to work with and within its health network. “We also have an established diversity, equity and inclusion committee and bring in speakers to broaden education around the challenges of providing equitable healthcare,” she says.

Her group is currently in talks to develop more mobile health services in the Bronx and beyond. “We are in the process of partnering with a group to use mobile CT units for lung cancer screening, for instance, and are just working out some logistical issues and multidisciplinary workflow solutions,” Yee says.

“We focus on a lot of screenings here, but colon screening is way behind lung and breast cancer screening,” Yee says. “Colorectal cancer is nearly always treatable, if caught early, and can even be prevented through timely screening.” Providing a less invasive method of colorectal screening may be more appealing to certain patient cohorts, Yee says, particularly for those in marginalized communities.

Barriers to Care and Medicare Coverage

There are some barriers to education and access to services for low-income and marginalized populations that radiologists can help patients and potential patients overcome. “Language is definitely a barrier, and we need to make sure we are communicating in not only a patient’s first language, but also at a level they can understand,” Yee says. Providing easily accessible on-site translation services can help.

English, Spanish and other languages are spoken at all local events to overcome communication barriers, Yee says. “We hired a bilingual lung cancer screening navigator to work with our cancer center to promote increased screening and improved follow-up care,” Yee says. “We also provide education and promote healthcare events on local TV stations in both English and Spanish.”

“Insurance coverage and payment for healthcare services is another barrier and always a concern for patients,” Yee says. “We can make the process more manageable in part with timely pre-authorizations and by ensuring adequate coverage for services.

“The lack of Medicare coverage for screening CTC is a major barrier and makes no sense,” Yee says. “Of all the colorectal cancer screening tests supported by the U.S. Preventive Services Task Force (USPSTF) and the ACS, CTC is the only one that is not currently approved by CMS.”

The ACS has adopted an approach to provide all the options recommended by the USPSTF as a solution to low screening rates. The ACR agrees with that approach and — along with a host of other national healthcare advocates and organizations — continues to submit requests to CMS to include screening CTC among the covered options offered to Medicare patients. USPSTF guidelines recommend colon screening for those at average risk beginning at age 45 instead of 50. It is more important than ever that these patients are identified and have access to all screening options.

“Adding CTC to the colorectal cancer screening test armamentarium is in the best interests of all individuals,” Yee says. “The best test is the one that gets done, but we are far from achieving optimal screening rates for colorectal cancer.”

Leadership and Building Networks

Advancing health equity through fair and more easily accessible screening requires effective communication of your strategy, Yee says. To build an effective health equity network, you need a clear vision and mission, with concrete goals and timelines. “Your network should be inclusive of radiology and imaging organizations but also needs to be multi-disciplinary to be most effective,” she says.

Funding for infrastructure to advance equitable support services must be diligently sought out, and there needs to be more rigorous education of trainees starting at least in medical school and during specialty training, Yee says. “It is equally important that all frontline staff are engaged and trained to foster a more like-minded workplace culture,” she says.

Institutions and practice groups attempting to launch or emulate health equity initiatives must have the full support of leadership at multiple levels — institutional, departmental, divisional and so on, Yee says. “There needs to be multiple approaches to achieving health equity, and it won’t happen overnight,” she points out. A phased approach involving many people — from the entire health care team — and establishing an open exchange of ideas can make it easier to achieve your goals.

To truly transform the healthcare landscape into a fair, inclusive and welcoming environment, it will take a national, or even global, push for more testing options. As Yee notes, “There must be a real commitment by all leaders — looking through the lens of social justice — to ensure equitable healthcare services for patients who have difficulty gaining access or who may be reluctant to seek care.”

Resources

About the RHEC

In addition to the ACR, members of the Radiology Health Equity Coalition include the American Board of Radiology, American Medical Association Section Council on Radiology, Association of University Radiologists, National Medical Association Section on Radiology and Radiation Oncology, Radiological Society of North America, Society of Chairs of Academic Radiology Departments, Society of Interventional Radiology, Society of Nuclear Medicine and Molecular Imaging and American Association of Physicists in Medicine — with other specialty and state radiology organizations joining the initiative.

This network of patient-focused radiology societies collects, assesses and disseminates resources and best practices, advocates for and connects with patients and community members, and collaborates on programs and services to improve access and use of preventive and diagnostic imaging.

Among the RHEC resources available:

 

Author Chad E. Hudnall  senior writer, ACR Press