System Dynamics of Selecting and Prioritizing CRC Screening Modalities
This diagram visualizes the complex interactions and factors influencing clinics’ decisions about whether to prioritize stool-based testing and/or routine colonoscopy screenings. This causal loop diagram illustrates the various factors affecting screening adherence rates and costs of screening depending on screening modality used.
Understanding the diagram:
- S (Same): Arrows marked with “S” indicate that the two connected variables move in the same direction. For example, if one variable increases, the other also increases.
- O (Opposite): Arrows marked with “O” suggest that the variables move in opposite directions. If one variable increases, the other decreases.
- Solid Lines: These lines represent direct relationships or influences between variables.
- Dotted Lines: Dotted lines indicate indirect relationships or feedback loops that may require additional steps to influence the connected variables.
The diagram serves as a roadmap for understanding CRC screening gaps and the short-term and long-term financial impacts of different screening modalities. By examining these loops, we can gain insights into the dynamics that clinics face when deciding which CRC screening modality to offer patients as well as the types of EBIs to implement to support screening.
Cited references for this diagram
Specifically, highly reported patient barriers among BCC and CRC PNs included lack of: knowledge about cancer; knowledge about cancer screening procedures; knowledge about the benefit of screening; motivation to get screened; transportation; and health insurance.
Barrington WE, DeGroff A, Melillo S, Vu T, Cole A, Escoffery C, Askelson N, Seegmiller L, Gonzalez SK, Hannon P. Patient navigator reported patient barriers and delivered activities in two large federally-funded cancer screening programs. Prev Med. 2019 Dec;129S:105858. doi: 10.1016/j.ypmed.2019.105858. Epub 2019 Oct 22. PMID: 31647956; PMCID: PMC7055651.
Currently, CDC's patient navigation policy requires that PNs deliver the following six activities: 1) assessment of patient's barriers to cancer screening, diagnostic services, or initiation of cancer treatment; 2) patient education and support; 3) resolution of patient barriers; 4) patient tracking and follow-up over at least two patient contacts to monitor completion of screening and diagnostic testing and treatment initiation; 5) collection of outcomes related to patient navigation (e.g., adherence to screening, diagnostic testing, and treatment); and 6) collection of patient-reported outcomes related to cancer screening, diagnosis, or treatment (Centers for Disease Control and Prevention (CDC); Centers for Disease Control and Prevention (CDC) and Division of Cancer Prevention and Control, 2019)
Barrington WE, DeGroff A, Melillo S, Vu T, Cole A, Escoffery C, Askelson N, Seegmiller L, Gonzalez SK, Hannon P. Patient navigator reported patient barriers and delivered activities in two large federally-funded cancer screening programs. Prev Med. 2019 Dec;129S:105858. doi: 10.1016/j.ypmed.2019.105858. Epub 2019 Oct 22. PMID: 31647956; PMCID: PMC7055651.
Results suggest that CRC PNs can increase follow-up efforts (e.g., reminder calls) for both fecal screening testing and colonoscopy as well as activities to address structural barriers.
Barrington WE, DeGroff A, Melillo S, Vu T, Cole A, Escoffery C, Askelson N, Seegmiller L, Gonzalez SK, Hannon P. Patient navigator reported patient barriers and delivered activities in two large federally-funded cancer screening programs. Prev Med. 2019 Dec;129S:105858. doi: 10.1016/j.ypmed.2019.105858. Epub 2019 Oct 22. PMID: 31647956; PMCID: PMC7055651.
However, some recent studies with more rigorous study designs have evaluated the effectiveness of PN in increasing CRC screening and found PN effective in addressing individual and system barriers to CRC screening faced by low-income, underserved populations,[[14–16]] improving screening quality, as well as follow-up and diagnostic care, for patients with abnormalities.[[17,18]]
Escoffery C, Fernandez ME, Vernon SW, Liang S, Maxwell AE, Allen JD, Dwyer A, Hannon PA, Kohn M, DeGroff A. Patient Navigation in a Colorectal Cancer Screening Program. J Public Health Manag Pract. 2015 Sep-Oct;21(5):433-40. doi: 10.1097/PHH.0000000000000132. PMID: 25140407; PMCID: PMC4618371.
The high percentage of grantees supporting navigators who are conducting tracking and follow-up activities for both FOBT and colonoscopy is promising, given that these efforts are critical to supporting screening and diagnostic test adherence.
Escoffery C, Fernandez ME, Vernon SW, Liang S, Maxwell AE, Allen JD, Dwyer A, Hannon PA, Kohn M, DeGroff A. Patient Navigation in a Colorectal Cancer Screening Program. J Public Health Manag Pract. 2015 Sep-Oct;21(5):433-40. doi: 10.1097/PHH.0000000000000132. PMID: 25140407; PMCID: PMC4618371.
Specific to screening provision, grantees using colonoscopy as the primary test (n = 12) reported that their navigators made reminder calls for colonoscopy appointments and for bowel preparation (both 92%), assisted patients in accessing bowel preparation materials (83%), tracked patients to ensure the procedure was performed (92%), and made follow-up calls after the colonoscopy to check on patients (83%).
Escoffery C, Fernandez ME, Vernon SW, Liang S, Maxwell AE, Allen JD, Dwyer A, Hannon PA, Kohn M, DeGroff A. Patient Navigation in a Colorectal Cancer Screening Program. J Public Health Manag Pract. 2015 Sep-Oct;21(5):433-40. doi: 10.1097/PHH.0000000000000132. PMID: 25140407; PMCID: PMC4618371.
For screening promotion, grantees reported navigators as having made reminder calls for colonoscopy appointments (83%) and assisted patients in accessing bowel preparation materials (83%). Only 56% of grantees reported that navigators made reminder calls to encourage patients to return FOBT or fecal immunochemical test (FIT) tests, although this may reflect fewer programs working with FOBT/FIT testing.
Escoffery C, Fernandez ME, Vernon SW, Liang S, Maxwell AE, Allen JD, Dwyer A, Hannon PA, Kohn M, DeGroff A. Patient Navigation in a Colorectal Cancer Screening Program. J Public Health Manag Pract. 2015 Sep-Oct;21(5):433-40. doi: 10.1097/PHH.0000000000000132. PMID: 25140407; PMCID: PMC4618371.
The largest time cost was related to bowel preparation and undergoing the colonoscopy procedure; therefore, potentially, noninvasive fecal-based tests could result in lower burden in terms of time lost. Fecal tests, though, require much more frequent screening than colonoscopy and, therefore, may not effectively save much money over the long term.
Hoover S, Subramanian S, Tangka FKL, Cole-Beebe M, Sun A, Kramer CL, Pacillio G. Patients and caregivers costs for colonoscopy-based colorectal cancer screening: Experience of low-income individuals undergoing free colonoscopies. Eval Program Plann. 2017 Jun;62:81-86. doi: 10.1016/j.evalprogplan.2017.01.002. Epub 2017 Jan 7. PMID: 28153341; PMCID: PMC5847315.
In this study, based on retrospective self-reports, patients spent, on average, 23.7 h preparing for, traveling for and having a colonoscopy, and an additional 5.1 h, on average, recovering from the colonoscopy. This translated into a total cost of $335.95 for the patient in lost time and $79.03 for the caregiver. In addition, an estimated $17.46 was incurred in travel and other costs. Even when colonoscopy is provided free of charge to the patient, additional costs may be incurred which could be a significant barrier for low income individuals to receive CRC screening.
Hoover S, Subramanian S, Tangka FKL, Cole-Beebe M, Sun A, Kramer CL, Pacillio G. Patients and caregivers costs for colonoscopy-based colorectal cancer screening: Experience of low-income individuals undergoing free colonoscopies. Eval Program Plann. 2017 Jun;62:81-86. doi: 10.1016/j.evalprogplan.2017.01.002. Epub 2017 Jan 7. PMID: 28153341; PMCID: PMC5847315.
Overall, the total cost of undergoing a “free” colonoscopy screening is substantial for a low-income patient, especially when the average hourly wage estimate used in this analysis for the patient was $11.68. This relatively high cost could explain the reason for the lower levels of compliance with screening recommendations among people with low education and generally low socioeconomic status (Centers for Disease Control and Prevention, 2013).
Hoover S, Subramanian S, Tangka FKL, Cole-Beebe M, Sun A, Kramer CL, Pacillio G. Patients and caregivers costs for colonoscopy-based colorectal cancer screening: Experience of low-income individuals undergoing free colonoscopies. Eval Program Plann. 2017 Jun;62:81-86. doi: 10.1016/j.evalprogplan.2017.01.002. Epub 2017 Jan 7. PMID: 28153341; PMCID: PMC5847315.
In total, patients needed 28.8 h to undergo the colonoscopy screening, resulting in an indirect average cost of $335.95, while it cost the caregiver $79.03.
Hoover S, Subramanian S, Tangka FKL, Cole-Beebe M, Sun A, Kramer CL, Pacillio G. Patients and caregivers costs for colonoscopy-based colorectal cancer screening: Experience of low-income individuals undergoing free colonoscopies. Eval Program Plann. 2017 Jun;62:81-86. doi: 10.1016/j.evalprogplan.2017.01.002. Epub 2017 Jan 7. PMID: 28153341; PMCID: PMC5847315.
Many studies have documented barriers to cancer screenings in general and CRC screenings in particular. The barriers include low levels of education, language or communication challenges, low socioeconomic status, and lack of insurance coverage (Gimeno Garcia, 2012; Heitman, Au, Manns, McGregor, & Hilsden, 2008; Subramanian, Klosterman, Amonkar, & Hunt, 2004). Cost has also been cited as a barrier (Jones, Devers, Kuzel, & Woolf, 2010; Klabunde et al., 2005).
Hoover S, Subramanian S, Tangka FKL, Cole-Beebe M, Sun A, Kramer CL, Pacillio G. Patients and caregivers costs for colonoscopy-based colorectal cancer screening: Experience of low-income individuals undergoing free colonoscopies. Eval Program Plann. 2017 Jun;62:81-86. doi: 10.1016/j.evalprogplan.2017.01.002. Epub 2017 Jan 7. PMID: 28153341; PMCID: PMC5847315.
Although the authors found that direct clinical costs were higher for colonoscopy-only screening programs than for FOBT/FIT-only programs, nonclinical costs did not vary by screening test type, suggesting that these programs have substantial fixed costs.
Joseph DA, DeGroff A. The CDC Colorectal Cancer Control Program, 2009-2015. Prev Chronic Dis. 2019 Dec 5;16:E159. doi: 10.5888/pcd16.190336. PMID: 31808418; PMCID: PMC6896829.
Implementation of patient navigation and community health workers remained flat over time, likely due, in part, to the need for ongoing funding for staff.
Maxwell AE, DeGroff A, Hohl SD, Sharma KP, Sun J, Escoffery C, Hannon PA. Evaluating Uptake of Evidence-Based Interventions in 355 Clinics Partnering With the Colorectal Cancer Control Program, 2015-2018. Prev Chronic Dis. 2022 May 19;19:E26. doi: 10.5888/pcd19.210258. PMID: 35588522; PMCID: PMC9165474.
Surveillance that occurs too frequently provides little or no benefit while exposing patients to the risk of complications, increasing costs, and wasting resources that could instead be used for primary screening. Waiting too long increases risk of disease progression to a point where treatment may be less effective.
Nadel MR, Royalty J, Joseph D, Rockwell T, Helsel W, Kammerer W, Gray SC, Shapiro JA. Variations in Screening Quality in a Federal Colorectal Cancer Screening Program for the Uninsured. Prev Chronic Dis. 2019 May 30;16:E67. doi: 10.5888/pcd16.180452. PMID: 31146803; PMCID: PMC6549419.
Based on a single screening cycle for FOBT, screening with FOBT, including colonoscopy follow-up, was less costly than colonoscopy, both per person and per program.
Seeff LC, DeGroff A, Joseph DA, Royalty J, Tangka FK, Nadel MR, Plescia M. Moving forward: using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts. Cancer. 2013 Aug 1;119 Suppl 15:2940-6. doi: 10.1002/cncr.28155. PMID: 23868488.
Data from the CRCSDP did not allow us to compare costs of an FOBT program with a colonoscopy program over multiple years, during which annually repeated FOBTs and diagnostic colonoscopies would accrue.
Seeff LC, DeGroff A, Joseph DA, Royalty J, Tangka FK, Nadel MR, Plescia M. Moving forward: using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts. Cancer. 2013 Aug 1;119 Suppl 15:2940-6. doi: 10.1002/cncr.28155. PMID: 23868488.
Additionally, the clinical cost of colonoscopy is almost four times the cost of FOBT/FIT per person when screening and diagnostic follow up tests are taken into account. Therefore, programs that use colonoscopy will only be able to screen about one-fourth the number of individuals during the early years of the program. As the colonoscopy screening interval is every 10 years compared to every year for FOBT/FIT, the numbers screened will converge over time but the initial screen will be delayed in the colonoscopy versus FOBT/FIT programs.
Subramanian S, Tangka FKL, Hoover S, Royalty J, DeGroff A, Joseph D. Costs of colorectal cancer screening provision in CDC's Colorectal Cancer Control Program: Comparisons of colonoscopy and FOBT/FIT based screening. Eval Program Plann. 2017 Jun;62:73-80. doi: 10.1016/j.evalprogplan.2017.02.007. Epub 2017 Feb 7. PMID: 28190597; PMCID: PMC5863533.
FOBT/FIT tests were the preferred approach when the primary goal was to offer first-time screening to a large cohort over a short period; we did not study FOBT/FIT with repeated testing. Future studies could assess additional program costs that may be incurred, to ensure adherence with colorectal cancer screening recommendations over the long term.
Subramanian S, Tangka FKL, Hoover S, Cole-Beebe M, Joseph D, DeGroff A. Comparison of Program Resources Required for Colonoscopy and Fecal Screening: Findings From 5 Years of the Colorectal Cancer Control Program. Prev Chronic Dis. 2019 Apr 25;16:E50. doi: 10.5888/pcd16.180338. PMID: 31022371; PMCID: PMC6513474.
The clinical cost of colonoscopy was almost 5 times the cost of FOBT/FIT per person when screening and diagnostic follow-up tests were included. Therefore, programs that use colonoscopy will only be able to screen about one-fifth the number of people that FOBT/FIT programs can for the same level of funding in the initial years of the program. This cost would only affect the number of people screened in the short term because colonoscopy is recommended every 10 years for those at average risk and with normal results, whereas FOBT/FIT is recommended to be performed annually. The clinical costs over a 10-year period for colonoscopy and FOBT/FIT may not be substantially different.
Subramanian S, Tangka FKL, Hoover S, Cole-Beebe M, Joseph D, DeGroff A. Comparison of Program Resources Required for Colonoscopy and Fecal Screening: Findings From 5 Years of the Colorectal Cancer Control Program. Prev Chronic Dis. 2019 Apr 25;16:E50. doi: 10.5888/pcd16.180338. PMID: 31022371; PMCID: PMC6513474.
Systematic reviews have identified barriers to CRC screening including low levels of education, language or communication issues, low socioeconomic status, lack of insurance coverage, and general attitudes towards prevention (for example, smokers are less likely to seek screening) (Gimeno Garcia, 2012; Subramanian et al., 2004).
Tangka FKL, Subramanian S, Hoover S, Royalty J, Joseph K, DeGroff A, Joseph D, Chattopadhyay S. Costs of promoting cancer screening: Evidence from CDC's Colorectal Cancer Control Program (CRCCP). Eval Program Plann. 2017 Jun;62:67-72. doi: 10.1016/j.evalprogplan.2016.12.008. Epub 2016 Dec 12. PMID: 27989647; PMCID: PMC5840873.
Grantees in areas with a screening prevalence of 69.6% or higher allocated the smallest proportion of their screening promotion funds to outreach and education compared with grantees in areas with a screening prevalence of 69.5% or lower. The priority for grantees in areas with higher screening prevalence is navigating the patients along the screening continuum to ensure adherence with recommended screening, diagnostic follow-up, and referral for treatment recommendations; thus, these grantees spent more resources on patient navigation.
Tangka FKL, Subramanian S, Hoover S, Cole-Beebe M, DeGroff A, Joseph D, Chattopadhyay S. Expenditures on Screening Promotion Activities in CDC's Colorectal Cancer Control Program, 2009-2014. Prev Chronic Dis. 2019 Jun 6;16:E72. doi: 10.5888/pcd16.180337. PMID: 31172915; PMCID: PMC6583814.
The patient navigator identified barriers (N=148) to patients being screened for colorectal cancer or other cancers. The largest categories of barriers identified included financial or insurance issues (30.4%, 45/148); psychosocial issues, such as fear of the test and fear of test outcome (23.6%; 35/148); and transportation (23.6%; 35/148).
Tangka FKL, Subramanian S, Hoover S, Cariou C, Creighton B, Hobbs L, Marzano A, Marcotte A, Norton DD, Kelly-Flis P, Leypoldt M, Larkins T, Poole M, Boehm J. Improving the efficiency of integrated cancer screening delivery across multiple cancers: case studies from Idaho, Rhode Island, and Nebraska. Implement Sci Commun. 2022 Dec 16;3(1):133. doi: 10.1186/s43058-022-00381-4. PMID: 36527147; PMCID: PMC9756516.
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