Quality in Colorectal Cancer Screening

Colorectal cancer (CRC) is the third most common cancer in the United States of America (USA) with a cumulative lifetime risk of approximately 4%. Over the last decades, the incidence of CRC has declined in the age eligible screening population due to increased uptake in CRC screening. The rapid and alarming rise of CRC, including fatal CRC, in individuals less than age 50 and modeling studies showing more benefit than harm in lowering the age to incept CRC screening in average-risk patients have supported national guidelines in their recommendations to offer CRC screening starting at age 45 years. While a variety of options exist, colonoscopy and stool-based tests are the mainstays of average-risk CRC screening in the USA. Their effectiveness can be significantly reduced if intentional attention to their quality control is not established. Measuring quality has proven beneficial for the protective benefit of colonoscopy; increasing adenoma detection rate is associated with lower post-colonoscopy cancer including fatal post-colonoscopy cancer. Additionally, quality improvement systems which ensure high patient adherence to programmatic fecal blood testing and timely follow-up colonoscopy of positive results have been associated with improved CRC outcomes. Interventions to increase adherence to screening and draw down disparities among minorities, individuals of low socioeconomic status, and other underserved populations with culturally sensitive public awareness, navigation, recall, and elimination of cost sharing should be instituted. Systematic approaches are more likely to succeed in improving the quality and adherence to CRC screening than opportunistic programs. The use of novel noninvasive tests is being studied and will undoubtedly improve the uptake of CRC screening in the eligible population.