August 17, 2020
Screening for presence of malignant tumors is the most common form of preventive screening. As a result of the development of more precise imaging and alternative screening modalities for colorectal cancer, much progress has been made in the way we can test for these cancers. However, adherence to testing recommendations remains a challenge.
Beginning at age 40, it is recommended that women of average risk be offered the choice to start annual breast cancer screenings with mammograms if they wish to do so. The American Cancer Society recommends that women aged 45 to 54 receive mammograms every year, while the USPSTF recommends that women aged 50 through 74 should undergo biennial screening.17 While screening mammography can reduce the risk of breast cancer, the risk of false positive results and unnecessary biopsies increases with the frequency of screenings performed. Diagnostic mammograms or sonograms are conducted when additional images are needed after the standard screening or when either the patient or physician notices a lump or thickening of the breast tissue: mammograms can also be considered routine chronic care when it is administered as a follow-up procedure to tissue removal.
Nearly half of all women age 40 and older who get mammograms are found to have dense breasts. Breast density is often inherited but can be associated with other factors such as age, having children and taking certain drugs indicated for treating early-stage breast cancer.18 While the NIH’s National Cancer Institute (NCI) highlights how dense breast tissue can make mammograms harder to read and therefore more difficult to depend on as a screening tool, they also note that these individuals are no more likely to die from breast cancer than those with breasts of average density.17
The USPSTF gave adjunctive breast cancer screenings (e.g., breast ultrasonography, MRIs, etc.) for women with dense breasts an “I” rating, determining that there is insufficient current evidence to determine whether the benefits outweigh the risks of covering these procedures as preventive. Therefore, HDHPs are not required to cover them before the deducible. However, employers may have more latitude to do so in non-HDHP plan designs. Because clinicians may choose to code certain procedures as diagnostic versus preventive (e.g., a sonogram along with a mammogram for breast cancer screening), employers should encourage their employees to discuss what is included under the umbrella of “free preventive testing” with their doctors so that they are aware of those services that may incur additional costs.
Colorectal cancer screenings are categorized either as visual tests or stool-based tests:
Visual tests are invasive procedures that look inside the colon/rectum for abnormal areas that might be cancer or polyps.
- Colonoscopy: This procedure uses a flexible lighted tube with a small camera on the end to look at the entire length of the colon and rectum. If polyps are found, they may be removed during the test. If the results come back normal, providers will typically recommend that colonoscopies only be completed once every 10 years for those without an increased risk of developing colon cancer due to other factors.
- CT colonography (virtual colonoscopy): This procedure scans the colon and rectum to produce detailed cross-sectional images that clinicians can use to look for polyps and/or cancer. If something is seen that may need to be biopsied, a follow-up traditional colonoscopy will be needed. CT colonography should be done every 5 years if completed in lieu of traditional colonoscopy. CT colonography can also detect other abnormalities in the kidneys, liver, or pancreas.19
- Flexible sigmoidoscopy (FSIG): While this procedure is not widely used for colorectal screening in the United States, it functions as an abbreviated form of colonoscopy since it only looks at specific parts of the colon and rectum. If polyps are found, they may be removed during the test or during a subsequent colonoscopy. Flexible sigmoidoscopy should be done every 5 years, or every 10 years along with a FIT (stool-based test) conducted every year.20
Stool-based tests are non-invasive colorectal cancer screening options, as they do not require an office visit, anesthesia or bowel preparation. However, if the test indicates the presence of possible cancer or pre-cancer, a colonoscopy will be needed to confirm the result, possibly accompanied by the removal of any abnormal tissue or polyps.21 Abnormal test results may also be due to non-cancerous conditions, such as ulcers or hemorrhoids. Stool-based tests are recommended for people who have an average risk for colorectal cancer, such as those with no personal history of pre-cancerous polyps, no colorectal cancer that runs in the family or other risk factors. While decisions on the ideal colon cancer screening strategy are made between the patient and their provider, if stool-based tests are recommended, they typically should be completed every 1-3 years and between visual tests.17
- Stool DNA testing: This type of test looks for certain DNA or gene changes that often get into the stool and are sometimes found in pre-cancerous growths and cancer cells. It also checks for blood in the stool, which can be a sign of cancer. Patients use a take-home kit to collect a stool sample and mail it to a lab. Cologuard® is the name of a stool DNA test that is currently approved by the Food and Drug Administration (FDA).
- Fecal immunochemical test (FIT)/guaiac-based fecal occult blood test (gFOBT): These tests are used to find tiny amounts of blood in the stool that could be a sign of cancer or large polyps. Patients take these tests at home with a kit they receive from their doctor’s office, along with instructions on how to do the test and return it to the doctor’s office or lab to be checked for the presence of blood.17 Because this type of test cannot determine where blood in the stool might be coming from, any abnormal results need to be followed up with a colonoscopy.
Although the risk of developing colorectal cancer increases with age, with more than 90% of cases occurring in people age 50 or older, recent research shows that the incidence of colorectal cancer has been increasing 1% to 3% annually for people younger than age 50 while decreasing in older individuals.22 The rise in colorectal cancer incidence in younger adults correlates with increasing obesity rates in the United States, though it is unclear what role other common risk factors, including diet, inactivity, and family history, may be playing in the early onset of this disease. The American Cancer Society (ACS) recommends that people of average risk start regular colorectal cancer screenings at age 45. However, the USPSTF colonoscopy guidelines currently recommend that average risk individuals begin screening at age 50; this means that plans are only required to cover the cost of screenings from age 50 and older. Employers should consider beginning coverage at age 45 to adhere to the ACS guidelines.
In the United States, lung cancer is the second most common cancer in both men and women, as well as the leading cause of death compared to other cancers. The only recommended screening test for lung cancer is a low-dose CT scan, which is recommended for adults without symptoms who have a history of smoking or are current smokers and those who have quit within the last 15 years and are between 55 and 80 years old.23 Adults exhibiting symptoms that might be caused by lung cancer may need CT scans or other tests to find the underlying cause; however, this would be considered diagnostic services.24
Lung cancer screenings within the recommended populations are extremely underutilized, with fewer than 2% of those eligible undergoing LDCT at one of the approximately 1,800 screening centers across the country in 2016.25 While the lack of screening facilities in rural areas is likely a factor, as smoking and lung cancer mortality rates tend to be higher in these communities, patient education on the importance of screening is key to ensuring that those who would benefit most are completing these tests.
- 1 | United States Preventive Services Task Force (USPSTF). Recommendation Topics. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics. Accessed July 8, 2020.
- 2 | Business Group on Health. ACA Preventive Services Chart. https://www.businessgrouphealth.org/resources/aca-preventive-services-chart. Accessed July 31, 2020.
- 3 | Business Group on Health. HSA/HDHPs Can Now Provide Pre-Deductible Coverage for Insulin and Other Chronic Condition Treatments. https://www.businessgrouphealth.org/resources/hsa-hdhps-can-now-provide-pre-deductible-coverage-for-insulin-and-other-chronic-condition-treatments. Accessed July 8, 2020.
- 4 | Primary Care Collaborative. Spending for Primary Care Fact Sheet. https://www.pcpcc.org/sites/default/files/resources/PCPCC%20Fact%20Sheet%20PC%20Spend%20Aug%202018.pdf. Accessed July 31, 2020.
- 5 | Beckman AL, Becerra AZ, Marcus A, et al. Medicare Annual Wellness Visit association with healthcare quality and costs. Am J Manag Care. 2019;25(3):e76-e82. Published 2019 Mar 1.
- 6 | Medical Mutual. The Difference Between Preventive and Diagnostic Medical Care. https://www.medmutual.com/For-Individuals-and-Families/Healthy-Living/What-Is-Preventive-Healthcare/The-Difference-Between-Preventive-and-Diagnostic-Medical-Care.aspx. Accessed July 8, 2020.
- 7 | American Academy of Family Physicians (AAFP). Choosing Wisely® annual EKGs for low-risk patients. https://www.aafp.org/patient-care/clinical-recommendations/all/cw-ekg.html. Accessed July 8, 2020.
- 8 | Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics—2018 update: a report from the American Heart Association. Circulation. 2018;137:e67–e492.
- 9 | Pippitt K, Li M et al. Diabetes mellitus: Screening and diagnosis. Am Fam Physician. 2016 Jan 15;93(2):103-109.
- 10 | United States Preventive Services Task Force. Final Recommendation Statement: Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening. October 26, 2015. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes. Accessed July 8, 2020.
- 11 | United States Preventive Services Task Force. Screening for Cardiovascular Disease Risk with Electrocardiography: Recommendation Statement. https://www.aafp.org/afp/2018/0915/od1.html. Am Fam Physician. 2018 Sep 15;98(6):online.
- 12 | United States Preventive Services Task Force (USPSTF). Final Recommendation Statement: Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medicine. November 13, 2016. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/statin-use-in-adults-preventive-medication. Accessed July 31, 2020.
- 13 | United Kingdom National Health Service (NHS). Diagnosis: Chronic kidney disease. August 29, 2019. https://www.nhs.uk/conditions/kidney-disease/diagnosis/. Accessed July 8, 2020.
- 14 | United States Preventive Services Task Force (USPSTF). Understanding Task Force Recommendations: Screening for Chronic Kidney Disease. August 2012. https://www.uspreventiveservicestaskforce.org/Home/GetFileByID/1881. Accessed July 31, 2020.
- 15 | Business Group on Health. New ACA Preventive Service Coverage Requirement for HIV (PrEP). https://www.businessgrouphealth.org/resources/new-aca-preventive-service-coverage-requirement-for-hiv-prep. Accessed July 8, 2020.
- 16 | Business Group on Health. HIV/AIDS: Despite Progress, Much Work Remains. https://www.businessgrouphealth.org/en/resources/hiv-aids-despite-progess-much-work-remains. Accessed July 31, 2020.
- 17 | Centers for Disease Control and Prevention. Breast Cancer Screening Guidelines for Women. https://www.cdc.gov/cancer/breast/pdf/BreastCancerScreeningGuidelines.pdf. Accessed July 8, 2020.
- 18 | National Institute of Health: National Cancer Institute. Dense Breasts: Answers to commonly asked questions. https://www.cancer.gov/types/breast/breast-changes/dense-breasts. Accessed July 8, 2020.
- 19 | Mayo Clinic. Virtual Colonoscopy. https://www.mayoclinic.org/tests-procedures/virtual-colonoscopy/about/pac-20385156. Accessed July 8, 2020.
- 20 | Centers for Disease Control and Prevention. Colorectal (Colon Cancer): Screening Tests. https://www.cdc.gov/cancer/colorectal/basic_info/screening/tests.htm. Accessed July 8, 2020.
- 21 | Simon S. Colorectal Cancer Screening: What Are My Options? American Cancer Society. March 2, 2020. https://www.cancer.org/latest-news/understanding-tests-that-screen-for-colon-cancer.html. Accessed July 8, 2020.
- 22 | Cavallo J. Solving the mystery of why colorectal cancer Is on the rise in young adults: A conversation with Kimmie Ng, MD, MPH. The ASCO Post. https://www.ascopost.com/issues/june-25-2019/solving-the-mystery-of-why-colorectal-cancer-is-on-the-rise-in-young-adults/. Accessed July 8, 2020.
- 23 | Centers for Disease Control and Prevention. Lung Cancer: Who Should Be Screened for Lung Cancer? https://www.cdc.gov/cancer/lung/basic_info/screening.htm. Accessed July 8, 2020.
- 24 | American Cancer Society. Can lung cancer be found early? https://www.cancer.org/content/cancer/en/cancer/lung-cancer/detection-diagnosis-staging/detection.html. Accessed July 8, 2020.
- 25 | Business Group on Health. Webinar Presentation: A conversation about the Impact of the expanding field of genetic testing on employers and key considerations for coverage. February 4, 2020.
- 26 | United States Preventive Services Task Force (USPSTF). Final Recommendation Statement: BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing. August 20, 2019. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/brca-related-cancer-risk-assessment-genetic-counseling-and-genetic-testing. Accessed July 8, 2020.
IntroductionEmployers' Guide to Preventive Care
Part 1Preventive Care: Regulatory Framework
Part 2Preventive Care: "Annual" Visits and Preventive Screening Considerations
Part 3Preventive Care: Role of Preventive Screenings in Managing Chronic Conditions
Part 4Preventive Care: Cancer Screening Guidelines
Part 5Preventive Care: Emerging Preventive Care Coverage Considerations
Part 6Preventive Care: Opportunities for Employers