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Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole. Joining me in this panel today is Dr. Michelle Olson, she's a colorectal surgeon and Tara Ganley, she's a registered nurse and a performance improvement specialist. They're both with the Carle Foundation Hospital, and they're here to tell us about colon cancer screening and alternative options for colon cancer screening. Thank you both so much for being with us today. This is a great topic. People have a lot of questions about this. So Dr. Olson, starting with you set the table for us a little bit about the prevalence of colon cancer and awareness. What you've been seeing in the trends for other providers?

Dr Michelle Olson: Sure. Thank you so much. So colon cancer is the third, most common cancer diagnosis in the United States. And it's the second leading cause of cancer death in patients in the United States, approximately 151,000 new people will be diagnosed with colon cancer. Just this. So we know that the risk of actually getting colon cancer is about one in 25. And the average age of someone to be diagnosed with colon cancer is about 66 years old. What we also know is that colon cancer screening saves lives over the last 20 years. We've seen the rates of colon cancer actually decrease in patients who are of screening age.

Unfortunately, what we are seeing now is the one age group where we're seeing the, diagnosis of colon cancer actually increased in patients under 50 years old. So most recently, the United States preventive services task force has decreased the age for screening from 50 years old to 45. And that's really in response to this rising incidents that we've had.

Melanie Cole (Host): So is that change in the criteria the same for average versus high risk individuals? Speak a little bit about, what's been put out there as far as criteria, and now what we're looking at as far as yearly, or when you start your first one or what determines when your next one happens?

Dr Michelle Olson: So most of the screening recommendations that are talked about in the media and just online are really referring to average risk patients. And a lot of patients aren't really clear about what makes someone average risk and what puts you at high risk. So an average risk patient is someone who has no personal history of colon cancer. Or colon polyps or other conditions like inflammatory bowel disease that might actually lead them to have an increased risk of colon cancer. It also means that you don't have a family history of colon cancer in a first degree relative.

So mother, father, brother, sister, child, or in multiple second degree relatives. So people a little further back on the family tree, grandparents, aunts, uncles. If you have any. Increased risk. If you have this family history, if you have this personal history, or if you have current symptoms that could be concerning for colon cancer, that takes you right out of these, average risk screening recommendations. I hope that sounds clear.

Melanie Cole (Host): Well, it certainly does. And I know that it can be confusing for people. And before I move on to Tara to talk about some alternative screening methods, doctor. Tell us a little bit about what's new in the prep world, because I think that when providers are counseling their patients, the first thing that they hear and the questions that they hear are mostly about the prep, but it's kind of changing and ebbing and flowing, and we're not using the big gallon all the time anymore. And tell us what's going on in the world of prep?

Tara Ganley: So prep is always the more difficult part of the procedure for patients because it is very difficult to go through these bowel cleanse, mechanisms at home. What we're doing now is using smaller volume preps and actually splitting them up. So, previously your doctor might have given you a gallon of a very salty solution to drink and you have to drink it rather quickly over the period of about an hour. And that can give people a lot of nausea, a lot of bloating. what we find is that you can get good results by doing, smaller volume preps, especially if you split it up.

So you take the first half of the prep, in the evening and you actually finish the prep a lot of times the morning of your procedure, and it allows your bowel to have a little bit of time to relax and recover so that you're not walking around feeling maybe as crampy as bloated, but ultimately every patient responds differently to the preps. And your doctor has to actually think about which prep is going to be right for you based on maybe your history of constipation, or other medical issues that you might have that we have to keep in mind as you're going through about prep like this.

Melanie Cole (Host): Thank you for that concise information, Dr. Olson and Tara, some people are not always willing or able to do their colonoscopy when they're supposed to. And when they tell this to their providers, the providers need to be able to outline some alternative screening methods that are out there. So in addition to colonoscopy, can you speak about some of the other screening methods that are out there?

Dr Michelle Olson: Certainly, recently, our Carle Foundation Hospital implemented a few infographics and a few alternative ways to outline those different screening methods. The fit test, which is to be completed yearly, the SQL occult blood test, which has also to be completed yearly, or a colo guard test, which can be completed by the patient every three years. And because of the lack of familiarity with these different screening modalities and kind of what's involved with each, we created a one-page infographic that's available at all of our primary care locations, just to give an overview of. is involved with each test. And additionally, what is the requirement for the patient with each test. It also outlines, if the test can be done at home or if it has to be done as an outpatient and then insurance costs associated with each test.

Melanie Cole (Host): Well, this is such an important part of this discussion. And as we're looking at other providers when they are counseling their patients. And we're hoping. And we really need to improve colon cancer screening rates in the community and really all around the country. Can you discuss some of the resource challenges in the digestive health Institute and that need for these alternative screening methods?

Dr Michelle Olson: One of the most important things that we have to remember is that if you look at patients who are eligible for screening, right now in the United States, it's less than 70% of folks who are actually proceeding to get that screening. So some type of screening is more important than not doing it at all. Right? So the ability of these home tests really give patients an option when they are reluctant to undergo colonoscopy. One of the things that we've noticed though, with just resources that we need to take care of our patients who are getting, high risk screening, where really the only option is to do a colonoscopy.

These other stool tests are not options for people who are in the high-risk category, or for people who need diagnostic testing done. Our volumes are so high that it can be very difficult for patients of average risk to actually get in a timely fashion, to get their screening done, which is why we've been offering, more information to primary care providers about these other testing options.

Tara Ganley: And just to kind of build on, what Dr. Olson said. Additionally, there's pretty significant backlog, ue to COVID. Most patients weren't wanting to be seen for routine screening appointments. They were very fearful early on during COVID. And so a lot of these, preventative health screenings weren't completed at that time. And so now that's added additionally to the backlog and it caused even more of an issue and people are having to wait so long for these tests that we really want them to explore these screening modalities, that they can get themselves and get the results turned around in a timely manner.

Melanie Cole (Host): That's a great point. And Tara tell us about some of the recent updates to the HMA to capture all those screening modalities without requiring a big manual change by the staff or provide.

Tara Ganley: Yeah. So one of the things that we identified that was a big challenge in our current, EMR system is that, any patients that had a, an alternate screening modalities such as the fit or the cold guard, it required the primary care provider or their staff to manually go in and update those health maintenance alerts. So that way they knew when the patient was due for screening again. So a group of us worked with our EMR Epic team and made it such that now the health maintenance alert will update automatically. And that way we're getting more accurate, reflection when the patient's being seen, whether or not they're due for screening. And hopefully that will make little bit less of a barrier for the primary care aproviders to order those different screening modalities.

Melanie Cole (Host): That's an excellent initiative and terroristic and with you for a minute, let's speak about the implementation of the nurse driven protocol that allows the nursing and CMA staff to place an order for fit or colo guard or any of these alternative screening methods as an adjunct to provide our conversations regarding screening.

Tara Ganley: Yeah, thank you. So the group that worked on this, really felt that there was opportunity, for patients, to have kind of collaborative care, both with the CMA, and the nursing staff, that way, if the patient that wasn't necessarily due to be seen by the provider, if they were having an immunization appointment with the CMA staff or a telephone conversation. The nursing staff. there was a really that touch point with the patient. Then there was the opportunity for those staff members to offer those screening modalities to the patient themselves at that time, instead of having to wait until they were seen by the provider.

The thing that we stressed is, the education that was to be provided to the patient, just to outline that colonoscopy is the gold standard. BUt to also outline the effectiveness of the other screening modalities and then, additionally to help with the numbers across the system for, how many patients were getting screen.

Melanie Cole (Host): Dr. Olson, can you speak about the availability of patient infographic in Martin One Source thatoutlines all the screening modalities we've discussed here today, the efficacy of each and the preparation involved for each one?

Dr Michelle Olson: I think it's wonderful this project that has been put together provided some information that can really go out, not only to the providers, but also to the patients to explain this. The colonoscopy, as Tara said is obviously the gold standard for screening, but just undergoing the bowel prep can be very concerning for patients as well as the time it requires you to be off of work, the special diet that you may have to follow. And so, getting the information in front of people so that they can see that these homes. are going to be covered by most insurances and, for something like the fit test specifically, they don't have to do any special, bowel preparation or any special changes to the diet to really get an accurate result.

Melanie Cole (Host): Wow. This is just really so interesting. It's just fascinating. The advancements that we're making and what an exciting time to be in your field. I'd like you each to have a chance for a final thought. Tara, wHat would you like other providers to know about everything we've discussed here today and the alternative screening methods and why these methods and the nurse driven protocol is really, it's just so helpful for practice?

Tara Ganley: Thank you for that. just to summarize with the primary care providers said, this has meant to be a collaborative effort, the nurse driven protocol and that CMA is ability to order those tests. It's not meant to replace those critical conversations, with the provider themselves, but just again, to kind of serve as an adjunct. And again, to reiterate the fact that, any screening is better than not having a patient screened at all, and the earlier we can detect these cancers, the better success rates we can have for our patient population.

Melanie Cole (Host): And Dr. Olson last word to you. What would you like other providers to know when they're counseling their patients about the importance and the need for colonoscopy? The change in the criteria and looking at the big picture that there are now other screening methods, but that colonoscopy is still the gold standard?

Dr Michelle Olson: Yes. I think the most important thing is that we can show data over time that undergoing colorectal cancer screening has actually saved lives. It has decreased the incidents of this cancer in our population, but it only works if you actually do the screening, the reason why colonoscopy maintains the gold standard, For itself, is that it's the only mechanism that actually lets you identify these polyps, which we know are ultimately what leads to the cancers and actually treat them at the same time. These home tests, they are able to identify the presence of cancer and also identify the presence of some polyps.

But they won't ever really be as good as colonoscopy at being able to identify polyps and then remove them. The other thing that's important for physicians to counsel their patients on is if they choose one of these other modalities fit testing, or Cola guard testing, if that test does come back with a positive result, the next step is going to be colonoscopy. So it's not something where there's another alternative after. if the test comes back positive, the next option is colonoscopy and that needs to be done in order for the patient to get the best care.

Melanie Cole (Host): Great information. Thank you both so much for joining us today and sharing your expertise for other providers. For more information, and to get connected with one of our providers, please visit carle.org or for a listing of Carle providers and to view Carle's sponsored educational activities, please visit our website at carleconnect.com. That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole. Thanks so much for joining us today.