By Molly Maher
The second deadliest cancer in the United States today is considered by many physicians to be among the most preventable.
The Centers for Disease Control report that if all Americans over the age of 50 were screened, 60 percent of colorectal cancer related deaths could be avoided. That means that between 29,952 and 39,936 lives could have been saved in 2009.
In Colorado, one source of funding for screening of colorectal cancer, commonly known as colon cancer, recently was redirected because of the fiscal emergency.
Colorectal cancer and screening
“Colonoscopy is one of the few cancer screenings that is actually a curative,” said Lynn Clark, communications director at the University of Colorado Cancer Center.
Since the cancer develops from polyps, the discovery and early removal of these precancerous abnormal growths through regular colonoscopies prevents cancer from forming. Early detection of cancerous polyps also increases the rate of survivorship, said Dr. Holly Wolf, director of the Colorado Colorectal Screening Program.
An estimated 70 percent of people diagnosed with colon cancer have no symptoms at all, Wolf said.
“It is really important for us to be sure that people who are otherwise healthy and well get in for screenings,” Wolf said.
Dr. Tim Byers, a former director of UCCC and current associate director for cancer prevention and control, said that screening is not sufficiently widespread.
“Even though this has been a health insurance benefit for a long time, we’ve been sort of slow in getting the job done,” Byers said. “And people without health insurance really have limited resources to get colorectal cancer screening done.”
Amendment 35 and preventative health care
Funding for colorectal screening initiatives in the state has come through Amendment 35, which was enacted in January 2005. Coloradans approved the amendment in 2004, increasing taxes on tobacco products and placing the revenues into the Tobacco Tax Cash Fund. The fund is divided among specific health initiatives.
Those initiatives include education programs on tobacco risks; outreach for the Children’s Basic Health Plan; and the Prevention, Early Detection and Treatment Fund, which receives 16 percent of the Tobacco Tax Cash Fund annually. This fund is distributed by the Colorado Department of Public Health and Environment through its Cancer, Cardiovascular Disease and Pulmonary Disease Competitive Grants Program. The Colorectal Cancer Screening Program at the University of Colorado Cancer Center has served as “essentially the coordinating center” for colorectal screening in the state since 2006, said Public Awareness Coordinator Terri Spector.
As of December, the Colorectal Cancer Screening Program at UCCC completed 12,006 screens. In about 25 percent of them, physicians removed adenoma polyps, the most likely to become cancerous. More than 100 cancer cases have been diagnosed.
In order to be screened through this program, patients must be at least 50 years of age or at high risk, be uninsured or not covered for any costs of colorectal screening, be lawfully present in the country, and have an income below 250 percent of the federal poverty level.
This year, UCCC’s original contract was $2,759,942 and was increased to $3,650,000 mid-year, as compared to a contract of around $5 million in 2010, Wolf said. The amount is determined by a review committee that ensures equal amounts of funding go to cancer, cardiovascular and pulmonary diseases, and preventative care, as allotted by Amendment 35.
The lower funding means that fewer Coloradans are being screened and treated through the program, Wolf said. The changes are felt particularly in rural areas, where fewer asymptomatic patients are screened in order to tend to those who have symptoms. Managers at partner clinics are also hoping that the health care system will help treat some patients diagnosed with cancer, as the clinics are no longer able to pay for this care.
Few alternatives exist for these often-uninsured patients who want to be screened, Wolf said. Preventative care, such as colorectal screening, is not considered an urgent problem, so it’s seldom a priority in indigent care programs.
Escape clause implemented
The budget reduction reflects the reallocation of some of the tobacco monies for the 2011 fiscal year. Amendment 35 includes an escape clause in case of fiscal emergency. It specifies that the entire Tobacco Tax Cash Fund can be moved to address the financial situation with a two-thirds vote of Colorado legislators.
The funds must remain under the “general umbrella of health care,” said Cody Belzley, who served as a consultant for the proponents of Amendment 35 and later as health care policy advisor for former Gov. Bill Ritter.
“The coalition that passed Amendment 35 was pretty thoughtful in crafting a measure that could ensure that we advance access to health care for Colorado, but also ensure some flexibility for lawmakers to exercise their discretion,” Belzley said.
“It allows state policymakers to look at what the most pressing needs are and then allocate Amendment 35 revenue to meet those most pressing needs as appropriate in the face of fiscal crisis.”
She also stressed that, although increasing access to colorectal screening may be one important health care goal, the state has “many competing health care needs…and is being forced to make drastic cuts.”
Fiscal emergency and budget balancing
Martha King, health program group director for the National Conference of State Legislatures, echoed these thoughts.
Since under the constitution, they have to present a balanced budget by June 30, “legislators are in a real quandary,” she said.
- 70 percent of patients diagnosed with colorectal cancer show no symptoms
- 60 percent of deaths could be avoided with screens
- The Colorectal Cancer Screening Program has funded 12,006 screens in Colorado
- The CCSP has a contract for $3.6 million this year, as compared to $5 million in previous years
- Colorado has an estimated structural imbalance of $1.1 billion dollars for fiscal year 2012
Colorado is far from alone in making these difficult decisions. NCSL estimates that between fiscal years 2008 and 2013, the combined budget gap for all states will be about $563 billion. Faced with one of the biggest multiple-year gaps the country has seen, states are seriously cutting programs, King said.
“States first look at low-hanging fruit,” tapping into reserves or special cash funds as a way to balance budgets without reducing fixed spending in such areas as K-12 education and Medicaid, King said.
Byers said that he understands very well why the funding for the colorectal screenings and other preventative care programs was reduced, even if screening measures are cost-effective.
The common measurement for cost-effectiveness is by cost per year of life saved. For colorectal screening, the cost per year of life saved is around $25,000. This compares to $35,000 for breast cancer screens, a major screening program supported nationwide, Wolf said.
The number of cancers prevented through screenings would offset even the most conservatively estimated costs of avoided cancer treatments, Byers said. “Still, it makes it different in times that are economically tough.”
King and Byers were among about 120 people who spent Sept. 10 at a meeting focused on using this low point of funding through Amendment 35 as an opportunity to look critically at how to utilize funds effectively when the fiscal situation stabilizes.
Hosted by the Center of Public Health Practice at the Colorado School of Public Health, the meeting was meant to foster a dialogue about how to “ramp up” use of funds when they return, rather than “crying on everybody’s shoulder because of what we lost from the past,” said Byers, who also serves as the associate dean of the center.
By the time funding under Amendment 35 is restored, Byers said a reauthorization process likely will be necessary to ensure that the money is used wisely.
At this point, the CDPHE has indicated that the program can apply for funding equal to the contract for this year through a competitive process. The expectation is that the program will be able to screen about 2,300 patients next year. The average is 2,000 to 3,000 annually, Wolf said.
Previously, health care providers had little incentive to pay the short-term costs for the long-term gains of preventative screening because “the health insurance industry assumes people will roll in and out in a five-year period,” Byers said. But depending on how health care reform progresses, new incentives may develop so that public funds will not be needed to cover colorectal screenings or other preventative care.
“We are starting to design what will be a more rational health care system,” Byers said.
“From my standpoint, colorectal screening provides a fantastic example of the type of preventative service we hope will be derived from health reform,” Wolf said. But for now, the program will continue to compete for secure what available funds to produce “any effort that we can make in order to have people carry out this really simple behavior to take care of yourself.”
About the writer: Molly Maher is an intern with Solutions.