Dr. Michael Pignone, a professor at Dell Medical School, saw a problem with a solution in reach: Too few Austinites were getting screened for colorectal cancer, especially among low-income, uninsured and minority groups. All he had to do was get patients to send samples of their poop in the mail.
Pignone’s interest in getting screening rates up began early in his career as a primary care doctor in the mid-1990s. At the time, awareness about colorectal cancers was low.
“I was looking for an area to work on where there was good evidence of benefit, but underutilization,” he said.
Cancers that affect the colon and rectum are the second-leading cause of cancer death in the United States, according to the American Cancer Society. They are also largely preventable with regular screening through methods like colonoscopies and stool tests. Colorectal cancers are slow-developing; a potentially problematic growth in the lower intestine can take a decade to become cancerous, so regular screening helps stop these cancers in their tracks.
The U.S. Preventive Services Task Force recommends people begin screening at age 45. That recommendation was moved from age 50 in 2021 in response to data that showed rising colorectal cancer rates in younger people.
In the early 2000s, national awareness campaigns brought attention to colorectal cancers, and screening rates saw a steady and progressive uptick. The National Cancer Institute estimates screening rates for adults aged 50-75 went from 38% in 2000 to 68% in 2019.
Colon cancer screening is expensive without health insurance, though. And colonoscopy, the leading screening method, is inconvenient for many people: It involves a full day of preparation in which patients have to stick to a liquid diet and take laxatives. As a result, testing for certain groups lags. As of 2019, Americans at less than 200% of the federal poverty level — that's an annual income of around $29,000 for a single person — were being screened at a rate 16% lower than their peers who earned more.
A local solution
Pignone saw this as a particularly salient issue in Texas, which has the highest rate of uninsured residents in the U.S. at 18%. He wanted to eliminate barriers to screening for uninsured Texans by meeting people where they are; he would mail stool tests to patients’ homes, where they could collect a sample themselves and send it back to a lab for screening. This was already a tested method commonly used in other countries, like Australia, where Pignone had helped implement a test-by-mail program in 2010. However, the U.S. health care system presented roadblocks to this solution.
“The economics of it just aren’t all that favorable,” Pignone said. “If you’re running your private practice and relying on being able to charge for stool testing, the amount you get back is not equal to the cost of running the whole program.”
Additionally, if a patient’s stool test indicates a problem, follow-up care can be costly. According to Pignone, many care providers are hesitant to push for screening if they know a patient won’t be able to afford the treatment that comes with a positive test.
To launch a viable program in Austin, he got grants from the Cancer Prevention Research Institute of Texas (CPRIT), a state agency that provides funding for cancer research. He also established a partnership with a chain of local health clinics called CommUnityCare. As a federally qualified health center, CommUnityCare primarily serves low-income and uninsured residents and had previously seen low rates of colorectal cancer screening.
Beginning in 2017, CommUnityCare sent stool tests out to every patient in the clinic’s rolls who was in the recommended age bracket and wasn’t up to date on screening. Instructions in English and Spanish told patients how to collect their sample and send it back in the mail. If a test was positive, bilingual coordinators were available to help with next steps.
Since 2017, the clinics have sent out more than 60,000 tests, and around 13,500 patients have completed testing. In just the first year of the program, CommUnityCare’s rate of screening for recommended patients went from 18.4% to 37%. As of this year, that number has inched up to 44%.
Among the people who sent in stool samples, 726 had a positive test, meaning blood was found; 75% of those folks were brought in for colonoscopies, the next step in testing.
“There has been a lot of benefit already on a population health level. And because we are targeting marginalized communities, this is really driving improvements in health equity,” Dr. Nicholas Yagoda, Chief Medical Officer for CommUnityCare, said.
Scaling challenges
Dell Medical School and CommUnityCare won a major national prize this year given by the American Cancer Society, the CDC and the National Colorectal Cancer Roundtable in honor of their work. And Pignone received the American Cancer Society’s prestigious Clinical Research Professor Award, which comes with a grant he’ll use to focus on expanding his test-by-mail efforts and other projects.
Pignone has already used CPRIT funding to start another mail-in screening partnership with Lone Star Circle of Care clinics in Central Texas. He has also been in talks with other federally qualified health centers throughout the state to discuss how they might create a centralized program for mail-in colorectal screening.
But to truly scale the program, funding problems must be solved. CPRIT funding covered follow-up colonoscopies and further testing for CommUnityCare patients who had positive stool tests, and Travis County’s public hospital district, Central Health, helped cover care for patients with cancer. But partnerships like this don’t exist in every county, so more expansive funding is needed to establish a statewide initiative.
Expanding Medicaid in the state so fewer residents are uninsured would be one way to move the needle. However, Texas lawmakers haven’t moved any bills to expand Medicaid during the current legislative session, save one pending in the Senate that applies to new moms.
However, there is a rider in the proposed state budget that asks for $10 million annually to fund colorectal cancer treatment for uninsured and low-income Texans.
“That's what it would take to build out a full statewide program and move Texas from the lower end of performance in terms of cancer screening and prevention into the higher end of performance,” Pignone said. “It's my hope that we can become an exemplar for states in the Southeast about how to make that conversion.”
