3 Pillars of CRC Prevention Can Curb Rising Mortality: Jordan Karlitz, MD

Amid the rise of colorectal cancer (CRC)-related deaths in younger adults, Jordan Karlitz, MD, of Exact Sciences, continued his conversation with The American Journal of Managed Care^® (AJMC^®) by emphasizing the 3 pillars of CRC prevention and early detection: getting screened on time, knowing your family cancer history, and acting promptly on concerning symptoms.

He also discussed emerging diagnostic tools, or biomarkers, that can aid in early detection and shared his perspective on the interventions needed to reverse the upward CRC mortality trend going forward.

Read part 1 of this Q&A here.

This transcript has been lightly edited for clarity.

AJMC: What does the overall shift in CRC mortality reveal about gaps in prevention or early detection for younger adults, and how can these be overcome?

Karlitz: To sum it up, I think there are really 3 pillars for CRC prevention and early detection. They include getting screened on time, knowing your cancer family history, and acting early on concerning symptoms.

These are the 3 pillars that everybody needs to be aware of, whether you’re a community member, a health care provider, or working in another role, because I think gaps in any of them could increase the risk of developing CRC and, unfortunately, lead to presenting with more advanced-stage disease.

To address potential gaps in these pillars, education and public health messaging are key. Number one, we need to continue getting the word out that average-risk screening now starts at age 45. There are a lot of people out there who still think it’s at age 50, even though the recommendations have been out for a few years now. Then, when 50 hits, they may delay screening further, and before you know it, they’re 55, 56, or even older before being screened. We cannot assume that just because health care professionals know the new guidelines, everyone in the community does.

"These are the 3 pillars that everybody needs to be aware of... because I think gaps in any of them could increase the risk of developing CRC and, unfortunately, lead to presenting with more advanced-stage disease."
—Jordan Karlitz, MD

We also have to talk about different options for CRC screening. I work at Exact Sciences, and I think Cologuard is an excellent option for younger individuals in the 45 to 50 age group. It’s a noninvasive, highly accurate test that could detect both early-stage cancer and polyps.

Again, we need to get the word out that concerning symptoms, like rectal bleeding, are not always benign. Patients cannot just assume it’s hemorrhoids or something like that. They need to take those symptoms seriously and make sure they relay that information to their providers.

AJMC: Are there emerging diagnostic tools or biomarkers that could help detect CRC earlier in this population?

Karlitz: There are new screening options for CRC. Exact Sciences has a new iteration of Cologuard called Cologuard Plus, optimized for higher sensitivity and specificity. Specificity is, obviously, the ability to detect lesions if they're present. Specificity correlates with the false positive rate, so this test has excellent sensitivity for early-onset CRC and also precancerous polyps.

I'm a gastroenterologist. I'm very interested in polyps with high-grade dysplasia. These are polyps with histologic changes that are sort of on the brink of becoming cancer but are not quite cancer yet. The Cologuard Plus test has a sensitivity of about 75% for high-grade dysplasia, and that's just for one application of the test. With things like stool-based testing, you get a cumulative sensitivity over time. For Cologuard, if you're getting the test every 3 years, you have multiple shots to pick up these polyps and prevent the development of cancer or pick it up at an earlier stage.

People may be hearing things about some of the new blood tests for CRC screening. These tests have limitations in their ability to detect early-stage CRC. In particular, they could be very limited in their ability to detect precancerous polyps compared with something like Cologuard or a colonoscopy. I think people need to be aware of the limitations when they hear about these blood tests and that tests like Cologuard and a colonoscopy are much better at detecting polyps.

With stool-based testing, like a fecal immunochemical test (FIT) or Cologuard, or even blood tests, if you have a positive test, you have to get a complete colonoscopy. For Cologuard, if your test is positive, you want to complete the colonoscopy so that you can find the lesions and, if they're polyps, remove them. Our real-world evidence team has been monitoring adherence and time to follow-up colonoscopy after a positive Cologuard test and compared that with FIT testing.

We've used these very large claims databases to try and figure that out, and what we saw in the 45- to 49-year-old population was that completion of colonoscopy after a positive Cologuard test was 85% vs only 35% for FIT. This is something we're really keeping an eye on, because it's about adherence to not just completing the stool-based test but also getting that follow-up colonoscopy.

AJMC: Looking ahead, what clinical, behavioral, or policy-based interventions could most effectively reverse the rising trend in CRC mortality?

Karlitz: Clinically, acting early on symptoms, confirming symptoms, knowing your cancer family history, and getting screened on time are the pillars I mentioned.

Behavior-related risk factors, many of which are modifiable, can also be addressed. Like a sedentary lifestyle, you could hopefully change that and avoid certain foods that may be associated with increased cancer risk. I think some of these behavioral issues can be addressed

In terms of policy, obviously, you want to make sure to minimize or completely avoid out-of-pocket costs, particularly for screening. There has been legislation addressing this; fortunately, we’ve made a lot of headway with that.

The last thing I wanted to talk about is patient navigation. Helping individuals complete a CRC screening test, and if that screening test is noninvasive, like Cologuard, making sure that they’re educated on what a positive test means and that they need a colonoscopy is going to be really critical. At Exact Sciences, we have a robust patient navigation service, including in Spanish, and I think that really contributes to some of the high adherence we’re seeing with Cologuard testing.

Navigation is really important. It was also critical at the safety-net hospital where I was chief [Denver Health Medical Center]. We focused on navigating individuals from primary care into the endoscopy unit, which was a critical area of focus that I had when I was at that hospital.