May 09, 2023

Exploring Innovation in Preventive Care

A fresh look at updated screening guidelines and evolving testing methods to assist employers in evaluating ways to improve their members’ screening compliance and reduce hidden cost barriers to accessing preventive care.

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The most common cancer screenings include breast, colorectal, cervical, prostate and lung tests. As a result of the development of more precise imaging and alternative screening modalities for breast and colorectal cancer, much progress has been made in the way malignant tumors are detected. However, adherence to testing recommendations remains a challenge, especially following the pandemic, when fewer patients pursued screenings for breast, cervical and colorectal cancer.²² During the initial phase of the pandemic, preventive screenings took a nosedive, initially decreasing by 80%.²³ Subsequently, screenings have risen but have not returned to pre-pandemic levels. Therefore, mechanisms employers can use to help employees engage with prevention are very important.²⁴

Employers can consider offering paid sick leave to reduce barriers to accessing screening services and encourage hourly employees to have the recommended cancer screenings. One study from the National Cancer Institute found that private sector workers in the U.S. who had access to paid sick leave demonstrated higher rates of cancer screening compared to workers without access to paid sick leave.²⁵

Using Genetic and Biomarker Testing to Drive Early Detection

Genetic tests aimed at identifying gene mutations that indicate a higher risk of developing cancers or chronic diseases are rapidly evolving and becoming more accessible. Currently, more than 76,000 genetic tests are on the market, with hundreds more entering the market each year.

As with other screenings, the cost and potential for unnecessary follow-up services should be considered in the context of the potential benefits of covering genetic tests. Patients who have a confirmed genetic mutation and/or family history can, as advised by a genetic counselor, alter the frequency of targeted screening or in more severe risk cases choose organ removal to prevent cancer from developing. For example, patients with BRCA1 or BRCA2 genes can choose to begin having mammograms done earlier in life and more frequently to increase the likelihood of early detection. One study found that the prevalence of these genomic conditions in the United States population was 0.7%, with Ashkenazi Jews at the highest risk of the variants.²⁶ The USPSTF recommends that plans cover genetic counseling and evaluation for BRCA1 and BRCA2 for women who have family members with breast, ovarian, tubal or peritoneal cancer.²⁷

Biomarker testing is another tool to drive early detection and treatment. Biomarker tests are laboratory tests that examine a sample of tissue, blood or other bodily fluid for certain genes, proteins or other substances that could indicate the presence of a condition or illness. These tests can also complement treatment protocols to help clinicians determine how well treatment is working or predict the likelihood that a disease will recur.²⁸ Multi-cancer early detection tests have risen in prevalence, and one Business Group on Health survey found that 11% of employers would be cover these tests in 2023.²⁹ In 2021, the health care company GRAIL rolled out the Galleri test, a multi-cancer early-detection blood test that can detect 50 types of cancer. One study found that Galleri has a false positive rate of 0.5% and is capable of detecting multiple types of cancer before the onset of symptoms. Though this test is not FDA-approved, it is available under a Clinical Laboratory Improvement Amendments (CLIA) waiver.³⁰ Overall, genetic and biomarker tests have become powerful tools to help employers identify employees who are at higher risk for certain diseases, tailor treatment to patients and allow for early intervention and treatment.

Breast Cancer

Beginning at age 40, the USPSTF recommends that women of average risk receive biennial mammograms until 74 years of age.³¹ Conversely, the American Cancer Society recommends that women aged 45 to 54 receive mammograms every year.³² While screening mammography can lead to early detection 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 they are administered as a follow-up procedure to tissue removal.

More than half of all women age 40 and older who get mammograms are found to have dense breasts.³³ 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.³⁴ 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, NCI also notes that these individuals are no more likely to die from breast cancer than those with breasts of average density.¹⁷ In March 2023, the FDA made updates to mammography regulations. These updates strengthen the FDA's enforcement capabilities requiring that mammography facilities inform patients about the density of their breasts and assist physicians reading the images become better at classifying and evaluating mammograms.³⁵ These updates are intended to make sure that crucial information that can influence patients’ decisions, such as the need for more testing or a repeat mammogram, is well understood and explained.

Colorectal Cancer

Colorectal cancer screenings are categorized either as visual tests (colonoscopies) 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. Providers will typically recommend that colonoscopies only be completed once every 10 years for those without an increased risk of developing colon cancer.
• 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. CT colonography should be done every 5 years if completed in lieu of a traditional colonoscopy. CT colonography can also detect other abnormalities in the kidneys, liver or pancreas.³⁶
• 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. Flexible sigmoidoscopy should be done every 5 years or every 10 years along with a FIT (stool-based test) conducted every year.³⁷

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.³⁸ Stool-based tests should be completed every 1-3 years and between visual tests.¹⁷

• Stool DNA testing: To perform this test, patients use a take-home kit to collect a stool sample and mail it to a lab. This test is recommended to be completed once every 3 years. Cologuard® is the most common brand of stool DNA test that is FDA-approved.
• 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. It is recommended that patients take these tests annually at home with a kit they receive from their doctor’s office.

Although the risk of developing colorectal cancer increases with age, with more than 90% of cases occurring in people aged 50 or older, recent research shows that the incidence of colorectal cancer has been increasing by 1% to 3% annually for people younger than age 50 while decreasing in older individuals.³⁹ In the last 25 years, colorectal cancer has risen from 11% to 20% , nearly doubling for Americans under 55. This meteoric rise now puts colorectal cancer as the leading cause of cancer death for Americans aged 20 to 49.⁴⁰

Lung Cancer

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 are between 50 and 80 years of age with a history of smoking.⁴¹ Adults exhibiting symptoms that might be caused by lung cancer may need CT scans or other tests to find the underlying cause; however, such scans would be considered diagnostic services.⁴²

Lung cancer screenings within the recommended populations are extremely underutilized. In a 2020 study performed by the CDC, just 12.5% of eligible adults who met the USPSTF criteria for lung cancer screening had a low-dose CT scan.⁴³ 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 and provider education on the importance of screening is key to ensuring that those who would benefit most are completing these tests.

Cervical Cancer

Cervical cancer is detected in roughly 13,000 new individuals each year, and about a third of those diagnosed will die of the condition. The vast majority of cervical cancer diagnoses are caused by the human papillomavirus (HPV). Specifically, two strains of the HPV, HPV 16 and HPV 18, account for about 70% of all cervical cancer cases in the U.S. The primary barrier to diagnosis is that those infected with HPV have very few symptoms.

The USPSTF recommends that women aged 21 to 29 be screened for cervical cancer every 3 years using cervical cytology. For women aged 30 to 65 years, the USPSTF recommends screening every three years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (co-testing).⁴⁴ Additionally, the ACIP recommends that children ages 9 to 12 be vaccinated for HPV.⁴⁵ Furthermore, cervical cancers are among the most curable form of cancer when diagnosed at an early stage; these patients have a survival rate of 92%. Those diagnosed at a later stage, however, have a survival rate of 59%.⁴⁶

Unfortunately, in the U.S. today, less than two-thirds of women aged 30 to 65 are up to date with their cervical screening, and women at the highest risk of being diagnosed with cervical cancer often lack access to the screening needed for diagnosis.⁴⁷ One study published in JAMA found that overall uterine cancer death rates in the U.S. increased by 2% between 2010 and 2017. One solution touted amid the pandemic was the nasal swab test for the cervix. A team at NCI found that 93% of women would be willing to perform self-screening at home, greatly improving the odds of cancer detection and prevention.⁴⁸

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