Changing the Storyline

Radiologists can rewrite the existing narrative on health disparities by reaching out to underserved communities about the lifesaving benefits of CTC.

As the third most common and second deadliest cancer in the U.S., colorectal cancer (CRC) remains one of the most preventable cancers by appropriate screening.¹ Because CRC starts from an adenomatous polyp that develops over a period of years into a cancer, this extended timeframe provides an ideal window of opportunity for detection, removal, and prevention. Despite this, nearly one-third of eligible candidates remain unscreened.² As the recommended age to start CRC screening has been lowered to age 45, that percentage may increase.³

As unfortunate as these numbers are, they’re even worse when we zoom in on minorities in the U.S. For example, the incidence of CRC in Black Americans is 20% higher than White Americans, and the mortality rate from CRC is 40% higher.⁴ CRC is 40% more common in those with a lower socioeconomic status than those of a higher socioeconomic status. Forty-four percent of this racial healthcare disparity is attributed to differences in screening rates, according to the American Cancer Society.⁵ This is one healthcare disparity that radiologists can work to improve through promoting increased uptake of CRC screening within minority communities.

The most prevalent CRC screening method currently in use is called optical colonoscopy (OC). Although OC is the most well-known CRC screening exam, it presents significant challenges for uptake among minority groups. For instance, the use of anesthesia requires a driver post-procedure. Undergoing OC also often requires patients to take a day off from work, which can be a challenge for those in underserved populations. The anesthesia involved with OC also evokes fear in some cultural and ethnic minority groups.⁶ Furthermore, access to OC continues to be limited by the number of available gastroenterologists to perform the exam and the lower number of gastroenterologist practices in locations convenient for minority screening candidates.⁷

By comparison, although less widely used than OC, CT colonography (CTC) presents fewer barriers to adoption in underserved communities. Despite the recommendations of the U.S. Preventive Services Task Force (USPSTF) to make CTC screening widely available to all eligible screening candidates, CMS does not currently reimburse for screening CTC unless the patient meets very specific criteria.⁸ In practice, however, this “one-size-fits-all” approach does not facilitate access to minority screening candidates and contributes to the healthcare disparities we are trying to overcome in the medical community.

Although CTC still requires bowel prep, CTC helps overcome many barriers to resistance. First, CTC does not require anesthesia. Second, the procedure takes approximately 20 minutes to perform, and screening candidates can resume normal activities or work immediately afterwards. Plus, CT scanners are widely available to a variety of patients regardless of zip code. For these reasons, CTC has been shown to increase screening percentages for some groups who are offered this option.^6–8 Establishing a CTC program to optimize access has realistic potential to impact both CRC incidence and mortality disparities.

Optimizing the EHR

One tool that radiologists can enlist in their effort to improve access to CRC screening is the EHR system. Results from a 2017 survey indicated that 99% of hospitals and healthcare systems use EHRs.⁹ Many EHR systems can be programmed to identify patients who have not been screened for colon cancer when they present to a healthcare provider. Once identified, communication tools can educate and encourage minority screening candidates to schedule CRC screening via CTC.

Similarly, patient letters, email, or electronic patient portal messages have been used with some success in reaching minority breast cancer screening candidates.¹⁰ Building on this success, many healthcare systems are now consolidating these communication channels into centralized systems for health maintenance. The use of automated reminders to “nudge” physicians to order timely CRC screening for minority candidates has been shown to decrease the bias previously seen as a disparity in physician ordering practices.¹¹

Radiologists can play a vital role in decreasing health disparities by extending access to CTC for minorities.

Also in line with breast and lung cancer screening programs, CTC makes use of evidence-based dedicated screening intervals and standardized follow-up strategies when it comes to handling abnormal results. Utilizing either established health maintenance modules or working with IT departments to build similar workflows to identify and contact unscreened candidates is possible with a modicum of effort.¹²

One major advantage of enlisting the EHR in these communications efforts is that if the proper permissions can be approved, the primary care provider (PCP) does not need to activate the screening visit. It is, however, always important to keep the PCP informed of findings and next actions. A recent article indicated that high patient satisfaction scores can be achieved by healthcare systems with automated navigation of patients for preventive oncology screening as opposed to direct involvement of a patient’s frequently over-taxed PCPs.¹³

Involving Patient Navigators

Although the EHR is an important tool in identifying eligible minority CRC screening candidates, its value can be accentuated when used in tandem with nurses, medical assistants, or even community health volunteers — also known as healthcare navigators — who bring a human element to shoring up healthcare disparities. For example, navigators can increase CRC screening uptake among underserved communities by calling unscreened candidates to schedule initial screens. This same approach can work for contacting patients to schedule follow-up appointments for abnormal screening results. Follow-up of abnormal results is another key step to decreasing CRC mortality.

Multiple studies have demonstrated success in achieving higher screening rates among minorities with the use of navigators. Surveys indicate that patients are satisfied, are better informed on expectations for follow-up visits, and have increased compliance with follow-up instructions.¹⁴ Several studies involving cancer screening have shown that employing patient navigators is an effective way to reduce the number of missed care opportunities and improve patient compliance with both initial screenings and follow-up care.^15–17 Although navigators can prove relatively expensive, implementing a strategy to target candidates with higher rates of missed care opportunities can result in cost-effective savings for health systems focused on achieving a healthier population of “covered lives.”¹⁸

Beyond enlisting the help of navigators in the clinical setting, the use of community health volunteers as navigators may provide an additional opportunity to address the cultural fears and obstacles unique to specific minority populations. Barriers to CRC screening for minorities have included affected groups being less informed about options and lacking trust in healthcare systems in light of past injustices, such as the Tuskegee Study of untreated syphilis and the forced sterilization of Black patients.^19–25 Community navigators may have already established trust with patients within their own communities and can prove vital to extending a CRC screening program’s reach.²⁶

Despite having made great inroads, CTC is still not a widely used alternative for CRC screening. While this can be seen as suboptimal, it also presents an opportunity. Social media announcements, radio spots, church events, and other communication avenues can be used to educate both providers and minority communities about this option for CRC screening. In addition, the ACR offers an online locator tool (bit.ly/CTCFind) to help providers and patients find a nearby site offering CTC.

Radiologists can play a vital role in decreasing health disparities by extending access to CTC for minorities. As radiologists, most of us want to help ensure quality care across the board but have found it challenging to do so given that we don’t often interface directly with patients. This is one way to rewrite the script we’ve been given and help those most in need.

The Exceptionalism of Radiology

As the ACR develops its new strategic plan, it is guiding the specialty and the broader community to work together to realize radiology's potential.

Benjamin S. Bloom, a professor of educational psychology at the University of Chicago, published a landmark book in 1985, Developing Talent in Young People.¹ According to Bloom, all the superb performers he investigated practiced intensively, studied with devoted teachers, and were supported enthusiastically by their families throughout their developing years. Later research building on Bloom’s pioneering study revealed that the amount and quality of practice were key factors in the level of expertise people achieved. Consistently and overwhelmingly, the evidence showed that experts are made, not born.

Many others claim to be experts in the skills that radiologists provide. There have been continuous attempts to commoditize medical imaging and discount the value of radiologists. Yet it is radiology and radiologists that remain exceptional in our commitment and devotion not only to the realized benefits of medical imaging today but to innovation and the promise of its impact on patients and future population medical management.

At times, we may be myopic in realizing the exceptionalism of our chosen profession. We focus on potential threats and commoditization of what we deliver to our patients and referring physicians. No doubt these are important concerns for us to identify and address, especially during our strategic plan development process. Yet, if we step back and look at the macro-environment, it is undeniable that radiology is in an incredible position. Imaging-based care is at the forefront of modern medicine. We are just at the infancy of detecting the information hidden in our digital data. Metabolic and functional imaging techniques are emerging and will be fundamental to how we consider diagnosis and therapeutic options. With emerging modern techniques such as AI, the integration with pathology, and population and personalized health management, the potential is limitless.

So many entities, including big tech, are looking at medical imaging and what we do — for very good reason. Healthcare has always been an attractive industry. Radiology is in an advantageous position to deliver essential data and micro-interventions for future healthcare paradigms. Embedded in our training and orientation are both short-term and longer-trajectory opportunities to utilize medical data and informatics. Imaging and data are going to be key for the objective assessment and planning of medical care, in whatever future payment systems develop.

As a science, the future is ours to realize. Radiologists are advancing the applications, science, and innovations of imaging, therapy, and interventions. We can reduce costs. We can take a leading role in population health management. As our predictive modeling evolves and matures, we can tell an individual what their risk factors are and guide them through a personalized medical care plan.

Radiology is in an advantageous position to deliver essential data and micro-interventions for future healthcare paradigms.

As a profession, we continue to attract the best and brightest. A brief glimpse at our literature will uncover the innovations that continue to evolve in our space. While some pundits had transiently focused on the potential negative impact of AI on our specialty, most population health management experts understand that imaging and informatics can shift healthcare paradigms to deliver better evidence-based care with greater efficiency and more value.

Exceptionalism does not end at our shores. The international interest and excitement in our specialty is inspiring. Working with international partners, radiologists are raising the profile and awareness of medical imaging — especially in countries where resources are scarce. We are learning best practices as medical imaging is being applied in multiple national delivery systems with various populations and demographics. As medical imaging is being primarily recognized in delivering even basic healthcare needs, we have the opportunity — if not the obligation — to impact global health. This is truly an exceptional time to be a radiologist.

Radiology continues to be an incredible profession — providing societal value, professional satisfaction, and intellectual curiosity. Our specialty is witnessing the explosion of technology and science amidst the promise of our future.

As I speak with residents and fellows across the country, I congratulate them for choosing radiology as a specialty. Despite all the distractions, they are entering the specialty at an exciting time. Yes, there will continue to be challenges. In an earlier era, the introduction of Medicare was thought to be the end of radiology. But radiology survived — and even thrived. The specialty looks very different from the time when we had rolloscopes. The promise is that radiology will look very different even ten years from now. We will continue to innovate, adapt, and serve our patients.

Radiology is indeed exceptional. We are well-positioned for continued success. The ACR is a crucial organization in guiding the specialty. As we develop our new strategic plan, we will focus on maximizing our collective potential. I encourage all of our members and the broader radiology community to work together to realize our future — for our specialty and our patients.