A Q&A With Ian Kahn, Health Systems Manager, The American Cancer Society

As healthcare continues to change, employers are addressing the impact that conditions like cancer, especially colorectal cancer (CRC), can have on their company as well as their employees and their family members. Every year in the U.S., CRC affects more than 136,830 people and is the third most commonly diagnosed cancer in both men and women. However, it’s also one of the most preventable and, if found early, most treatable forms of cancer. In addition to promoting healthy behaviors that reduce the risk of developing CRC, many employer wellness programs now offer convenient, at-home CRC screening kits.

“Screening can prevent CRC or catch it early when it’s highly curable – improving the patient’s prognosis, and greatly reducing healthcare costs and missed days of work,” said Ian Kahn, a Health Systems Manager for the American Cancer Society (ACS). As the largest voluntary health organization, ACS’s efforts have contributed to a 25 percent decline in the cancer death rate in the U.S. since 1991, driven by less smoking, better treatments and earlier detection.

Below, Kahn explains the importance of CRC screening and early detection – for both employers and their employees, and how ACS is working with organizations across the U.S. to create a culture that promotes health screening.

What is colorectal cancer and what are the risk factors?

Kahn: Colorectal cancer (CRC) is a cancer that starts in the colon or the rectum. These cancers can also be named colon cancer or rectal cancer, depending on where they start. Colon cancer and rectal cancer are often grouped together because they have many features in common. Most colorectal cancers begin as a growth called a polyp on the inner lining of the colon or rectum. Some types of polyps can change into cancer over the course of several years, but not all polyps become cancer.

A recent study found that maintaining a healthy weight, being physically active, limiting alcohol consumption, and eating a healthy diet reduce the risk of CRC by more than 37 percent. Heredity and family history can also have an impact on one’s risk of developing CRC. Twenty to twenty-five percent of CRC patients have a family history of the disease, about five percent of which are due to an inherited genetic abnormality.

Why is early detection of CRC so important – for both employees and their employer?

Kahn: Colorectal cancer tumors grow very slowly, and there are many high-accuracy screening methods available that can detect early-stage cancer, as well as warning signs that indicate cancer may develop. Earlier detection significantly increases the chance of survival and significantly reduces the costs and time spent away from work associated with treatment.

A local diagnosis (the cancer is growing in the colon or rectum walls but nearby tissue is unaffected) has the highest five-year survival rate, ranging from 88 percent to 93 percent, depending on race. This rate drops significantly when diagnosed regionally (a growth is in the tissue or lymph nodes) to 66–74 percent, and again with a distant diagnosis (cancer has spread to other parts of the body) to nine percent in American Indian/Alaska Natives to 17 percent in Hispanics. Looking at just survival rates, these statistics do not account for quality life years lost due to treatment, surgeries, pain, fatigue and other side effects, all of which can increase with a later-stage diagnosis. Additionally, the out-of- pocket costs for treating a later-stage diagnosis are much higher.

The impact of the stage of diagnosis to an employer is a little different. The employer is not just impacted by the terrible personal effect that cancer can have on a patient’s support system. Employers stand to gain significantly if cancer is detected early — both by reducing absenteeism and the lost productivity associated with treatment and side effects, and by significantly reducing healthcare costs.

According to one study, the average cost associated with a colonoscopy and the treatment of CRC with a local diagnosis for year one is roughly $50,000. Year one cost for a regional diagnosis is about $151,000 and $193,500 for a distant diagnosis. There is a clear correlation with the stage of diagnosis and the cost of treatment – the later the stage, the higher the cost.

How does the American Cancer Society work with employers to raise awareness of CRC?

Kahn: The ACS works with employers by providing educational materials, screening guidelines, toolkits and evidence-based interventions that help raise colorectal cancer screening rates. Because each employer is unique, we don’t have a one-size-fits-all plan to raise awareness of CRC and the importance of being screened on time. Rather, we will work with each employer individually by providing technical assistance in helping to get a CRC screening and employee education campaign running.

80% by 2018 is a National Colorectal Cancer Roundtable initiative in which more than 1,500 organizations are working to screen 80% of eligible adults for CRC by 2018. How can employers get involved?

Kahn: The first step for employers to get involved with 80% by 2018 is to sign the pledge. The pledge represents a commitment to work toward increasing the number of people screened for colorectal cancer and substantially reducing this disease as a major public health problem. By working together and collectively pushing harder, we will make greater progress, prevent more cancers and save more lives.

Once a partner organization signs the pledge, the next step is looking at how they can make an impact. Conveniently, the National Colorectal Roundtable has created an 80% by 2018 employer toolkit. This toolkit includes an overview with five steps an employer can take to increase their CRC screening rates. The ACS team that supports your state can work with you to be successful!

What are a few ways organizations can create a culture that promotes the importance of health screenings, including CRC?

Kahn: Employers can work with their insurance provider to reduce financial barriers to screening tests. For example, consider partnering with your insurance provider(s) or screening and wellness partners to supply free FIT kits, which can be completed at home and detect early signs of CRC, and establish a process to ensure proper follow up. Organizations can also address other barriers to screening by offering a comp day for employees ages 50 and older and for younger employees who are at high risk of colon cancer to get tested.

When a person has a colonoscopy, they need to take a day off from work, which may be a very real barrier to testing for some employees. By offering a comp day, employers send an important message to their employees about the value they place on CRC testing and the health of their team. Employers could also consider offering a comp day for employees who need to drive their spouse to and from testing.

It’s often said that when it comes to CRC screening, the best test is the one that gets done. What screening methods does ACS recommend?

Kahn: Yes! The best test IS the one that gets done. Studies have shown that when patients are offered a choice of which CRC screening method they would like, they are more likely to choose one as opposed to choosing to not get screened when only offered one option. However, this is a tricky question. Let’s break this down into two categories – screening options for people at average risk and options for those with increased risk.

Starting at age 50, men and women at average risk for developing colorectal cancer should use one of the screening tests below:

  • Flexible sigmoidoscopy every 5 years*
  • Colonoscopy every 10 years
  • Double-contrast barium enema every 5 years*
  • CT colonography (virtual colonoscopy) every 5 years*
  • Guaiac-based fecal occult blood test (gFOBT) every year*,**
  • Fecal immunochemical test (FIT) every year*,**
  • Stool DNA test every 3 years*

*Colonoscopy should be performed if test results are positive.
** Highly sensitive versions of these tests should be used with the take-home multiple sample method. A gFOBT or FIT done during a digital rectal exam in the doctor’s office is not enough for screening.

Men and women with increased or high risk of colorectal cancer may need to start colorectal cancer screening before age 50 and/or be screened more often. The following conditions contribute to higher than average risk:

  • A personal history of colorectal cancer or adenomatous polyps
  • A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease)
  • A strong family history of colorectal cancer or polyps (see Colorectal Cancer Risk Factors)
  • A known family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary non-polyposis colon cancer or HNPCC)

The ACS has created screening guidelines for people with an increased or high risk for colorectal cancer based on specific factors. Some people may have more than one risk factor. Refer to the guidelines and discuss these recommendations with your healthcare provider, who can suggest the best screening option for you, as well as any changes in the schedule based on your individual risk.

Many employers choose to offer a fecal immunochemical, or FIT test to employees. What are the benefits of this screening method?

Kahn: FIT tests, also known as FIT kits, are a great screening method for colorectal cancer. These kits are inexpensive, accurate and noninvasive. They can be done in the privacy of your home and do not require any bowel prep. Additionally, FIT kits can be mailed, making it easier to reach populations that may not otherwise have access to other types of CRC screening, like colonoscopy.

What are the most common reasons people aren’t getting screened for CRC and what can their employers do to inspire action and break down these barriers?

Kahn: There are three major reasons people aren’t getting screened:

Education: Employers need to educate employees on colorectal cancer screening. Make them aware of the importance of timely, appropriate screening options for their risk level. Work with your health plan or local ACS staff to get the CRC materials and resources you need.

Unwanted procedure: Many people do not get screened because they don’t want to go through the bowel prep for a colonoscopy or they don’t want to have the procedure in the first place. This is why offering more than one screening method can be so successful.

Leadership buy-in: Any employer-sponsored health initiative will always have barriers, but the successful ones all have buy-in from key leaders within the organization. Gaining support and participation from leadership will show the importance of this initiative and empower employees to take the time they need to complete this life-saving screening.

What are some factors an employer should consider prior to launching a CRC awareness program? Are there advantages to partnering with an outside organization?

Kahn: The “C” word, cancer, can be a scary word for many people. It is sometimes overlooked because it can be hard to talk about. But almost everyone has been affected or knows someone who has been affected by cancer and this is why it is so important to discuss – cancer screening saves lives.

There are several considerations employers should make before launching a CRC awareness program:

Start with a baseline measurement of the percent of your eligible employees who have been screened. This will help gauge progress after the program has been launched.
Educate your HR/benefits staff on local resources available for cancer screening and treatment. ACS has found that employees will often turn to their employer’s HR or benefits team to get more information on screening methods or for resources after a diagnosis.
Prepare a communications campaign. Align with a national awareness campaign for greater coverage. March is Colorectal Cancer Awareness Month.
There’s a major advantage in partnering with an outside organization when launching a CRC awareness program. The employer’s health plan can provide baseline data and reporting and often has educational materials on CRC screening. ACS can provide educational materials, in-person employee education, training for HR/benefits staff and can be a partner in planning the program.

Ian Kahn is a Health Systems Manager for the American Cancer Society, covering Colorado. He works with health plans, state and local health departments and quality improvement organizations to improve cancer screening and HPV vaccinations rates. He is an active member of both the Colorado and Wyoming Cancer Coalitions.

Kahn received a Master of Public Health in community health education from East Stroudsburg University and began his career in public health with Seton Healthcare Family in Austin, Texas. He has also worked for the City of Austin Parks and Recreation department and the Austin Independent School District, where he managed a wellness program for 12,000 employees and launched the district’s first employee health risk assessment.