Statement of Bernard Levin, M.D., Vice President for Cancer Prevention,
M.D. Anderson Cancer Center, Houston, Texas,
on behalf of the American Gastroenterological Association

Testimony Before the Subcommittee on Health
of the House Committee on Ways and Means

Hearing on H.R. 15 "Medicare Preventative Benefit Improvement Act of 1997

March 13, 1997

Chairman Thomas, Members of the Subcommittee: I am Dr. Bernard Levin, Vice President for Cancer Prevention at the M.D. Anderson Cancer Center in Houston, Texas. On behalf of the American Gastroenterological Association, thank you for the opportunity to discuss colorectal cancer screening before the Subcommittee today. By providing access to proven screening measures, H.R. 15, the "Medicare Preventive Benefit Improvement Act of 1997" will help to prevent pain and suffering for many thousands of Americans, and do so in a cost-effective manner.

Several years ago the AGA joined with the American Society for Gastrointestinal Endoscopy and the American Association for the Study of Liver Diseases to form the American Digestive Health Foundation. I have been pleased to serve as Co-chair of the Foundation's Digestive Health Initiative Colorectal Cancer Education Campaign. Our mission is to deliver a message of vital importance to the public, namely, that:

• Colorectal cancer is serious and often deadly - about 140,000 new cases occur each year, and 55,000 people die. For both men and women, it is the second deadliest cancer in this country, second only to lung cancer.

• Colorectal cancer is largely preventable - most colorectal cancers develop from benign polyps. Finding and removing these polyps reduces the risk of colorectal cancers by up to 90%.

• For men and women 50 or older, as well as those with a family history of cancer, getting a colorectal cancer screening test is one of the best steps they can take to protect their health - in fact, it is estimated that widespread compliance with colorectal cancer screening could save the lives of more than 25,000 Americans each year.

The fact that colorectal cancer screening saves lives is strongly supported by the recommendations of the American Cancer Society, the World Health Organization, and the U.S. Preventive Services Task Force. Earlier this year, major national clinical practice guidelines emphatically endorsed the importance of colorectal cancer screening for men and women aged 50 and above, and for persons at increased risk of colon cancer due to their family or personal medical histories. These guidelines, produced by the American Gastroenterological Association, American College of Gastroenterology, the American Society of Colon and Rectal Surgeons, the American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal Endoscopic Surgeons, included a rigorous review of the scientific literature on the efficacy of screening to detect colorectal cancer. An independent panel of 16 experts representing the fields of medicine, nursing, consumer advocacy, health care economics, behavioral sciences and radiology studied 3500 peer-reviewed, published papers, analyzing the performance, effectiveness, patient acceptance, cost effectiveness and outcome of screening tests currently in use. The panel estimated and compared the benefits, (that is, cancers detected) and risks (the number of severe complications) of each test. The panel's conclusions were unequivocal: colorectal cancer screening can save lives, and screening tests should be encouraged for both average and high-risk populations. In addition to literally saving lives, the national guidelines panel found that screening and surveillance for colorectal cancer also saves money for the health care system in the long run. The panel concluded that the costs associated with colorectal cancer screening are as cost-effective as many other preventive tests, and have a high return on investment in terms of lives saved.

In short, we have the tools to fight colorectal cancer, and screening makes good financial sense. Fortunately, most health insurers have recognized these facts. Today, colorectal cancer screening services are covered in most managed care plans, and every major Federal employee health care plan provides coverage for these services. Just last year, Congress directed the CHAMPUS program to cover colorectal screening tests. CHAMPUS will cover screening services for all beneficiaries from age 50, with examination by colonoscopy every five years beginning at age 40 for individuals at increased risk of developing colon cancer. But, unfortunately, the Medicare program lags behind -- despite the fact that Medicare beneficiaries are very vulnerable to colon cancer, and the average age of diagnosis of this deadly disease is 71.

As a physician I can tell you that there is nothing more frustrating for me, and more tragic for the patient, than to see an advanced colon cancer in a 75 year old man or woman that could have been caught as a benign polyp five or 10 years earlier. Through the Digestive Health Initiative, we are doing all we can to educate the public on the importance of colorectal cancer screening. But education does little good when cost is a significant barrier to patients who want to get these important medical tests. Yet, that is the problem Medicare beneficiaries face today.

The preventive services provided by H.R. 15 will move Medicare significantly in the direction of what we know works in health care today: emphasizing prevention and early treatment, and empowering patients to help protect and manage their own health. In regard to colorectal cancer screening, the legislation provides for:

• a fecal occult blood test annually;

• a screening flexible sigmoidoscopy every four years;

• and for those who, because of family or personal history or other predisposing factors, are at increased risk of developing colorectal cancer, a thorough examination by colonoscopy once every two years.

Coverage of this screening regimen represents an enormous step toward the goal of promoting cancer prevention for Medicare beneficiaries, yielding tremendous savings for the program in the long run. Our principal objective, as physicians, is to support the compelling need for improvement of preventive health benefits under Medicare.

On behalf of the American Gastroenterological Association, I would like to thank Chairman Thomas, Mr. Bilirakis, and Mr. Cardin for their leadership in introducing H.R. 15 and thank also the six members of the subcommittee who are now co-sponsors. I am pleased that the American

Gastroenterological Association is working actively in a coalition of more than 40 professional and advocacy groups in support of H.R. 15, and we look forward to working closely with you to secure its passage.

In closing, Mr. Chairman, I would note that Medicare has two stark options with respect to colon cancer. It can sit back and pay the bills for treating individuals with cancers that went undetected--or it can actively seek to reduce the financial cost and human suffering caused by this devastating disease by supporting and covering screening services. I urge this Committee to support the latter course, and in turn save the lives of thousands of Americans.

I thank the Subcommittee for the opportunity to appear here today, and I would be happy to answer any questions.