[Congressional Record Volume 142, Number 92 (Thursday, June 20, 1996)]
[Extensions of Remarks]
[Pages E1140-E1141]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




    PROVIDING COLORECTAL CANCER SCREENING COVERAGE FOR ALL AMERICANS

                                 ______


                         HON. ALCEE L. HASTINGS

                               of florida

                    in the house of representatives

                        Thursday, June 20, 1996

  Mr. HASTINGS of Florida. Mr. Speaker, when I first became involved in 
the issue of colorectal cancer screening, I did so not because I am an 
African-American, but because providing colorectal cancer screening as 
a covered benefit funded the Medicare Program has the potential to save 
thousands of lives each year in this country. The statistics on 
colorectal cancer cannot be ignored. There are about 150,000 new cases 
of colorectal cancer each year in the United States, and about 60,000 
people will die in the United States from that disease each year. 
Colorectal cancer is the second leading killer of all the cancers. It 
also is an equal opportunity disease whose victims include Americans of 
all races, creeds, and ethnic groups.
  I recently became aware, however, of a number of medical studies that 
make me realize that, as an African-American, I have a special reason 
to be concerned about this issue. These studies have found that 
colorectal cancer strikes African-Americans differently than it does 
the general population in the United States. Moreover, these 
differences are critical with regard to screening to detect this 
disease. The data in these studies make clear that sigmoidoscopy is not 
an effective screening procedure for African-Americans. Rather, a 
barium enema or other procedure that views the full colon is clearly 
preferred for this population, and perhaps for other groups as well.
  In the opening weeks of this Congress, I introduced a bill, H.R. 
1046, that would expand the Medicare Program to provide coverage of 
periodic colorectal cancer screening services. Because this bill 
provides coverage for all of the currently available screening 
procedures, it would allow all Medicare recipients at average-risk for 
colorectal cancer, including African-Americans, to decide to be 
screened with the more comprehensive barium enema procedure or, if they 
prefer, sigmoidoscopy. As of last week, the Colorectal Cancer Screening 
Act has 30 cosponsors in the House of Representatives, from both sides 
of the aisle, and the key provisions of the bill were included as part 
of the comprehensive reform of the Medicare Program in President 
Clinton's most recent budget proposals.
  H.R. 1046 is distinguished from other colorectal cancer screening 
legislation by the fundamental belief that the decision on how to 
screen each patient should be left to the patient and his or her 
physician--not the Federal Government. For this reason, H.R. 1046 
authorizes Medicare coverage for colorectal cancer screening for 
individuals at average-risk for colorectal cancer that includes an 
annual fecal occult blood test [FOBT] and direct screening every 5 
years with either a barium enema procedure or sigmoidoscopy. For 
individuals at high-risk for colorectal cancer, the bill provides an 
annual FOBT and direct screening every 2 years with either a barium 
enema procedure or colonoscopy. The bill also authorizes the Secretary 
of Health and Human Services [HHS] to authorize coverage for new 
screening procedures as they become available. Unlike other colorectal 
cancer screening bills that would provide Medicare reimbursement for 
only some of the currently available screening procedures, H.R. 1046 
recognizes that different screening procedures may be appropriate for 
different individuals. The bill, therefore, provides a range of options 
and leaves the choice to patients and their physicians.
  The validity of this approach is confirmed by the medical studies on 
colorectal cancer in African-Americans. The studies were unanimous in 
their conclusions--that ``the entire colon of * * * black patients is 
at greater risk than that of white patients to develop cancer of the 
colon.'' They found that colon cancer tends to strike African-Americans 
more commonly on the right side of the colon than the general 
population in the United States.
  These studies raise serious questions about the approach taken by 
other colorectal cancer screening bills, which provide coverage only 
for sigmoidoscopy and not the barium enema. While the barium procedure 
allows for screening the whole colon, the flexible sigmoidoscope 
screens only about one-half of the colon. Sigmoidoscopy does not screen 
the right side of the colon where African-Americans more frequently 
develop colon cancer. Thus, providing coverage only for sigmoidoscopy 
puts African-Americans and possible other unidentified ethnic groups at 
risk. Let me cite the conclusions of several of these studies:

       ``Current screening recommendations [sigmoidoscopy] may not 
     be effective enough for preventing colon cancer in this 
     population.'' ``Distribution of Adenomatous Polyps in 
     African-Americans,'' Lisa A. Ozick, MD, Leslie Jacob, MD, 
     Shirley S. Donelson, MD, Sudhir K. Agarwal, MD, and Harold P. 
     Freeman, MD, The American Journal of Gastroenterology, May 
     1995, p. 758.
       ``This study points out the potentially discrepant 
     sensitivity and value of this instrument [sigmoidoscope] 
     between black and white patients, suggesting that colonoscopy 
     and/or air contrast barium enema examinations are the 
     screening methodologies of choice in black patients.'' 
     ``Anatomical Distribution of Colonic Carcinomas Interracial 
     Differences in a Community Hospital Population,'' Houston 
     Johnson, Jr., MD and Rita Carstens, RN, Cancer, 1986, p. 999.
       ``This study challenges this recommendation [sigmoidoscopy 
     every three to five years] as unsatisfactory for blacks since 
     50 percent of neoplasms could be missed in blacks compared to 
     only 20 percent in whites.'' ``Site-Specific Distribution of 
     Large Bowel Adenomatous Polyps: Emphasis on Ethnic 
     Differences,'' Houston Johnson, Jr., MD, Irving Margolis, MD, 
     Leslie Wise, MD, Dis. Colon Rectum, April 1988, p. 260.
       ``Data support the clinical impression that blacks have 
     relatively more proximal colonic tumors than the general 
     population. They also suggest that early full study of the 
     colon, including barium enema with air contrast or 
     colonoscopy (opposed to flexible sigmoidoscopy), is highly 
     indicated in screening or work up for earlier diagnosis in 
     patients, especially blacks suspected of polyps or carcinoma 
     of the colon.'' ``Anatomic Distribution of Colonic Cancers in 
     Middle Class Black Americans,'' John W.V. Cordice, Jr. MD, 
     Houston Johnson, Jr. MD, Journal of the American Medical 
     Association, 1991, p. 730.
       ``Unless barium enema studies or colonoscopic studies are 
     employed, significant numbers of premalignant lesions or 
     early cancers could be missed in a black population if the 
     distribution of lesions found in this study is generally 
     applicable to black populations.'' ``Untreated Colorectal 
     Cancer in a Community Hospital,'' Dr. Houston Johnson, 
     Jr., Journal of Surgical Oncology, July 3, 1984, p. 198.

  These medical studies have caused me to redouble my efforts on this 
legislation. We need to enact a colorectal cancer screening bill that 
serves all Americans, and that provides an equal opportunity for all 
Americans to have a screening procedure that is effective

[[Page E1141]]

for them, and which will prevent this horrible disease.
  Mr. Speaker, I encourage all of my colleagues to reexamine this 
issue, and to contact me or my staff if you would like to obtain copies 
of the studies I have cited here, or other studies on colorectal cancer 
and the alternatives for screening. I also encourage you to join me as 
a sponsor of H.R. 1046, and to work to establish colorectal cancer 
screening as a covered benefit under the Medicare program. With this 
step, we can begin to make serious progress in reducing the avoidable 
pain, anguish, and excessive medical costs that this disease imposes on 
all of our citizens.

 Colorectal Cancer in African-Americans: Medical Studies Indicate That 
Screening With Sigmoidoscopy and FOBT Is Inadequate for This Population

       A number of recent medical studies have confirmed earlier 
     reports that polyps and colon cancer occur more commonly in 
     the right (proximal) colon of African-Americans, as compared 
     with the general population. These studies raise questions 
     with regard to the adequacy of colorectal cancer (CRC) 
     screening with sigmoidoscopy, given that a sigmoidoscopy 
     procedure examines only the left (distal) side of the colon, 
     and suggest the use of the barium enema or colonoscopy as 
     preferred screening methodologies for African-Americans.
       The principal findings of these studies are as follows:
       (1) ``Distribution of Adenomatous Polyps in African-
     Americans,'' Lisa A. Ozick, MD, Leslie Jacob, MD, Shirley S. 
     Donelson, MD, Sudhir K. Agarwal, MD, and Harold P. Freeman, 
     MD, The American Journal of Gastroenterology, May 1995, pp. 
     758-760.
       ``Previous research has suggested that polyps and colon 
     cancer occur more commonly in the right colon in African 
     Americans compared with the general population.'' (p. 758).
       ``This study supports previous work that suggests that 
     there is a significant shift to the right in the anatomical 
     distribution of polyps in African-Americans. It also shows 
     that the malignant potential is as high for right-sided 
     polyps as it is for those on the left. Current screening 
     recommendations [sigmoidoscopy] may not be effective enough 
     for preventing colon cancer in this population.'' (p. 758).
       (2) ``Anatomical Distribution of Colonic Carcinomas 
     Interracial Differences in a Community Hospital Population,'' 
     Houston Johnson, Jr., MD and Rita Carstens, RN, Cancer, 1986, 
     pp. 997-1000.
       ``This study points out the potentially discrepant 
     sensitivity and value of this instrument [sigmoidoscope] 
     between black and white patients, suggesting that colonoscopy 
     and/or air contrast barium enema examinations are the 
     screening methodologies of choice in black patients.'' (p. 
     999).
       ``The finding that . . . indeed the entire colon of this 
     population of black patients is at greater risk than that of 
     white patients to develop cancer of the colon is 
     astounding.'' (p. 1000).
       (3) ``Site-Specific Distribution of Large Bowel Adenomatous 
     Polyps: Emphasis on Ethnic Differences,'' Houston Johnson, 
     Jr., MD, Irving Margolis, MD, Leslie Wise, MD, Dis. Colon 
     Rectum, April 1988, pp. 258-260.
       In a study at Queens Hospital Center in New York, it was 
     found that ``[f]ifty-two black and 46 white patients had 130 
     adenomatous polyps. . . . A separate racial analysis 
     demonstrated an unexpected pattern of distribution among 
     blacks and whites. Adenomatous lesions were more broadly 
     distributed in all segments of the large bowel for blacks, 
     but were disproportionately concentrated in the sigmoid and 
     rectum of whites.'' (p. 259).
       ``The findings of this study underscore the important 
     ethnic differences in the site distribution of adenomatous 
     polyps. The right-sided dominance of neoplastic lesions in 
     blacks emphasizes the importance of total colonic 
     surveillance to detect these large bowel neoplasms in this 
     racial group.'' (p. 259).
       ``This study challenges this recommendation [sigmoidoscopy 
     every three to five years] as unsatisfactory for blacks since 
     50 percent of neoplasms could be missed in blacks compared to 
     only 20 percent in whites.'' (p. 260).
       (4) ``Anatomic Distribution of Colonic Cancers in Middle 
     Class Black Americans,'' John W.V. Cordice, Jr. MD, Houston 
     Johnson, Jr. MD, Journal of the American Medical Association 
     1991, pp. 730-732.
       ``Data support the clinical impression that blacks have 
     relatively more proximal colonic tumors than the general 
     population. They also suggest that early full study of the 
     colon, including barium enema with air contrast or 
     colonoscopy (opposed to flexible sigmoidoscopy), is highly 
     indicated in screening or work up for earlier diagnosis in 
     patients, especially blacks suspected of polyps or carcinoma 
     of the colon.'' (p. 730).
       (5) ``Untreated Colorectal Cancer in a Community 
     Hospital,'' Dr. Houston Johnson, Jr., Journal of Surgical 
     Oncology, July 3, 1984, pp. 198-200.
       ``Generally, sigmoidoscopic examinations are recommended to 
     complement physical examinations and stool blood tests. While 
     this recommendation may be appropriate for white patients, it 
     may not be appropriate for black patients. Unless barium 
     enema studies or colonoscopic studies are employed, 
     significant numbers of premalignant lesions or early cancers 
     could be missed in a black population if the distribution of 
     lesions found in this study is generally applicable to black 
     populations.'' (p. 198).

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