Deaths from colorectal cancer in Appalachian Kentucky have declined, but far less than in the rest of the nation, UK study says

County rates per 100,000 are seen in five ranges or quintiles.(Map adapted by Kentucky Health News)

Kentucky Health News

Deaths from colorectal cancer in Appalachian Kentucky declined from 1999 to 2020, but far less than the rate of decline in the rest of the nation.

That's the upshot of a University of Kentucky study analyzing death data.

It found that in the 54 Kentucky counties served by the Appalachian Regional Commission, the mortality rate fell from 31.24 deaths per 100,000 residents in 1999 to 24.46 per 100,000 in 2020. But the national rate dropped by almost half, from 27 deaths per 100,000 Americans in 1999 to 14.81 in 2020. In non-Appalachian Kentucky, the rate dropped from 27.6 to 17.1.

During the entire 21 years covered by the study, the colorectal-cancer death rate in Appalachian Kentucky was 25.8 per 100,000 residents. In the 66 non-Appalachian counties, the rate was about 22 per 100,000. The national rate was 19.43 deaths per 100,000. Kentucky has the fourth highest death rate. 

The Kentucky county with the highest age-adjusted rate from 1999 through 2020 was Fleming, at 39.6 deaths per 100,000 residents. The next highest were Harlan, 34.4; Bath, 33.2; Pike, 32.1; Breckinridge, 31.6; Henry, 31.5; Todd, 31.1; Carter, 30.7; Lewis, 30.7; Cumberland, 30.6; Mason, 30.5; Lawrence, 30.4; Morgan, 30.4; Clay, 30.2; Letcher, 29.7; Washington, 29.4; Nicholas, 28.6; Breathitt, 28.5; Perry, 28.5; Floyd, 28.3; Monroe, 28.3; Powell, 28.2; and Nelson, 27.9 (all in dark blue on the map).

The counties with the 10 lowesr rates were Lyon, 14.9 per 100,000; Trimble, 16.97; McCracken, 17.7; Jessamine, 18.2; Shelby, 18.3; Madison, 18.4; Bullitt, 18.7; Trigg, 18.8; and Owen, 18.8.  Rates for Hickman and Robertson counties were not reported due to small case numbers.

The study, in the journal Gastroenterology, used data from the Centers for Disease Control and Prevention on the causes of death for Americans 15 or older. Its lead author is Dr. Syed Hassan, a research coordinator and clinical research scientist in UK's Department of Internal Medicine.

Hassan "said efforts to enhance screening rates should be improved and more education on colorectal cancer is needed," according to a UK news release.

He noted that In Appalachian Kentucky, nearly 41% of the colorectal cancer deaths occurred at home, suggesting that many victims might not have been seen by a doctor until the cancer had significantly advanced.

“That’s concerning, in my opinion,” Hassan said. “Access to health care, lifestyle related modifiable risk factors and education are important factors we should further work upon.”

Hassan also said anxiety about colonoscopies and other cancer screenings, and lack of education about the disease, may also play a role: “Many of these patients might’ve believed that they probably wouldn’t be able to afford as much care due to their socioeconomic status.”

Screening for colon cancer is recomended to start at age 45, because cancers of the colon and rectum tend to occur after age 40, but recent studies have shown increases in younger people, especially those with risk factors.

These cancers tend to run in families; studies show that if a close relative has had colorectal cancer, you can be predisposed to polyps — pre-cancerous lesions that can lead to the development of the cancer,

Other risk factors include age and lifestyle factors such as smoking, sedentary living, obesity, a diet rich in red meat, salt and saturated fats or a low-fiber diet.

All 45 and older should be screened for colon cancer, earlier if you have family history of it; Ky. has made much progress against it

Colon Cancer Prevention Project graphic

Ky. Health News

March is Colorectal Cancer Awareness Month, which serves to remind everyone who is 45 and older – or is younger than 45 with a family history of colon cancer – to get screened.

That's because colorectal cancer is one of the leading causes of cancer-related deaths in Kentucky and often doesn't cause any symptoms, especially in early stages when the only way to detect it is through screening, says Dr. Avinash Bhakta, a colorectal surgeon at the University of Kentucky Markey Cancer Center. 

The Colon Cancer Prevention Project says regular screening is recommended to begin at 45 for people who do not have a family member who has had colon cancer and/or polyps. Those who have a family history of colon cancer should get a colonoscopy at age 40 or earlier. 

For those without a family history of colon cancer, two types of tests are recommended by the U.S. Preventive Services Task Force: visual exams (primarily colonoscopies) and stool-based tests that check a stool sample for signs of cancer. 

UK's Bhakta writes that while colonoscopy is the gold standard for screening that must be done in a clinic or hospital under sedation, stool-based tests offer an alternative that is less invasive and can be more accessible. 

Stool-based tests check for blood and/or abnormal DNA in the stool, and can be done in the privacy of your own home, Bhakta notes. The test is then returned to a doctor or mailed to a laboratory for testing. All at-home tests need to be repeated every year, and any positive findings will require a follow-up colonoscopy.

Colonoscopies involve finding pre-cancerous lesions and removing them before they turn into cancer, and that means that most cases of colorectal cancer are considered preventable. Screenings also allow physicians to find cancer at an earlier stage when it is more treatable.

And as Bhakta wrote in her headline,  "The best screening test is the one you take." 

Colorectal screening in Kentucky

Kentucky has made great progress when it comes to getting Kentuckians screened for colon cancer.

"Twenty years ago, Kentucky had the highest colorectal cancer incidence and mortality rates in the U.S., as well as the second-lowest colorectal cancer screening rate," Elizabeth Chapin reports for UK. "Today, thanks to the coordinated efforts of state agencies and organizations, these dire statistics have turned around. Since 2002, colorectal cancer screenings have doubled in Kentucky, which has led to a more than 30% decrease in incidence and mortality rates."

Much of this success is due to efforts made by the Kentucky Cancer Consortium in collaboration with several major cancer groups that worked to make colorectal screenings more accessible to Kentuckians.

"What we've seen happen with colorectal cancer rates in Kentucky over the past two decades is truly a public health success story," Thomas Tucker, the Markey Cancer Center's senior director for cancer surveillance, told Chapin. "It goes to show that significant change can happen when we work together and coordinate our efforts."

Chapin reports that the KCC and its partners' efforts inspired an initiative to encourage primary care physicians to recommend and schedule colorectal cancer screenings. It also brought about two successful Kentucky bills: the first, approved in 2002, requires all health insurers in Kentucky to cover the cost of screening for age-eligible patients; the second, passed in 2008, established the Kentucky Colon Cancer Screening Program to screen uninsured age-eligible patients and educate the public about the importance of being screened.

These initiatives helped move the state's colorectal cancer screening rates from 49th in the nation to 20th.

"The results have saved thousands of lives," Tucker told Chapin. "To put it into perspective, today, 650 fewer Kentuckians are diagnosed and 270 fewer die from colorectal cancer each year than in 2001."

The Kentucky Cancer Program has also worked with KCC to increase screening rates by fostering community colon cancer screening programs, Chapin writes.

"The KCP's success in increasing colorectal cancer screening rates is attributed to working within communities at the local level," said KCP-East Director Mindy Rogers. "As residents of the areas they serve, our specialists have an understanding of their communities and the particular barriers they face when it comes to cancer screenings, treatment and care."

Despite Kentucky's progress, Chapin reports that roughly a third of eligible Kentuckians still do not seek colorectal cancer screenings due to health, socioeconomic and education disparities. 

She adds that the KCP team is collaborating with community partners to identify resources that can help overcome barriers such as transportation and family care.

Both the KCC and KCP model has led to a similar screening effort around lung cancer, including legislation to create the lung cancer screening program in the Kentucky Department for Public Health. 

"There’s more work to do because the goal is to be ranked number one in the nation for screening rates,” Tucker told Chapin.  “But Kentucky has a number of barriers not faced by many other states and together, we’ve made some remarkable change in the face of these incredible challenges.”

Black Kentuckians need more information about colon cancer screening, especially the availability of in-home tests, study finds

Most focus-group participants in Louisville said they had not
been offered stool-based testing as an option for colorectal
cancer screening, stressing the need for more community-
based outreach. (Photo by fizkes, iStock/Getty Images Plus)

By Elizabeth Chapin

University of Kentucky

A recent study at the University of Kentucky's Markey Cancer Center highlights the need for increased outreach and education to reduce colorectal cancer screening disparities in Black communities.

According to the study, published in the Journal of Cancer Education, people in Kentucky’s Black communities may not be aware of all of the colorectal-cancer screening options available to them, particularly stool-based tests.

Black communities are disproportionately affected by colorectal cancer. In Kentucky, Blacks who have colorectal cancer are more likely to die from the disease than whites.

Since about half of the racial gap can be explained by differences in screening rates, educating Black communities about screening options can save lives, says Markey Cancer Center researcher Aaron Kruse-Diehr, the study’s principal investigator.

“In the colorectal-cancer screening world, we like to say ‘the best test is the one a patient completes’ — and giving people multiple options has been shown in previous studies to increase their likelihood of completing screening,” said Kruse-Diehr, who is an associate professor in the UK College of Medicine. “To reduce the Black-white colorectal cancer mortality rate, we need to make sure Black people of screening age are being provided all available options.”

Regular screening, beginning at age 45 is the key to preventing colorectal cancer and finding it early. Two types of tests are recommended by the U.S. Preventive Services Task Force: visual exams (primarily colonoscopies) and tests that check a stool sample for signs of cancer. Stool-based tests are less invasive and, for many, more accessible since they can be done at home.

Kruse-Diehr said, “Home tests can reduce a number of both individual-level and structural barriers that often exist for many people with respect to completing colonoscopy, such as needing to take time off work, finding an individual to drive the person to/from the procedure, and travel distance to a provider who can perform colonoscopy.”

The research team partnered with five Black churches in Louisville, which has bihg racial differences in screening, to conduct focus groups exploring screening barriers and facilitators for cancer education and outreach.

While focus-group participants overwhelmingly recognized the importance of being up to date with screening, nearly all reported that they had never heard about stool-based tests or heard health-care providers offer them as an option.

To address this knowledge gap, participants stressed community-based outreach and communication from trusted individuals, such as local Black medical providers and colorectal cancer survivors.

Kruse-Diehr led the study with Elizabeth Holtsclaw, cancer support strategic partnerships manager at the American Cancer Society. Two of the study’s co-authors, College of Public Health undergraduates Carlee Combs and Rose Wood, helped analyze the data and write the results as part of an independent-study course.

The research team is now planning to pilot a church-based screening program with one of the partner churches, with hopes of eventually expanding the program across Kentucky.

“These study results are informing outreach efforts that we hope will make a huge dent in the death rates from colorectal cancer among Black Kentuckians,” said Kruse-Diehr.

Colorectal screening now available at participating Ky. pharmacies

L-R: Brooke Sorgi of Exact Sciences, maker of Cologuard, a

DNA-based screening test, and Capital Pharmacy pharmacist

Dr. Emily Wilkerson mark the first pharmacist-led colorectal

cancer screening via a stool-based test on Sept. 29.

Kentucky's pharmacists and health insurers have teamed up to offer what they say is the nation's first "pharmacist-led colorectal cancer screening via a non-invasive stool-based test."

The test was done Sept. 29 at Capital Pharmacy & Medical Equipment in Frankfort, the Kentucky Pharmacists Association and the Kentucky Association of Health Plans said in a Nov. 17 news release.

“Health plans and pharmacists are joining together to tackle a leading cause of death in the commonwealth,” KAHP Executive Director Tom Stephens said.

KAHP gave the Kentucky Pharmacists Education and Research Foundation a $50,000 grant to expand access to these screenings in Kentucky. Participating pharmacies are being reimbursed for pharmacist-led screening and follow-up.  

KPA Executive Director Ben Mudd said, “Adding assessment of and screening for colorectal cancer to existing pharmacy protocols can greatly impact our two-decade-long fight to increase CRC screening rates. With early detection, colorectal cancer is a preventable, treatable, and beatable disease.”

The screenings were authorized by a new protocol approved by the Kentucky Board of Pharmacy in September 2021. It lets pharmacists initiate dispensing of noninvasive, stool-based colorectal cancer screening such as a fecal immunochemical test or a stool DNA test. Pharmacies interested in providing the service can contact Dr. Emily Wilkerson at fellow@kphanet.org for more information.

Governor signs 13 health-related bills into law, including one that caps co-payment for insulin at $30/month for an estimated 22,000

Reps. Minter and Bentley, Beshear and interpreter Virginia Moore

By Melissa Patrick

Kentucky Health News

Gov. Andy Beshear signed 13 health bills into law Monday, highlighting one that caps insulin costs for about 30 percent of Kentuckians who need the life-preserving hormone. 

The limit is $30 for a 30-day supply. "This is the right thing to do and it's a game changer for those who rely on insulin to live," Beshear said. "Until now, a single dose of insulin which cost between $2 and $7 to manufacture could sell for an average wholesale price of around $300 per vial."

Beshear noted that in a lawsuit he filed against insulin companies while attorney general over their "unconscionable overpricing," revealed that over 10 years, the price of one insulin product went up 311%, and another rose 285%, including a rise from $325 per package in 2011 to $530 in 2017. 

"While these companies work to increase bottom lines and sustain market shares," he said. "Kentucky families hit hardest by this price gouging can be paying more than $1,000 a month on insulin just to stay alive."

House Bill 95, co-sponsored by Reps. Danny Bentley, R-Russell, and Patti Minter, D-Bowling Green,  will cap the monthly out-of-pocket cost for a 30-day supply of insulin at $30 for Kentuckians covered by state-regulated employer health plans or plans purchased on the marketplace exchange. 

Minter, whose son has Type 1 diabetes, has said the bill will cover about 30% of insulin-dependent Kentuckians. It doesn't cover Medicare, Medicaid or self-funded employer plans except the one for state employees.

"I want to be very clear, this is only a first step," Minter said. "There is much more work to do. . . but today is a very big deal. It will save lives and it will give people hope." She said that for many families, it will make the difference between bankruptcy and keeping a child alive.

In a video, Angela Lautner, Kentucky #insulin4all legislative lead, expressed her gratitude to the lawmakers for the bill, but she too warned that more work needs to be done, saying it will help about 22,000 people. 

"Much more has to be done, but HB 95 is a step forward,” said Lautner, "My chapter is here for insulin for all and that's why we must continue this momentum into the next session with urgency, with priority." 

More than half a million Kentuckians have diabetes, and Kentucky ranks seventh-highest in the U.S. for diabetes prevalence. Lautner said more than one in four insulin-dependent people ration insulin due to cost. 

The price cap will apply regardless of the amount or type of insulin the person with diabetes needs.

In addition to capping the price, HB 95 requires health plans to provide the equipment, supplies and outpatient training and education needed to help diabetics stay healthy, and forbids any reductions from this coverage by others involved in coverage.

The fiscal impact statement attached to the bill says it will increase premiums for health benefit plans, not including the state employee plan, by about 80 cents a month. 

Bentley said that's a small price to pay to make sure diabetics keep getting their insulin, because without it they can suffer amputations, loss of vision, neuropathy, ketoacidosis and even death. "The costs on the medical side is much more than the cost that we're going to have by helping people with insulin," he said. 

Beshear also signed bills addressing these health topics:

Telehealth: HB 140, sponsored by Rep. Deanna Frazier, R-Richmond, will permit telehealth services that were allowed to expand due to the pandemic to remain in place. The bill requires reimbursement for telehealth to be equivalent to reimbursement for the same service provided in person. "I think it's one of the most important bills that have been passed," Beshear said. 

Substance-use disorder: HB 219, sponsored by Bentley, allows pharmacies to sell hypodermic syringes and needles without a prescription. The aim is to increase access to clean supplies for people who inject drugs, which will help to decrease the risk of blood-borne diseases such as hepatitis C and HIV/AIDS.

Medicaid and hospitals: SB 55, sponsored by Sen. Stephen Meredith, R-Leitchfield, abolishes co-payments required by Medicaid.

HB 183, sponsored by Rep. Brandon Reed, R- Hodgenville, will allow Kentucky hospitals to get more money from Medicaid, based on an "average commercial rate" instead of the current Medicaid rate, which is often below that amount. The program would not cost the state anything, because Kentucky's hospitals have agreed to cover the cost. To get the money, hospitals will have to abide by higher quality standards that are still being decided by the Kentucky Hospital Association and the Cabinet for Health and Family Services. The bill is expected to help many of the state's rural hospitals; a recent report shows that 16 of them are at risk of closing. 

Colon cancer and genetic testing: HB 108, sponsored by Melinda Gibbons Prunty, R-Belton (Muhlenberg County), codifies current Medicaid coverage of colorectal cancer, including screenings starting at 45 for most people and genetic cancer-risk testing, to align Medicaid and commercial coverage.

Mental health parity: HB 50, sponsored by Rep. Kim Moser, R-Taylor Mill, will make health-insurance plans comply with a 2008 federal law that requires them to treat mental-health conditions and substance-use disorders the same as physical health. It also requires health insurers to file annual reports with the state to show how they are complying with the federal law.

Workforce: HB 276, sponsored by Moser, allows Kentuckians trained as temporary Covid-19 personal-care attendants under an executive order to apply their supervised training toward their Registered Nurse Aide certification. About 300 personal-care attendants work in Kentucky long-term care facilities, Moser said while presenting the bill to the House in February.

SB 154, by Sen. Tom Buford, R-Nicholasville, lets advanced practice registered nurses and physician assistants prescribe and supervise home-health services, as federal law has allowed them to do in the pandemic. An emergency clause ensures there would be no gap in care if the federal rule ended.

HB 448, sponsored by Rep. Bill Wesley, R-Ravenna, expands the definition of "qualified mental-health professional" so that it fits the state's juvenile code, allowing those who work in private agencies to testify in child-welfare hearings, especially around issues of emotional injury.

Alzheimer's Disease: SB 74, by Sen. Ralph Alvarado, R-Winchester, creates but does not not fund a dementia services coordinator in the heath cabinet to manage the Alzheimer’s Disease and Related Disorders Council, the state plan to address Alzheimer’s in Kentucky, and apply for federal funding.

Living organ donors: HB 75, sponsored by Rep. Shawn McPherson, R-Scottsville, prohibits insurance companies from increasing rates on organ donors or dropping their coverage. It would also encourage the cabinet to develop educational materials relating to organ donation.

Charitable care: SB 163, sponsored by Sen. Alice Forgy Kerr, R-Lexington, expands the definition of "charitable health care provider" to include those that provide invasive or surgical procedures. This change was needed to allow the non-profit surgery program "Surgery on Sunday" in Lexington to be reimbursed for liability insurance premiums. 

 
Beshear also vetoed five bills that would strip power from the governor or the executive branch. None were related to health. 

With just six days left in Kentucky's short legislative session, many health-related bills are near final passage; here's a roundup

By Melissa Patrick
Kentucky Health News

With just six days left in the General Assembly's short, odd-year session, many health-related bills remain on the table, and only a few have become law. Here's a roundup of health-related legislation.

Abortion: The first health-related bill to become law this year was Senate Bill 9, sponsored by Sen. Whitney Westerfield, R-Crofton, which requires medical providers to give “medically appropriate and reasonable life-saving and life-sustaining medical care and treatment to preserve the life and health of a born-alive infant,” including after a failed abortion. It also requires them to give any “nourishment, medical care, medical treatment and surgical care that is medically appropriate.” Gov. Andy Beshear declined to sign the bill but allowed it to become law without his signature.

Colon cancer: The only other health bill to become law as of March 7 was House Bill 108, sponsored by Melinda Gibbons Prunty, R-Belton (Muhlenberg County). It codifies existing Medicaid coverage of colorectal cancer, which includes screenings starting at age 45 for most people and genetic cancer risk testing for the disease, to ensure uniform coverage for Medicaid patients that lines up with commercial plan requirements. Beshear signed the bill March 5. 

Dr. Whitney Jones, the founder of the Colon Cancer Prevention Project and chair of the Kentucky Colon Cancer Screening Program, said at the Senate Health and Welfare Committee meeting on the bill that in the last 20 years, Kentucky has gone from ranking 49th for colon cancer screening to as high as 17th and is now 22nd. He said colon-cancer cases are down 27 percent, and deaths from the disease are down more than 30%, which amounts to 400 fewer colorectal cancer cases and 250 fewer deaths per year. 

Another bill that addresses colon cancer is getting close to the finish line. SB 16, sponsored by Sen. Ralph Alvarado, R-Winchester, addresses several issues related to the screening program, including adding "prevention" to its name and requiring the Department of Medicaid Services to compile and present annual statistics on services related to colorectal cancer.  The bill has had two readings in the House and awaits a floor vote for final passage. 

Mental health: Several pending bills involve mental health. One on the governor's desk is HB 50, sponsored by Rep. Kim Moser, R-Taylor Mill. It would make health-insurance plans comply with a 2008 federal law that requires them to treat mental-health conditions and substance-use disorders the same as physical health. It also requires health insurers to file annual reports with the state to show how they are complying with the federal law.  

“Mental health and substance use disorders are often treated differently than other health conditions by insurers, but there is no health care without mental health care,” Alvarado said while presenting HB 50 on the Senate floor. “When there is a disparity in treatment, it causes harm. Many people go without treatment for years with disparities worsening by the day. There is an average delay of 11 years between the onset of mental illness symptoms and the time most people access treatment.”

Other mental-health bills that could pass include those to:

• Ban people with severe mental illness from being executed (HB 148);
• Expand the definition of qualified mental-health professional so that it fits the state's juvenile code, allowing those who work in private agencies to testify in child-welfare hearings, especially around issues of emotional injury (HB 448);
• Adopt the Psychology Interjurisdictional Compact, which facilitates telehealth and temporary in-person, face-to-face practice of psychology across state lines (HB 38);
• Allow any qualified mental-health professional to provide outpatient treatment to any child who is 16 or older and is an unaccompanied youth, and remove legal obstacles to transportation between a hospital and a psychiatric facility (SB 21);
• Create new credentialing requirements for alcohol and drug counselors and supervisors, aimed at increasing access to care (SB 166); and
• Require maternity patients to receive information on maternal depression and available resources, and make the Cabinet for Health and Family Services post information about providers who treat maternal depression on its website (HB 294). 

One bill deals with retailing of syringes.

Substance-use disorder: HB 219, sponsored by Rep. Danny Bentley, R-Russell, would remove pharmacy recordkeeping requirements for sale of hypodermic syringes or needles and allow their sale without a prescription, with a limit of 30 of each and proof that the purchaser is 16 or older. It would require pharmacies offering syringes and needles to provide educational materials on their safe and proper disposal, and referral information for syringe exchange programs and treatment of substance-use-disorder; and to offer naloxone, which is used to reverse opioid overdoses. This bill has passed both chambers and is awaiting formal enrollment and delivery to the governor. 

SB 51, sponsored by Alvarado, would ban the requirement of prior authorization for any prescription drug that is used in the treatment of alcoholism or opioid-use disorder that contains methadone, buprenorphine or Naltrexone, or that is approved by the U.S. Food and Drug Administration for the mitigation of opioid withdrawal symptoms. It awaits a vote on the House floor.

Diabetes: The Senate amended HB 95 to increase the monthly co-pay for insulin in state-sponsored health insurance plans to $35, instead of the $30 in the original bill. It also added an emergency clause to make it effective immediately. The increase was a compromise made to line it up with what Medicare charges, Bentley, the bill's sponsor, said at the March 2 Senate Banking & Insurance committee meeting.  This bill is awaiting House concurrence with the Senate's changes. 

Telehealth: HB 140 would permit telehealth services that were allowed to expand due to the coronavirus pandemic to remain in place even after the pandemic ends. The bill has passed both chambers without dissent but needs House concurrence with the Senate changes.

Rural hospitals: HB 556, sponsored by Bentley, would allocate $20 million to a rural hospital operations and facilities loan fund created but not funded in the 2020 session. “We have nearly 100 hospitals in Kentucky. Of those 100 hospitals, 24 are rural hospitals that are in danger of closing,” Bentley told the House. “This measure will not only aid our rural hospitals, but it will help our rural communities recover from the effects of the Covid-19 pandemic.” The bill is in the Senate Appropriations and Revenue Committee and could become part of the state budget being negotiated by legislative leaders and committee members.

Organ donation: SB 12, sponsored by Alvarado, would prohibit a person from selling or purchasing human organs or tissue and ban for-profit entities from procuring any eye, cornea, eye tissue, or corneal tissue. It has passed out of both chambers, but must be signed by the House speaker before moving to the governor's desk. 

HB 75, sponsored by Rep. Shawn McPherson, R-Scottsville, would keep insurance companies from increasing rates on organ donors or dropping their coverage. It would also encourage the cabinet to develop educational materials relating to organ donation. It has had two Senate readings and is awaiting Rules Committee action to put it on the floor for final passage.

More than 6,000 Kentucky residents are on dialysis waiting for a kidney transplant; there were 208 kidney transplants in Kentucky last year, 39 from living donors, the House Banking and Insurance Committee was told by April Abell, executive director of the National Kidney Foundation.

Insurance: SB 45, sponsored by Alvarado, would limit the use of copay-accumulator programs by health plans, which prevent cost-sharing amounts paid on behalf of enrollees from counting towards their maximum out-of-pocket limits. SB 44, sponsored by Alvarado, ensures that any insurance payments made on behalf of an individual by a nonprofit organization are counted just as if the patient made it themselves. Both bills have had two readings and await action by the House Rules Committee to put them on the House floor for final passage.

SB 55, sponsored by Sen. Stephen Meredith, R-Leitchfield, would get rid of all co-pays required by Medicaid.  It passed out of the House Health and Family Services Committee on March 5, and now moves to the full House for consideration.

Health dept. pensions: HB 8, sponsored by Rep. Jim DuPlessis, R- Elizabethtown, would have quasi-governmental entities, including health departments, to pay only what they owe to the Kentucky Retirement Systems instead of using the current "percentage of pay" formula. It passed out of the Senate with a floor amendment that added an appeals process that awaits approval by the House. 

Infants and new mothers: HB 155, sponsored by Rep. Nancy Tate, R-Brandenburg, would allow the use of a “newborn safety device” that would aid the anonymous surrendering of a newborn infant at a participating staffed police station, staffed fire station, or a staffed hospital. The bill is in the Senate Veterans, Military Affairs & Public Protection Committee.

HB 212, sponsored by Samara Heavrin, R-Leitchfield, would require data in an annual state report on fatalities among children and new mothers to include information on demographics, race, income and geography associated with the fatalities. It has received one of the constitutionally required three reading and is in the Senate Health &Welfare Committee. 

Immunizations: SB 8, sponsored by Sen. Mike Wilson, R-Bowling Green, would allow several exemptions for "any child or adult" in Kentucky who doesn't want to receive a vaccine that the state mandates during an epidemic or a pandemic, including religious grounds, medical reasons or a "conscientiously held belief."  The bill has received two readings and awaits action by the Rules Committee to put it on the House floor for final action. 

Alzheimer's and dementia: SB 61, sponsored by Meredith, would require all direct-care staff members who provide care for clients with Alzheimer's or other forms of dementia to receive initial and ongoing training. It passed out of the House Health & Family Services Committee on March 5 and now awaits action on the House floor. 

SB 74, sponsored by Alvarado, would establish a coordinator in the cabinet's Office of Dementia Services. It passed out of the House Health & Family Services Committee on March 5 and has had one reading in the House and now awaits action on the House floor.

Colorectal cancer screening should begin at age 45, says federal panel, following American Cancer Society's advice of 2 years ago

By Melissa Patrick

Kentucky Health News

A federal task force now recommends that adults with a normal risk for colorectal cancer get their first screening at age 45, instead of 50, as the American Cancer Society has recommended since 2018. 

Kentucky already requires health insurance plans to start screening for colorectal cancer at 45, and pay for it without any patient cost sharing, under legislation passed by the 2019 General Assembly.

But many other states still follow the U.S. Preventive Services Task Force guidelines, making this new guidance a welcome change in policy, Dr. Whitney F. Jones, founder of the Colon Cancer Prevention Project, said in a news release. 

“This long-anticipated and overdue course correction proposed by USPSTF is welcome in our state and nationally by patients and advocates,” said Jones. “In Kentucky, the potential to prevent colorectal cancers and reduce colorectal deaths for the 225,000 people between age 45 and 49 will further advance our nation-leading improvements in colorectal cancer screening rates.”

Kentucky leads the nation in colon cancer, but is nationally recognized for getting its citizens screened for it, with about 70% of Kentuckians who are 50 and older reporting  they have been screened for it. In the last 10 years, Kentucky colon cancer screenings have resulted in a 25% reduction in incidence and a 28% reduction in death, according to the prevention project website.

The state law on screening, sponsored by Sen. Ralph Alvarado, R-Winchester, also requires health plans to cover genetic tests for cancer, including those for colon cancer.  It took effect Jan. 1.  

The federal task force's proposal is still a draft open for public comment until Nov. 23. The task force is an independent group of experts appointed by the Department of Health and Human Services.

Once finalized,  private insurance plans that are subject to the Patient Protection and Affordable Care Act and Medicare plans would be required to cover colorectal-cancer screening with no co-pay or out-of-pocket cost, according to a group of colorectal-cancer organizations.

Like the Cancer Society's advice two years ago, the task force's decision is largely driven by increases in colorectal cancer in younger adults. The society says 12% of colorectal cancers will be diagnosed in people under 50. 

"Rates have been increasing since the mid-1980s in adults ages 20-39 years and since the mid-1990s in adults ages 40-54 years, with younger age groups experiencing the steepest increase," the society says. It also reports that in African Americans, colorectal-cancer rates are about 20% higher than whites, and death rates are almost 40% higher. 

Timely screening is important because colorectal cancer usually starts from polyps in the colon or rectum that can only be found during a screening so that they can be removed before they ever turn into cancer. Further, there are no symptoms for polyps or early colon cancer. 

"It is estimated that six out of 10 deaths from colon cancer could be prevented if everyone were screened at 45," says the prevention project.

The draft recommendations cover two types of screenings for colorectal cancer, including a direct visualization tests, such as a colonoscopy, or tests that can detect signs of cancer from a stool sample. 

Stool-based tests are noninvasive and can be done at home, but must be done more frequently. Colonoscopies are generally recommended every 10 years after the first one is done, as long as the patient is considered low risk. 

For people aged 76 to 85, the task force continues to recommend that the decision to be screened be made on an individual basis. 

Kentucky and Ohio researchers get $5.7 million grant to improve Appalachian colorectal cancer screening and follow-up care rates

Researchers in Kentucky and Ohio have received a $5.7 million grant from the National Cancer Institute to increase colororectal cancer screenings and follow-up care among under-served people in Appalachia.

The research will be led by the cancer centers at the University of Kentucky and The Ohio State University. "We are excited to have the opportunity to take on the challenge of promoting colorectal cancer screening and follow-up in rural communities that have an elevated burden of this disease," said Mark Dignan, co-leader of the Cancer Prevention and Control Research Program at UK'.

The five-year study is designed to help community health centers and communities implement multi-level evidence-based strategies to increase their rates of colorectal cancer screenings, as well as follow-up and referral-to-care for patients between the ages of 50 and 74.

Kentucky has doubled its colorectal screening rates in the past 20 years, "but more work is needed to increase access to screening and follow-up care in the Appalachian region," says the news release.

"Rates of colorectal cancer incidence and related mortality in Appalachia are among the highest in the United States, and far too many people in this region do not receive potentially life-saving colorectal cancer screening," said Electra Paskett, co-leader of the cancer research program at OSU.

In Appalachian Kentucky, for every 100,000 people, 50.6 colon and rectum cancer cases were reported in 2012-16; the non-Appalachian counties everaged 57.9 cases per 100,000, according to the Kentucky Cancer Registry.

In that same period, 4,275 Kentuckians died from colon and rectal cancer, according to the Centers for Disease Control and Prevention. For every 100,000 people in Kentucky who died from these cancers, 19.8 of them lived in Appalachian counties and 15.4 of them lived outside the region.

The study was piloted in Lewis County, Kentucky and Guernsey County, Ohio, with activities rolling out to 10 other counties over the next three years, including Breathitt, Carter, Lawrence, Morgan and Powell counties in Kentucky and Adams, Belmont, Hocking, Lawrence and Morgan counties in Ohio.

People in the most rural areas are more likely to die from colon cancer even though they are less likely to get it in the first place

Patients who live in remote or very small rural communities are a bit more likely to show up at their doctor's office with late-stage colon cancer than other Americans, which could help explain why patients who live in these areas have such poor colorectal cancer outcomes, a new study says.

Johns Hopkins Medicine image

The study, published in The Journal of Rural Health, looked at the relationship between late-stage colorectal cancer at diagnosis and county-level characteristics, including the level of rurality (how rural a place is), patient characteristics, and factors such as persistent poverty, low education, and low employment.

The study notes that cancer outcomes are often worse for rural patients, with various studies finding they have an 8 to 15 percent greater chance of dying from colon cancer.

"While rural communities overall have lower incidence of cancers compared to urban populations, they have higher cancer-related mortality rates," says the report. In other words, people in the most rural areas are more likely to die from colon cancer even though they are less likely to get it in the first place.

The researchers identified 132,777 patients in Kentucky and nine other states who had colorectal cancer in 2010-14. After placing patients in five rural-to-urban categories, the study found that the adjusted percentages of stage 4 colon-cancer patients by county geography were: metropolitan areas, 19.3 percent; micropolitan areas (with a city of 10,000 to 50,000) adjacent to a metro area, 20.4%; non-adjacent micropolitan areas, 19.2%; small rural places, 20.2%; and remote rural places, 22.7%.

"Patients living in remote, small counties were significantly more likely to present with stage 4 colorectal cancer than patients living in other counties," the study report says.

The data came from cancer registries in California, Connecticut, Georgia, Hawaii, Iowa, Kentucky, Louisiana, New Mexico, Utah and Washington. The registries included 352 rural and 235 urban counties, representing 18% and 20% of all rural and urban U.S. counties, respectively.

Among the 10 states studied, "Patients in Kentucky had the lowest adjusted rate (18.2%) of stage 4 diagnosis," the report says.

Kentucky's rate of colon cancer is the nation's highest, but the state has been nationally recognized for getting its citizens screened for it. A University of Kentucky news release in March said the Kentucky Cancer Consortium received an award for its efforts to increase screening. The release said that between 1999 and 2016 screening rates in Kentucky rose from 35% to 70%, improving more than any other state in the country and moving the state from a ranking of 49th to 17th.

Breakdown of study; click on image for a larger version

The study found that younger patients, black patients and single or widowed patients were more likely to present with late-stage colorectal cancer. The researchers note that these findings are consistent with decades of data and suggest that little or no improvement has been made in addressing these disparities.

It also found that a lack of insurance was the most significant predictor of late-stage diagnosis, which was also consistent with other research.

"Patient medical insurance categories had the greatest effects on the rate of stage 4 colorectal cancer at diagnosis. The rate was highest among uninsured patients (28.6%) compared to patients with any type of Medicaid insurance (24.4%) and other insured patients (18.4%)."

In addition to a known lack of screening services in rural areas, "the high cost of colonoscopy, access to specialty referral networks, lack of transportation, and lower health literacy may all play a role in these findings," says the report.

The American Cancer Society recommends colorectal screening for average risk individuals to begin at the age of 45, instead of 50. Those with a family history of colon or rectal cancer should check with their doctor about getting screened earlier. Colon cancer is 90 percent curable when detected early.

Cancer Society says screening for colon cancer should start at 45, not 50; Ky. leads the nation in colon cancer and deaths from it

By Melissa Patrick
Kentucky Health News

In response to rising rates of colorectal cancer among younger people, the American Cancer Society now recommends that adults with a normal risk for colon cancer get their first screening at age 45, instead of 50.

The change was prompted by an ACS study published last year in the Journal of the National Cancer Institute, which found that since the mid-1990s colon-cancer rates among Americans between the ages of 20 and 54 have been steadily increasing, between 0.5 percent and 2 percent per year. Rectal cancer has risen more rapidly, 2 to 3 percent a year.

"Millennials have double the risk of developing colon cancer and quadruple the risk of rectal cancer for reasons that are not yet 100 percent clear," Amanda Smart, executive director of the Colon Cancer Prevention Project, said in a news release about the new recommendations.

Graphic: Colon Cancer Prevention Project

Nationally, colon cancer is the second leading cause of death from cancers that affect both men and women with 43 percent of "young onset patients" diagnosed between the ages of 45 and 49, according to the release.

Kentucky leads the nation in colon cancer, but is nationally recognized for getting its citizens screened for it, moving from 49th to 19th in the past 15 years. However, only 65 percent of Kentuckians 50 and older have been screened. So, there's more work to do -- especially in a state that ranks fourth for colon cancer deaths.

Smart added, "No matter your age, if you are experiencing symptoms such as rectal bleeding, unexplained anemia, changes in bowel habits, unexplained weight loss or gain, or unexplained abdominal pain, please don’t wait to be screened!”

Dr. Whitney Jones, a Louisville gastroenterologist and founder of CCPP, emphasized that, while this policy change is a huge step forward, it only applies to individuals with average risk who do not have symptoms.

“Those with a family history of colon or rectal cancer, or advanced adenomatous colon polyps, should check with the doctor about on-time screening, which begins at 40 but could be necessary even earlier," he said in the release.

Options for screening include a colonoscopy, which is recommended every 10 years for people at average risk of the disease, a yearly stool test that looks for hidden blood, a DNA-based stool test done every three years, virtual colonoscopy and a flexible sigmoidoscopy, according to the National Cancer Institute.

Colon cancer usually starts from precancerous polyps in the colon or rectum, which can be removed before they turn into cancer. Screening also allows for early detection of the cancer, which is 90 percent curable when detected early.

In Kentucky, those with commercial insurance will be immediately eligible to receive "on-time" screening at 45, says the release.

Kentucky Medicaid has no age restrictions on colonoscopies for its fee-for-service members. The co-payment requirement is cancelled if it is billed as a preventive service for people 50 and older, but the state Department for Medicaid Servicessays it is working to have this changed to 45. The department said managed-care organizations will develop their own policies for their members.

Smart added that the new guideline may cause some confusion for doctors and patients, and stressed that it will be important for providers to enter the appropriate insurance code to make sure younger patients don't get charged for the exam.

The Patient Protection and Affordable Care Act requires colon cancer screenings be entirely covered by insurance. Kentucky has also passed a law to clarify that a fecal test to screen for colon cancer, and any follow-up colonoscopy, are also covered by insurance.

Smart said her Colon Cancer Prevention Project can help patients who have been wrongly charged.

The U.S. Preventive Services Task Force guidelines still recommend initial screening for colon cancer at age 50 for those with average risk.

Laurie McGinley of The Washington Post reports that the task force decided several years ago to not lower its recommended age because it concluded that the data was mixed and that a younger starting age would only proved a "modest" benefit. She adds that the cancer society, by extending the analysis used by the task force and incorporating recent data on the rising incidence of the disease among younger people, came to a different conclusion that shows the life-saving potential of earlier screening.

In a state thick with cancer, leaders of screening and research organizations targeted for cuts make cases for state money

Mammograms are a screening for breast cancer. (WTVQ image)

By Melissa Patrick
Kentucky Health News

Gov. Matt Bevin's proposed budget for the next two fiscal years calls for cuts to five cancer research and prevention programs, including screenings for breast, colon, cervical, lung and ovarian cancer, and for research on lung cancer, all of which plague the state.

The programs are included in a list of 70 that Bevin proposed to eliminate to save the state $85 million, or less than 1 percent of the overall budget. He has said these cuts are necessary to help fund the state's ailing pension system.

Dr. Whitney Jones, a Louisville gastroenterologist and founder of the Kentucky Cancer Foundation, which provides funds for colon-cancer screening, said he recognizes the challenges of balancing a state budget, but hopes the state will reconsider eliminating the colon cancer screening and prevention program. He said of Bevin, "We hope this is just his first position."

Jones, who also founded the Colon Cancer Prevention Project in Louisville, called the state's improvement from 49th to 19th for colo-rectal screening in the past 15 years, "the best public health story" in Kentucky.

He added that this was only possible because the state offered screenings to uninsured and under-insured Kentuckians, expanded Medicaid to those who earn up to 138 percent of the federal poverty level, and has a unique, multi-partner screening program -- all of which he said makes Kentucky "the envy of most states in the nation."

But he also said there is still work to be done, because Kentucky still leads the nation in colon cancer and remains in the top 10 for colon-cancer deaths.

Doug Hogan, a spokesman for the state Cabinet for Health and Family Services, said the state's screening programs, including those for colon, breast and cervical cancer, are no longer needed because they are now covered by all insurance plans with no deductibles or co-payments.

Jones acknowledged that the program needs to be restructured because of the Medicaid expansion, but argues that it is still necessary for several reasons. He said Kentucky still has a large number of people without health insurance; the federal law that requires almost all Americans to have insurance or pay a tax penalty will be repealed at the end of the year; the coming work requirements and premiums in Medicaid will lead to some people going without coverage; and there will be a continuing need for education and outreach about cancer and screening.

"There has to be a better way to cut out the bad and support or maintain the good," Jones said. "And I would just suggest that the Kentucky Colon Cancer Screening Program is the baby, and not the bathwater."

Lung cancer research targeted in a state that has the most of it

Another program set to lose about $5 million is the Lung Cancer Research Grant Program, a collaboration between the University of Kentucky and University of Louisville that is funded by funds from states' 1998 settlement with cigarette manufacturers. UK's portion is $2.4 million, spokesman Jay Blanton said.

Dr. Mark Evers of UK's Markey Cancer Institute said this statewide initiative seeds a number of pilot projects and "spans the gamut" from new lung-cancer therapies and treatments to new clinical trials and prevention strategies, such as lung-cancer screening. He said such pilot programs are often used to help get larger grants from the National Institutes of Health and other sources.

Evers noted that the Kentucky Lung Cancer Education Awareness Detection Survivorship Collaborative (the Kentucky LEADS Collaborative for short), now funded by a $7 million Bristol-Myers Squibb Foundation grant, is a great example of how a pilot project from this research grant program was able to get a larger grant to further its work.

"It really is a valuable mechanism for us to provide pilot funding for investigators to get the initial data so that they can carry that forward in larger extramural grants," Evers said.

He also noted that the research grant program is responsible for the Kentucky Clinical Trials Network, which he described as another joint venture with U of L that "pushes out" clinical trials for lung cancer, which have been conducted in about 90 percent of Kentucky's counties.

Asked if the program could survive without the state funding, Blanton, who sat in on the telephone interview with Evers, said, "We're just trying to get our arms around the numbers right now."

Asked why the program is important, Evers pointed to the state's high smoking rate, second in the nation, and its No. 1 rank in number of lung-cancer cases. "We've got a terrible problem with this in the state," Evers said.

When Kentucky researchers made a pitch to the National Cancer Institute, Evers said, "The first words out of their mouth were, 'What are you guys doing about your smoking problem?' So, it's really incumbent upon us to be able to have the resources to attack this by screening, prevention and treatment."

While Kentucky LEADS is on Bevin's list of programs that would get no state funding in the next two fiscal years, it has never received any, said Jamie Studts, a UK professor of behavioral science and the lead investigator for the collaborative. He said it had been slated to get $10,000 in each year of the current budget, but that Bevin had "red-lined" the allocation.

Studts said that the cut "doesn't directly affect us in terms of dollars, but indirectly it does send a message that the governor and this administration is not interested in making those kinds of efforts to address Kentucky's burden of lung cancer."

Breast and cervical cancer: state squeezes local health departments

As for the screening programs for breast and cervical cancer, Hogan said that in addition to these screenings now being covered by insurance, they are also operated by federal funds, so elimination of any state funds would not impact them.

Allison Adams, president of the Kentucky Health Department Association, said that while it's true that the breast and cervical screening programs have not received any state dollars for several years and get some federal funds, most of their funding for these programs come from local tax dollars.

For example, she said that in the fiscal year that ended in June 2017, local health departments received about $607,000 in federal funding for breast and cervical cancer screening, and the rest came from $2.3 million in local dollars. The programs serve about 20,000 patients a year.

Adams said the real challenge for health departments to continue such programs, or any of the other initiatives that involves direct patient care, is that Bevin's budget has added $38.5 million to their annual pension liability. She said that will force the departments to provide programs that focus on overall health, safety and prevention and look for ways to spend $1 to affect 10 people, instead of $10 to affect one.

"Local health departments need to be working on the prevention piece, and less on the treatment and intervention," Adams said, but they "will have to do their own prioritization and determine which programs have the absolute most health benefit for all of Kentuckians. We really have to make some tough decisions of where we are going to spend our money that's going to have the greater impact over the health of Kentucky."

The Ovarian Cancer Screening Program is also slated to be cut. Linda Blackford of the Lexington Herald-Leader reports that this UK program offers free vaginal ultrasound screenings to women for ovarian cancer and has provided nearly 50,000 free screenings since its creation 30 years ago.

Blackford notes that the Pediatric Cancer Research Trust Fund, established in 2015 by Sen. Max Wise, R-Campbellsville, has been approved to receive $2.5 million in each year of the biennium to fund pediatric brain cancer research at UK and U of L. Bevin's budget calls for each of the universities to provide a minimum of $1.2 million a year for the program.

Bevin's budget boosts efforts against opioid abuse but would cut several health programs, including poison control center

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. — Gov. Matt Bevin's proposed budget would boost programs that fight substance-use disorders and the state's over-burdened social-services system, but calls for cuts to other health-related programs, including the state's only poison control center and one that trains doctors in rural parts of the state.

Bevin's proposal to the General Assembly calls for an additional $34 million to fight the opioid epidemic, with a focus on helping pregnant women addicted to drugs. It also includes $24 million to hire more social workers and give raises to those already employed.

Medicaid, which covers about one-third of the state's population, is the state's largest health expense. The governor's budget recommendation for Medicaid is around $11.5 billion in the first year and $11.8 billion in the second year, mostly from federal funds. The Kentucky Hospital Association told Kentucky Health News that it was pleased with the numbers.

"It looked like there was just a minimal reduction so we were pleased that the budget maintained the funding for Medicaid," said Nancy Galvagni, senior vice president of the association. "We understand from talking with people at the Cabinet [for Health and Family Services] that they consider it funded going forward."

Administration officials told reporters at a Jan. 17 budget briefing that the Medicaid budget had been included in the governor's across-the-board 6.25 percent cuts, but the cut was taken from the projected need of the Medicaid program, not current funding.

The governor also proposed that 70 state programs lose all of their funding, with a projected savings of $85 million a year. At least nine of them related to health. Some haven't received state funding in recent years, but others have depended on it.

One of those is Norton Kosair Children's Hospital Poison Control Center, which is the state's only poison control center, serving all 120 counties. It received $729,000 in each of the past two fiscal years from the state, Joe Sonka reports for Insider Louisville.

Maggie Roetker, a spokeswoman for Norton Healthcare, told Sonka that the funding amounts to 43 percent of the poison center's $1.7 million annual budget. She said the federal government provides $234,000 and Norton makes up the rest.

Sonka reports that according to the center's current service contract with the state, it fields about 70,000 callers a year; saves Kentuckians more than $10 million a year by keeping people out of emergency rooms; and saves Kentuckians $3 to $5 million per year by consulting with patients who are already hospitalized by a poison, which decreases the length of their stay.

Another program set to lose funding is Madisonville's Trover Clinic, for a program that allows medical students from the University of Louisville to complete the last two years of medical school in rural communities. The Kentucky Center for Economic Policy reports that this program is scheduled to receive $910,000 in the fiscal year that ends June 30.

Two other health-related programs on the governor's chopping block include the Lung Cancer Research Grants Program at U of L and the University of Kentucky, which is getting $5,176,100 in the current fiscal year and the Autism Training Center, now getting $119,300, according to KCEP.

The budget would "eliminate state funding for five cancer research or prevention programs, including . . . screening programs for colon, breast, cervical and ovarian cancer," Linda Blackford reports for the Lexington Herald-Leader. But it includes $2.5 million each year in new money for the Pediatric Cancer Research Trust Fund, for brain-cancer research at the two universities, which would have to each provide $1.2 million to match the state appropriation.

The fund was created in 2015 by Sen. Max Wise, R-Campbellsville, whose son Carter, now 10, had cancer when he was six months old. Wise said he and the universities asked for $9.8 million over two years. "It shouldn't be a competition, but unfortunately it is," Wise told Blackford. "We were not trying to play priorities or favorites."

The screening programs for breast and cervical cancer are operated with federal funds, so elimination of any state funds would not impact it, said Doug Hogan, spokesman for the Cabinet for Health and Family Services. Hogan said the colon-cancer screening program had not received state funds for several years.

"Health screenings for preventive services are covered by all insurance plans and there are no deductibles or co-pays," Hogan said. "That applies to various preventive screens including those for colon, breast and cervical cancers."

Jaimie Studts, professor of behavioral science at the UK College of Medicine, said the Kentucky Lung Cancer Education Awareness Detection Survivorship Collaborative, also called the Kentucky LEADS Collaborative, has never received any state funding. He said it was slated to get $10,000 in each year of the current budget, but Bevin "red-lined" the allocation, saying the health secretary would need to determine how best to spend that money.

Including the program among the list of 70 to be cut "doesn't directly affect us in terms of dollars," Studts said. "But indirectly it does send a message that the governor and this administration is not interested in making those kinds of efforts to address Kentucky's burden of lung cancer."

Some other health programs on the list hadn't received any funding from the state for the past several years: ARC of Kentucky, a group that supports people with intellectual and developmental disabilities, and Madison County Early Intervention Services. They were not scheduled to get any funding in the 2018 fiscal year, according to KCEP. It has published a list of programs proposed for elimination and the current appropriation for each.

Bevin says his cuts are necessary to fully fund the state's pension obligations, with his budget setting aside about $3.3 billion, or 15 percent of state spending, for that purpose.

Opponents of the governor's budget cuts are calling for raising new tax revenue through comprehensive tax reform, which the governor said could happen in 2018. However, his office said in his budget news release that "He is calling for genuine tax reform that will make Kentucky more competitive with its neighboring states -- not merely a bump in the sales tax or an increase in the cigarette tax."

Whitesburg clinic shows rural lag in colon-cancer screening can be erased by overcoming the reluctance to talk about it

Screening for colorectal cancer isn't as common in rural areas as it is in metropolitan areas, partly because rural people seem to have trouble talking about it. Whatever the reason, the rural death rate from it is higher, and the disease is more common in Kentucky than any other state.

Dr. Van Breeding talks with a patient. (WEKU-FM photo)

When Dr. Van Breeding of Whitesburg found that only 19 percent of patients at Mountain Comprehensive Health Corp. had been screened, he said, "That's horrible! We've got to do better than that!" reports Dr. Kay Miller Temple for The Rural Monitor's Rural Health Information Hub: "He said their effort started with everyone in their clinic talking about it, from check-in personnel to lab team members to providers — everyone started talking about colorectal cancer screening." Breeding told her, "We got everyone who had contact with the patient to talk about it, starting with a simple question: ‘Have you ever been screened for colon cancer?’" Breeding says the rate is now 73 percent, in "an area where its incidence and death rates are the highest in the country," Temple notes.

Temple reports that a similar approach was used at Clearwater Valley Hospital and Clinics and St. Mary’s Hospital and Clinics in Idaho. "Using an electronic record indicator, providers were reminded to talk to unscreened patients during any appointment scheduled for any reason," Temple reports. "In addition to talk, they mailed reminders to patients" and did community outreach.

The screening rate at the Idaho facilities was much better, 52 percent, but their quality-improvement director, Heather Hodges, said their goal was 70 percent. They are now at 69 percent and have set a new goal of 75 percent. The national rate is 60 percent; the rural rate is 58 percent and the metro rate is 63 percent. Kentucky's statewide rate is 68 percent. The National Colorectal Cancer Roundtable’s 2018 goal is 80 percent, which acknowledges that some patients will always choose not to be screened.

"Hodges said the subject of CRC screening is a bit distasteful, but this can’t prevent healthcare organizations from doing community outreach," Temple reports. Such outreach includes a much-latger-than-life-size colon, through which people can walk. Here's a video:

“Screening rates are lower in rural areas, where geography causes barriers like lack of access to providers and lack of specialists or access to those specialists,” Dr. Djenaba Joseph, medical director for the federal Centers for Disease Control and Prevention’s Colorectal Cancer Control Program, told Temple. “In some states, there are hundreds of miles between the patient and the nearest endoscopist. But, regardless of location, I tell everyone, rural and urban, you can improve rates by knowing your population. Know the number of endoscopists in your area, know the population you are trying to reach, know the income limits, and know insurance status.”

Temple writes, “A recent American Cancer Society survey showed that 'nearly all unscreened people knew they should be screened.' Many who hadn’t completed screening assumed if they had no family history, they were at no risk for the disease. Others perceived the test was expensive, complicated, painful, embarrassing, and only needed for worrisome symptoms. With information like this, many providers feel that talking about CRC screening seems not only delicate, but time-intensive in order to dispel myths about screening, especially when discussions around other cancer screenings are often as simple as 'It’s time for you to make an appointment for a pap smear, mammogram or prostate check.'”

In Whitesburg, "as the CDC’s Joseph suggested, success came from knowing the population," Temple reports. "Breeding said they talked to their area insurance carriers about ensuring colonoscopy coverage. They also discovered that patients without insurance could get assistance from the health department due to the area’s high risk. Next, the local hospital decided to improve the endoscopy area, and the area’s surgeons, who performed the colonoscopies, immediately accommodated a structured approach to direct screening. Mondays and Fridays became designated testing days to accommodate prep and recovery times."

Breeding told Temple that one of the most powerful factors in his clinic's huge increase in screening "was a new dynamic that emerged in their tight-knit community: when community members looked into the face of a family member, a friend, a neighbor, and realized that person was living in an area of high colorectal cancer incidence and death rates, they encouraged one another to get screened. With this effort, Breeding shared that more than 30 lives have been saved. Their new screening goal — their community’s goal? It’s now 100%. Among the many lessons learned in this effort was patients’ understanding that the clinic was not just a place to come when sick, but a place to come to get, and stay healthy."

Colorectal cancer has declined, except in people under 30; overall, it's more common in Kentucky than in any other state

By Melissa Patrick
Kentucky Health News

Colorectal cancer has become less common since the mid-1980s, but has been increasing steadily in people younger than 50, according to a recent American Cancer Society study.

Infographic : The ColonCancer Prevention Project

Darla Carter of the Courier-Journal tells the story of Keisha Dalton, who was 30 when she noticed blood in her stool after eating spicy food and thought it was from hemorrhoids, but learned through a colonoscopy that it was cancer.

“I never thought in a million years that I would have colon cancer,” the Louisville mom told Carter. But she did.

The research, published in the Journal of the National Cancer Institute, found that while colorectal cancer rates have declined in adults age 55 and older since the mid-1980s, they increased in adults ages 20 to 39 by 1 to 2.4 percent in that period; and by 0.5 to 1.3 percent a year in adults aged 40-54 since the mid-1990s.

Rectal cancer rates increased by about 3 percent per year among people in their 20s from 1974 to 2013 and among people in their 30s from 1980 to 2013; and by 2 percent in adults ages 40 to 54 from the 1990s to 2013.

Put another way, people born in 1990 have double the risk of colon cancer and quadruple the risk of rectal cancer compared to someone born around 1950, when the risk was lowest.

The New York Times gives these numbers some perspective: "The risk of colon cancer for individuals in 1990 was 5 per million in that birth group, up from 3 per million at the same stage of life for those born in 1950. And the risk of rectal cancer for those born in 1990 was four per million, up from 0.9 million for those born in 1950."

The upward trend deserves attention, say the researchers and the Colon Cancer Prevention Project, which says one in seven colon cancer diagnoses are among people under 50.

The CCPP stresses on its website that everyone needs to be aware of the signs and symptoms of colon cancer and that providers must get an accurate family history "long before the age of 50" to make sure that people with a family history of colon cancer get screened earlier.

The study examined about 500,000 cases of colorectal cancer from 1974 to 2013. breaking down the cases by five-year age groups and by year of birth. The research does not explain the reasons for this increase in young people, but the report says increased obesity rates, poor diets, and lack of exercise are likely contributors.

And because many young people like Dalton attribute rectal bleeding to hemorrhoids and routine screening is generally not recommended for most people under 50, these cancers are often in more advanced states when they are discovered. The ACS says people under 55 are nearly 60 percent more likely than older adults to be diagnosed at a more advanced stage than those 55 and over.

The good news is that colorectal cancer rates for those older than 50 have fallen by 32 percent since 2000, while deaths from the disease fell 34 percent, likely due to increased screening, which detects and removes precancerous polyps, according to a separate study by the ACS.

This separate report notes that while every state saw a drop in colorectal cancers rates among people aged 50 and older, the slowest declines were seen in states with the highest rates, like Kentucky, which leads the nation in the incidence of colon cancer and ranks No. 4 for deaths from it.

The study authors recommend that because of this study, screening should be considered before age 50. The ACS said it is considering this suggestion.

Meanwhile, Dalton told Carter that she now educates others about colon cancer and encourages people to have open discussions with the provider, even if they are embarrassed by their symptoms or think they are too young to get cancer.

It's important to "make sure they do a colonoscopy, do any type of testing they can do, because you cannot take no for an answer," Dalton said. "This is your life. You're only getting one life."

Early colon cancer often has no symptoms, but if there are symptoms, they may include: change in bowel habits, rectal bleeding, cramping or abdominal pain, weakness and fatigue and unintended weight loss, according to the ACS. The CCPP says you can reduce your risk of colon cancer by staying active, reducing or eliminating red and processed meat, maintaining a healthy weight and stopping smoking.