Public Health Nursing Strategies to Overcome Multidimensional Barriers in Colorectal Cancer Screening: A Health Belief Model Approach with Clinical Translation in Mainland China

Colon Cancer Screening in 2005: Status and Challenges

Screening and Surveillance Colonoscopy and COVID-19: Avoiding More Casualties

Advancing Health Equity for Medicaid Beneficiaries by Adding Colorectal Cancer Screening to the Centers for Medicare and Medicaid Services Adult Core Set

Uptake of Colorectal Cancer Screening in 45 to 49 Year Olds: An Early-Inning View from the Endoscopy Suite

Measures for Ascertaining Use of Colorectal Cancer Screening in Behavioral, Health Services, and Epidemiologic Research

PURPOSE: We partnered with the largest FQHC in New Haven, CT to address overdue colorectal cancer screening with evidence-based interventions (EBI). We report on the 12-month follow up of a cohort of 3,127 patients overdue for CRC screening who received 1 or more evidence based interventions (EBIs) in October, 2021. BACKGROUND: Sociocultural and medical concerns are barriers to colonoscopy uptake contributing to disparities in CRC screening. An additional barrier is system level capacity. COVID-19 associated delays exacerbated the existing backlog of individuals overdue for CRC screening, underscoring the need to expand Fecal Immunochemical Testing (FIT) screening capacity. At the time of the study, colonoscopy was the front-line cancer screening strategy in this and other primary care settings in this region. METHODS: We tested the unique and additive value of multiple EBIs for increasing CRC screening in this low-income urban population. The EBIs included: medical reminder to all recipients (Arms 1-4), supplemented with information to address social determinants of health [SDOH]) barriers (Arm 2), offer of assistance from trained community health workers (CHW) to address SDOH barriers (Arm 3), and offer of educational intervention (video and pre- and post- survey) (Arm 4). Twelve-month outcomes include: 1) CRC screening test ordered; 2) CRC screening completed. RESULTS: Of the 3,127 randomized patients, ages 50-75, 77% were Hispanic (33%) or Black (44%). At 12 months post-intervention, 1,692 (54.1%) of the cohort received an order for CRC screening, and 541 (17.3%) of the cohort completed screening. With no path to CRC screening other than a provider order, among patients for whom CRC screening was ordered, nearly one-third (32%) completed screening within 12 months of the intervention. There were no differences in either outcome based on intervention Arm. DISCUSSION: Among the 3,127 individuals who were due or overdue for screening at the time of intervention, only 9 had documented CRC cancer screening in the 5 years before randomization. The promotion of stool-based testing may have brought individuals into CRC screening. There were no differences in CRC screening (colonoscopy or FIT) orders or completed tests across the 4 arms of the study, suggesting that the provider endorsed mailed screening reminder with information on in-home, stool-based testing option (FIT), and notice that CRC screening is now recommended beginning at age 45 was key to behavior change. Provider engagement and post-pandemic care-seeking on part of patients, as well as increased awareness of CRC screening following the death of high-profile actor at age 43 likely contributed to increased uptake of CRC screening. SUMMARY: A mailed reminder is a cost effective, scalable intervention that may be effective in safety net primary care settings that serve high-risk individuals. Closing the screening gap in CRC screening should include educating patients about their CRC screening options as well as the change in recommended age to begin CRC screening. Citation Format: Beth A. Jones, Sakinah C. Suttiratana, Sarah A. DeGiovanni, Levita Robinson, Michael Couturie, Steven J. Parra, Louie M. Gangcuangco, Laney Zhang, Denise Stevens, Margarita Vargas-Torres. Implementing on overdue colorectal cancer (CRC) screening in the Federally Qualified Health Center (FQHC) primary care setting: 12-month post intervention results [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C117.

Screening For Colorectal Cancer in the Age of Simulation Models: A Historical Lens

Implementing Fit Kit Colorectal Cancer (CRC) Screening in At-Risk Populations Study was a trial of 4 evidence-based strategies to increase colorectal cancer (CRC) screening in the primary care setting. The focus of this report is the factors that impacted implementation of these interventions in a safety net setting. Using the RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) framework, we evaluated providers’ assessments of the impact of the intervention on the 2 main outcomes: 1) CRC screening ordered; 2) CRC screening completed in a diverse population with more than 3,000 individuals overdue for screening. Methods: We conducted a Qualtrics evaluation survey among 51 staff members identified as individuals involved in cancer screening in a safety net primary care setting that serves over 38,000 individuals in New Haven, CT. The staff surveys are part of the evaluation of the program at one-year post-intervention. Invited staff were provided links through group emails from the provider partners requesting participation in a 2–5-minute Qualtrics survey. Questions on job title, role in CRC screening, and whether and how the interventions (referred to as “the study”) impacted CRC screening in this facility, understanding of the procedures in place to facilitate scheduling and completion of CRC screening, and the barriers and facilitators that impact CRC screening completion were queried. Descriptive results will be mapped to relevant aspects of the RE-AIM framework. Results: Twenty (39%) staff members completed the survey including 9 (45.0%) registered nurses/advanced practice registered nurses, 6 (30.0%) physicians, 2 (10.0%) physician assistants, and 3 (15.0%) individuals in other roles, e.g., schedulers. 87.5% (n=14) were authorized to order colorectal cancer (CRC) screening tests, either colonoscopy or stool-based testing, for their patients. By self-report, effectiveness of the intervention on provider behavior was limited with only 22.2% reporting that the study impacted decisions to order CRC screening. Yet 41% of providers in the study placed a “blanket order” for all individuals who were due for CRC screening even if they were not seen for an appointment during the study period. Barriers to completion of CRC screening were “patient factors” (37%) and insufficient consultation time during appointments (27.3%). Most health care providers cited COVID-19 as a significant factor in delivering an effective CRC screening program. Provider suggestions to improve CRC screening uptake included posted information in exam rooms, use of clinical decision-making tools in the electronic medical record to determine if colonoscopy or FIT (stool-based) testing is the best option, nurse visits to teach use of stool-based testing and making in-home test kits available over the counter in pharmacies. Discussion: Although the results from this small sample of providers has limited generalizability, the findings will be useful in designing scalable interventions in similar high volume primary care settings. Citation Format: Beth A. Jones, Denise L. Stevens, Sakinah Suttiratana, Sarah A. DeGiovanni, Laney Zhang, Margarita Vargas-Torres, Michael Couturie, Levita Robinson. Provider input following implementation trial to address overdue colorectal cancer screening [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C116.

To explore system/staff- and patient-level opportunities to improve colorectal cancer (CRC) screening within an 11-clinic Federally Qualified Health Center (FQHC) in rural Appalachia with CRC screening rates around 22%-30%. Using a convergent parallel mixed-methods design, staff (n = 26) and patients (n = 60, age 50-75, 67% female, 83% <college, 47% Medicare, 23% Medicaid) were interviewed about CRC-related screening practices. Staff and patient interviews were guided by the Consolidated Framework for Implementation Research and Health Belief Model, respectively, and analyzed using a hybrid inductive-deductive approach. Among staff, inner setting factors that could promote CRC screening included high workplace satisfaction, experiences tracking other cancer screenings, and a highly active Performance Improvement Committee. Inner setting hindering factors included electronic medical record inefficiencies and requiring patients to physically return fecal tests to the clinic. Outer setting CRC screening promoting factors included increased Medicaid access, support from outside organizations, and reporting requirements to external regulators, while hindering factors included poor social determinants of health, inadequate colonoscopy access, and lack of patient compliance. Among patients, perceived screening benefits were rated relatively higher than barriers. Top barriers included cost, no symptoms, fear, and transportation. Patients reported high likelihood of getting a stool-based test and colonoscopy if recommended, yet self-efficacy to prevent CRC was considerably lower. Contextualized perceptions of barriers and practical opportunities to improve CRC screening rates were identified among staff and patients. To optimize multilevel CRC screening interventions in rural Appalachia clinics, future quality improvement, research, and policy efforts are needed to address identified challenges.

Colon Cancer Screening Models: Lessons and Challenges

Computed Tomographic Colonography and High-Risk Adenomas: A Gap in the Guidelines?

Associations in breast and colon cancer screening behavior in women 1

Background Several initiatives have focused on increasing colorectal cancer (CRC) screening rates, but national rates still fall below 70% for many groups, particularly those in underserved communities. Examining CRC screening determinants in groups who have completed screening for other cancer sites may provide useful information to support future initiatives. In 2015, 71.6% of women nationally completed mammograms in the past two years, while only 63% completed any CRC screening procedures. Purpose We examined data from the 2015 National Health Interview Survey to identify determinants of CRC screening completion among women adherent to breast cancer (BrCa) screening guidelines. We hypothesized that race, income, and psychosocial factors would explain CRC screening non-adherence. Methods The sample contained women (N=1206), aged 50-74 years, BrCa free, who completed a mammogram in the past two years, and were of average CRC risk (no first degree relative with cancer, history of polyps or inflammatory bowel disease). Bivariate associations between sociodemographic, health access, perceived BrCa risk, perceived CRC risk variables, and CRC screening status were examined using chi-square tests. Multivariate logistic regression analysis was used to examine factors associated with CRC screening completion. Results Prevalence of CRC screening in this sample was 55.52% including: Sigmoidoscopy (1.47%), colonoscopy (50.33%), fecal occult blood test (10.81%). Significant differences in CRC screening (p &amp;lt;.01) by education, income, insurance, foreign birth status, and language regularly spoken were revealed. Having insurance (OR:4.52, CI:2.20-9.31) and being foreign-born (OR: 1.77, CI:1.17-2.66) were independently associated with CRC screening completion after controlling for all other factors. Conclusion CRC screening rates among women completing breast cancer screening were lower than the national average for women. Neither perceived BrCa risk nor perceived CRC risk explained CRC screening behavior. Income and health insurance variables appear to drive sociodemographic differences in screening completion. However, foreign-born status had a direct impact on CRC screening behavior. Differences in the availability of free or low-cost screening programs for BrCa and CRC may explain these findings. More research is needed to understand how sociodemographic factors interact to impact CRC screening rates in this group. Citation Format: Deeonna E Farr, Leslie E Cofie, Alison T Brenner, Ronny A Bell, Daniel S Reuland. Sociodemographic determinants of colorectal cancer screening completion among women adherent to mammography screening guidelines [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C108.

Background: Previous literature has revealed rural residents lagged behind their urban counterparts in colorectal cancer (CRC) and breast cancer screening. Between 2013 and 2017, 64 rural hospitals closed, which was double the amount in the preceding 5 years and consisted of 3% of all rural hospitals. Rural residents reported having to skip diagnostic imaging and preventative care due to local hospital closures. In light of continued rural hospital closures, this study aimed to further examine the trends and correlates of breast and colorectal cancer screening among females aged 50-74. Methods: This cross-sectional study analyzed the nationally representative datasets from the Behavioral Risk Factor Surveillance System (BRFSS) data available between 2014-2019. Focusing on females aged 50-74, we evaluated prevalence of breast and colorectal cancer screening overall and by urban-rural locations using multivariate logistic regression, adjusting for confounders including demographic, socioeconomic and behavioral factors. Results: This study included 255,737 urban and 127,810 rural residents. In total, urban areas have higher rates of breast (79.85% vs.74.97%; p&amp;lt;0.001) and colorectal (75.31% vs. 68.82%; p&amp;lt;0.001) cancer screenings. Between 2014 and 2019 the urban-rural difference in mammography has reduced with no significant difference between urban and rural residents in 2019 (82.78% vs 81.59%; p=0.710). A similar trend was seen in colonoscopy use however the difference remains significant in 2019 (81.20% urban vs 76.92% rural; p=0.046). Colorectal and breast cancer screening was associated with residential areas, race/ethnicity, and sexual orientation after adjusting for age, education, income, marital status, general health, checkup, health insurance, medical cost, smoking status, and binge drinking. Rural females were almost 10% less likely to have mammogram screening than urban counterparts (p&amp;lt;0.001). Non-Hispanic blacks (NHB), Asian, and Hispanic were 1.84, 1.22, and 1.36 times more likely to have mammogram screenings compared to their non-Hispanic white (NHW) peers respectively (p&amp;lt;0.001, p=0.011, &amp;lt;0.001). In addition, bisexual females were 24% less likely to have a mammogram than heterosexual/straight-identified females (p=0.003). In regard to colonoscopy, rural females were 16% less likely to have a colonoscopy than urban females (p&amp;lt;0.001). NHB were 1.3 times more likely to have a screening colonoscopy compared to their NHW peers (p&amp;lt;0.001). Lesbians were 1.3 times more likely to have a colonoscopy than heterosexuals (p&amp;lt;0.001). Conclusions: Disparities remain in CRC and breast cancer screening between urban and rural females. Our findings underline the importance of improving health access and cancer prevention in rural female Americans, a population characterized by a lower socioeconomic status, poor health literacy and lack of health access. Tailored geographic-based cancer prevention programs should be considered in addressing these disparities. Citation Format: Nicholas Theodoropoulos, Hui Xie, Qian Wang, Yannan Li. Rural-Urban differences in breast and colorectal cancer screening among United States females: 2014-2019 [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-266.

Racial and Ethnic Disparities in Colorectal Cancer Screening Pose Persistent Challenges to Health Equity