Increase Colorectal Cancer Screening Rates Research Articles

Strategies for expanding colorectal cancer screening at community health centers.

Community health centers are uniquely positioned to address disparities in colorectal cancer (CRC) screening as they have addressed other disparities. In 2012, the federal Health Resources and Services Administration, which is the funding agency for the health center program, added a requirement that health centers report CRC screening rates as a standard performance measure. These annually reported, publically available data are a major strategic opportunity to improve screening rates for CRC. The Patient Protection and Affordable Care Act enacted provisions to expand the capacity of the federal health center program. The recent report of the Institute of Medicine on integrating public health and primary care included an entire section devoted to CRC screening as a target for joint work. These developments make this the ideal time to integrate lifesaving CRC screening into the preventive care already offered by health centers. This article offers 5 strategies that address the challenges health centers face in increasing CRC screening rates. The first 2 strategies focus on improving the processes of primary care. The third emphasizes working productively with other medical providers and institutions. The fourth strategy is about aligning leadership. The final strategy is focused on using tools that have been derived from models that work. CA Cancer J Clin 2013. © 2013 American Cancer Society, Inc.

Strategies for expanding colorectal cancer screening at community health centers

Community health centers are uniquely positioned to address disparities in colorectal cancer (CRC) screening as they have addressed other disparities. In 2012, the federal Health Resources and Services Administration, which is the funding agency for the health center program, added a requirement that health centers report CRC screening rates as a standard performance measure. These annually reported, publically available data are a major strategic opportunity to improve screening rates for CRC. The Patient Protection and Affordable Care Act enacted provisions to expand the capacity of the federal health center program. The recent report of the Institute of Medicine on integrating public health and primary care included an entire section devoted to CRC screening as a target for joint work. These developments make this the ideal time to integrate lifesaving CRC screening into the preventive care already offered by health centers. This article offers 5 strategies that address the challenges health centers face in increasing CRC screening rates. The first 2 strategies focus on improving the processes of primary care. The third emphasizes working productively with other medical providers and institutions. The fourth strategy is about aligning leadership. The final strategy is focused on using tools that have been derived from models that work.

How to Increase Colorectal Cancer Screening Rates

Significantly fewer people undergo colorectal cancer (CRC) screening (60%) than breast cancer (72%) or cervical cancer (83%) screening. Researchers

A Randomized Comparison of Print and Web Communication on Colorectal Cancer Screening

New methods to enhance colorectal cancer (CRC) screening rates are needed. The web offers novel possibilities to educate patients and to improve health behaviors, such as cancer screening. Evidence supports the efficacy of health communications that are targeted and tailored to improve the uptake of recommendations. We identified unscreened women at average risk for CRC from the scheduling databases of obstetrics and gynecology practices in 2 large health care systems. Participants consented to a randomized controlled trial that compared CRC screening uptake after receipt of CRC screening information delivered via the web or in print form. Participants could also be assigned to a control (usual care) group. Women in the interventional arms received tailored information in a high- or low-monitoring Cognitive Social Information Processing model-defined attentional style. The primary outcome was CRC screening participation at 4 months. A total of 904 women were randomized to the interventional or control group. At 4 months, CRC screening uptake was not significantly different in the web (12.2%), print (12.0%), or control (12.9%) group. Attentional style had no effect on screening uptake for any group. Some baseline participant factors were associated with greater screening, including higher income (P = .03), stage of change (P < .001), and physician recommendation to screen (P < .001). A web-based educational intervention was no more effective than a print-based one or control (no educational intervention) in increasing CRC screening rates in women at average risk of CRC. Risk messages tailored to attentional style had no effect on screening uptake. In average-risk populations, use of the Internet for health communication without additional enhancement is unlikely to improve screening participation. clinicaltrials.gov Identifier: NCT00459030.

Enhancing cancer screening in primary care: Rationale, design, analysis plan, and recruitment results

Colorectal cancer (CRC) is the third leading type of cancer and the third leading cause of cancer death in the United States. National policy-making organizations recognize and support a variety of CRC screening strategies among average-risk adults aged 50 and older based on strong evidence showing that screening decreases mortality from CRC and can also reduce the incidence of the disease. The goal of this study was to test a multi-level stepped intervention to increase CRC screening rates. We used a group-randomized trial design where the units of assignment were clinics and the units of observation were eligible patients receiving care at those clinics, with stratified random assignment of clinics to study conditions. The primary analysis was planned as a mixed-model logistic regression to account for the expected positive intraclass correlation associated with clinics. Our recruitment experience reflected the difficulties of conducting research in the real world where changes in economic conditions, staff turnover/layoff, inadequate medical records, and poor acceptance of research can significantly impact study plans. It demonstrated the problems that can emerge when procedures used in the study depart from those used in the pilot work to generate parameter estimates for power analysis. It also demonstrated the importance of allowing for attrition at the group and patient levels so that if recruitment falls short, it is possible to maintain adequate power with only a slight increase in the detectable difference. This experience should assist others planning group-randomized trials, whether in cancer screening or in other areas.

Physician-Patient Colorectal Cancer Screening Discussions by Physicians' Screening Rates

Most physicians report routinely recommending colorectal cancer (CRC) screening, but many eligible patients are not screened. To better understand this finding, we explored the relationship between the content of hypothetical patient-physician CRC screening discussions and CRC screening rates in physicians' practices. Semistructured interviews, including role-playing, with 24 primary care physicians explored their CRC screening approach with average-risk patients. Qualitative analysis examined physician-reported components of the CRC screening discussion, then compared findings between physicians with high (≥60%, n = 16) and low (≤45%, n = 8) CRC screening rates (based on HEDIS criteria). We conducted no statistical tests because of the small sample size and its exploratory aims. High screeners used dramatic language (eg, patient stories) and mentioned risk of death, disability, or surgery from CRC in screening discussion role-plays more often than low screeners. High screeners frequently offered fecal occult blood testing, flexible sigmoidoscopy, and colonoscopy as equally acceptable screening options. High screeners more commonly described solutions for overcoming CRC screening barriers. Encouraging providers to use risk-specific messaging about the consequences of CRC, offering screening option choices, and promoting a problem-solving approach to surmount barriers are potential strategies for increasing CRC screening rates.

Policy Directives in Cancer, Organizational Responses, and the Need for Evaluation

Policy Directives in Cancer, Organizational Responses, and the Need for Evaluation

Strategies to increase colorectal cancer screening

Colorectal cancer screening (CRCS) is the only way to detect colorectal cancer in its earlier stages when morbidity and mortality are low. The literature has shown provider-directed recommendations with office system-directed interventions are the best way to increase CRCS rates.

Implementation of a performance improvement initiative in colorectal cancer care.

In the United States, colorectal cancer (CRC) is the third leading cause of cancer after breast and prostate cancer. Numerous improvement programs have been implemented to increase CRC screening rates, but few have focused on improving the care and management of patients with a diagnosis of this malignancy. As national medical organizations focus on quality of care, efforts are necessary to provide clinicians the opportunity for self-assessment and methods for practice improvement. With this goal in mind, a national continuing medical education-certified performance improvement initiative was conceived. THE INITIATIVE CONSISTED OF THREE STAGES: First, participants self-assessed their performance of predetermined topic measures through a review of patient charts. The topic areas included patient safety and supportive care, evidence-based surveillance, and evidenced-based treatment and were derived from current guidelines and other successful quality-improvement initiatives. Second, an actionable plan for practice improvement was developed in at least one of the three topic areas. Third, after a period of self-improvement, participants reassessed their performance of the same topic measures to determine tangible changes in patient care. A total of 540 patient charts were reviewed by 27 clinicians. Notable results showed large gains in areas of supportive care, such as quantitative pain assessments and emotional well-being evaluations, which traditionally have been a minor focus of other quality-improvement initiatives. Participants also showed tangible improvements in the performance of leading measures of quality care. These findings support the need for continued efforts toward performance improvement in both established and emerging areas of CRC patient care.

The last frontier: innovative efforts to reduce colorectal cancer disparities among the remote Alaska Native population

The Alaska Native (AN) population experiences twice the incidence and mortality of colorectal cancer (CRC) as does the U.S. white population. CRC screening allows early detection and prevention of cancer. We describe pilot projects conducted from 2005 to 2010 to increase CRC screening rates among AN populations living in rural and remote Alaska. Projects included training rural mid-level providers in flexible sigmoidoscopy, provision of itinerant endoscopy services at rural tribal health facilities, the creation and use of a CRC first-degree relative database to identify and screen individuals at increased risk, and support and implementation of screening navigator services. Alaska Tribal Health System. AN population. Itinerant endoscopy, patient navigation. AN patients screened for CRC, colonoscopy quality measures. As a result of these ongoing efforts, statewide AN CRC screening rates increased from 29% in 2000 to 41% in 2005 before the initiation of these projects and increased to 55% in 2010. The provision of itinerant CRC screening clinics increased rural screening rates, as did outreach to average-risk and increased-risk (family history) ANs by patient navigators. However, health care system barriers were identified as major obstacles to screening completion, even in the presence of dedicated patient navigators. Continuing challenges include geography, limited health system capacity, high staff turnover, and difficulty getting patients to screening appointments. The projects described here aimed to increase CRC screening rates in an innovative and sustainable fashion. The issues and solutions described may provide insight for others working to increase screening rates among geographically dispersed and diverse populations.

Mailed Fecal Immunochemical Tests Plus Educational Materials to Improve Colon Cancer Screening Rates in Iowa Research Network (IRENE) Practices

Only about half of all eligible Americans have been screened for colorectal cancer (CRC). The objective of this study was to test whether mailed educational materials and a fecal immunochemical test (FIT), with or without a scripted telephone reminder, led to FIT testing. In addition, we compared changes in attitudes toward, readiness for, and barriers to screening from baseline to follow-up after education about screening. Subjects due for CRC screening were recruited from 16 Iowa Research Network family physician offices. Half of the subjects were randomized to receive mailed written and DVD educational materials, along with a FIT, either with or without a telephone call designed to encourage screening and address barriers. Subjects completed surveys regarding their attitudes and readiness for CRC screening at baseline and after education about screening. The main outcome was whether the subject completed FIT testing. A total of 373 individuals received educational materials (including a FIT) and 231 (62%) returned a posteducation survey. The mean age was 61.2 years; 52% were women, 99% were white, 39% had a high school education or less, 39% had a total family income of less than $40,000, and 7% had no insurance. The written materials were read by 82%, understood by 91% (of those who read them), and 82% felt their knowledge was increased. The DVD was viewed by 67%, understood by 94% of those who viewed it, and 86% felt the DVD increased their knowledge. Compared with baseline, individuals reported being significantly more likely to bring up CRC screening at their next doctor's visit (P < .0001) and being more likely to be tested for CRC in the next 6 months (P < .0001). Comparing baseline with follow-up, summary attitude scores improved (P < .0001), readiness scores improved (P < .0001), and there were fewer barriers (P = .034, Wilcoxon signed rank). The FIT return rate increased from 0% to 45.2% in the education alone group and from 0% to 48.7% for the group receiving education plus the telephone call (P < .0001 for each group individually and overall when compared with Medicare beneficiaries in Iowa). Mailing FIT kits with easy-to-understand educational materials improved attitudes toward screening and dramatically increased CRC screening rates among patients who were due for screening in a practice-based research network. A telephone call addressing barriers to screening did not result in increased FIT testing compared with mailed education alone.

Patient Activation Increases Colorectal Cancer Screening Rates: A Randomized Trial among Low-Income Minority Patients

Colorectal cancer (CRC) screening rates remain low among low-income and minority populations. The purpose of this study was to determine whether providing patients with screening information, activating them to ask for a screening test, and telephone barriers counseling improves CRC screening rates compared with providing screening information only. Patients were randomized to CRC screening information plus patient activation and barriers counseling (n = 138) or CRC screening information (n = 132). Barriers counseling was attempted among activated patients if screening was not completed after one month. CRC screening test completion was determined by medical record review at two months after the medical visit. Logistic regression was used to determine whether activated patients were more likely to complete CRC screening, after adjustment for confounding factors (e.g., demographic characteristics and CRC knowledge). Patients were African American (72.2%), female (63.7%), had annual household incomes less than $20,000 (60.7%), no health insurance (57.0%), and limited health literacy skills (53.7%). In adjusted analyses, more patients randomized to the activation group completed a screening test (19.6% vs. 9.9%; OR = 2.35, 95% CI: 1.14-5.56; P = 0.020). In addition, more activated patients reported discussing screening with their provider (54.4% vs. 27.5%, OR = 3.29, 95% CI: 1.95-5.56; P < 0.001) and had more screening tests ordered (39.1% vs. 17.6%; OR = 3.40, 95% CI: 1.88-6.15; P < 0.001) compared with those in the control group. Patient activation increased CRC screening rates among low-income minority patients. Innovative strategies are still needed to increase CRC screening discussions, motivate providers to recommend screening to patients, as well as assist patients to complete ordered screening tests.

In Search of a Perfect Solution to Ensure that “No Colon Is Left Behind”

It is well known that blacks suffer a disproportionately higher burden from colorectal cancer (CRC) [1, 2]. However, the root cause of the problem and hence, the perfect solution to eliminate this major public health problem is unclear. Several possible causes have been identified as contributory to this problem but can be broadly classified into three domains: healthcare access, healthcare utilization and biological differences. Healthcare access differences: CRC screening is an elective medical care. Therefore, having healthcare insurance is sine qua non for getting optimal medical care including CRC screening. In the United States, blacks tend to have lower socioeconomic status and lack health insurance coverage. This has been associated with lower CRC screening rates [3]. Healthcare utilization differences: Research has shown that blacks tend to underutilize healthcare resources when compared with whites even within the same healthcare system [4, 5]. Some of the reasons underlying this difference may be care provider factors such as lack of CRC screening recommendations [6] or patient factors due to mistrust of the medical system and poorer healthcare education [7]. Adoptions of medical advances also lag behind among blacks [8]. Biological differences: Studies have suggested that CRC burden differences may be due to differences in tumor biology by race. The prevalence of CRC risk factors including economic factors is fairly comparable between Hispanics and blacks, yet Hispanic Americans consistently have lower CRC incidence and mortality when compared to non-Hispanic whites and blacks [1, 2]. Earlier age of CRC diagnosis, late stage presentation and proximal location of CRC have been reported among blacks as compared to whites [9, 10]. However, most studies that have investigated CRC disparity by race have been limited by non-screening populations, small sample sizes, single institution experience, retrospective designs, and lack of histopathologic diagnosis [2–11]. The critical challenge is to understand the differential contributions of these three domains to CRC disparity by race such that interventions can be prioritized accordingly. Unfortunately, no study has evaluated this. The ongoing Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) provided an opportunity to evaluate two of these three domains within the same cohort of participants who underwent trial sponsored flexible sigmoidoscopy and suggested that healthcare utilization differences may be playing more of a role than biology [12]. At the present time, stakeholders have adopted different strategies to address this public health problem. The Center for Disease Control established the Colorectal Cancer Control Program (http://www.cdc.gov/cancer/crccp/about. htm) which will provide funding to 25 states and four tribes across the United States in order to increase CRC screening rates to 80% in the funded states by 2014. The District of Columbia Cancer Consortium also instituted an ongoing 1 year DC Screen for Life program to educate 1,000 DC residents and provided funds to screen 600 uninsured and underinsured 50–64-year-old DC residents with colonoscopy and fecal immunochemical tests (DC Screen for Life: http://cancer.howard.edu/patients/screening.htm; http://www.cdc. gov/cancer/npcr/success/south/dc/dc1.htm). In New York, a 20% improvement in colonoscopy screening in New York City A. O. Laiyemo (&) Division of Gastroenterology, Department of Medicine, Howard University College of Medicine, 2041 Georgia Avenue, NW, Washington, DC 20060, USA e-mail: adeyinka.laiyemo@Howard.edu

Your Body Is the Temple

Colorectal cancer (CRC) is third in cancer incidence and mortality, due in part to lack of awareness and low rates of screening. The purpose of the present study was to evaluate the efficacy of a spiritually based CRC educational intervention delivered by trained Community Health Advisors, in Alabama churches. The aim of the intervention was to increase knowledge and awareness of CRC and early detection, and to eventually increase CRC screening rates. Participants age-eligible for screening (N = 122) completed baseline, 6-month, and 12-month surveys by telephone. Increases in CRC knowledge, perceived benefits of CRC screening, and awareness of the screening modalities and decreases in perceived barriers to screening suggested that this type of intervention may be promising for CRC control and should be examined further.

Correlates of Colorectal Cancer Screening Adherence Among Men Who have been Screened for Prostate Cancer

Prostate cancer screening rates are higher than colorectal cancer (CRC) screening rates, despite the established benefit of screening in reducing CRC incidence and mortality. We used data from the 2006 Behavioral Risk Factor Surveillance System to identify correlates of CRC screening among men who have undergone prostate cancer screening. Our sample included 41,781 men aged 50years and older who reported undergoing prostate cancer screening in the last year. More than two thirds (69.2%) of the men were up-to-date with CRC screening. On multivariable analysis, men who were younger, Hispanic, less educated, not married or partnered, employed, not a veteran, did not have a personal doctor, lacked a recent medical checkup, smoked, or were sedentary were less likely to be adherent to CRC screening. Tailored interventions targeted toward men who have already undergone prostate cancer screening may improve rates of CRC screening in a group that may be already aware of and interested in the benefits of cancer risk prevention. The prostate cancer screening encounter may represent a "teachable moment" to increase CRC screening rates.

Targeted Messages May Encourage Colorectal Cancer Screening

Personalized electronic messages to patients overdue for screenings or mailings targeted to patients with expired orders for colonoscopies may each increase colorectal cancer screening rates over the short term, according to two reports published online December 13, 2010, in the Archives of Internal Medicine.

Underuse of colorectal cancer screening among men screened for prostate cancer: a teachable moment?

Evidence suggests that colorectal cancer (CRC) screening reduces disease-specific mortality, whereas the utility of prostate cancer screening remains uncertain. However, adherence rates for prostate cancer screening and CRC screening are very similar, with population-based studies showing that approximately 50% of eligible US men are adherent to both tests. Among men scheduled to participate in a free prostate cancer screening program, the authors assessed the rates and correlates of CRC screening to determine the utility of this setting for addressing CRC screening nonadherence. Participants (N = 331) were 50 to 70 years old with no history of prostate cancer or CRC. Men registered for free prostate cancer screening and completed a telephone interview 1 to 2 weeks before undergoing prostate cancer screening. One half of the participants who underwent free prostate cancer screening were eligible for but nonadherent to CRC screening. Importantly, 76% of the men who were nonadherent to CRC screening had a regular physician and/or health insurance, suggesting that CRC screening adherence was feasible in this group. Furthermore, multivariate analyses indicated that the only significant correlates of CRC screening adherence were having a regular physician, health insurance, and a history of prostate cancer screening. Free prostate cancer screening programs may provide a teachable moment to increase CRC screening among men who may not have the usual systemic barriers to CRC screening, at a time when they may be very receptive to cancer screening messages. In the United States, a large number of men participate in annual free prostate cancer screening programs and represent an easily accessible and untapped group that can benefit from interventions to increase CRC screening rates.

Evaluating the impact of an educational intervention to increase CRC screening rates in the African American community: a preliminary study

Despite the acknowledged importance of colorectal cancer (CRC) screening and its proven prognostic benefit, African American men and women simultaneously possess the highest rates of CRC-related incidence and mortality (Swan et al. in Cancer 97(6):1528-1540, 2003) and lowest screening rates in the United States (Polite et al. in Med Clin N Am 89(4):771-793, 2005). Effective, targeted interventions that promote CRC screening for this community are therefore critical. The current study evaluated the impact of a print-based educational intervention on screening behavior and associated patient-based factors, including cancer-related knowledge, fatalism, worry, and decisional balance (pros-cons). One hundred and eighteen individuals (mean age=56.08, SD=5.58) who had not undergone screening were recruited from two health clinics in New York City. Each participant received educational print materials regarding the need for screening, the process of undergoing screening, and the benefits of regular CRC screening. One in four individuals had undergone post-intervention screening at a three-month follow-up. Whereas all participants reported a decrease in cancer-related worry (p<.05), it was a decrease in fatalism (p<.05) and an increase in decisional balance (p<.05) that was associated with post-intervention screening behavior. These preliminary results suggest that fatalistic beliefs and an individual's assessment of the benefits and barriers of screening may be critical in the decision to undergo CRC screening. Future interventions to increase CRC-screening rates for this community may be improved by focusing on these patient-based factors.

M1188 A Practice-Randomized Controlled Pilot Study of the National Colorectal Cancer Roundtable (NCCRT) Toolbox to Increase Colorectal Cancer Screening Rates in Primary Care Practices

M1188 A Practice-Randomized Controlled Pilot Study of the National Colorectal Cancer Roundtable (NCCRT) Toolbox to Increase Colorectal Cancer Screening Rates in Primary Care Practices

Abstract LB-434: Colorectal, prostate, and skin cancer screening among Hispanic and white non-Hispanic men, 2000-2005

Abstract One of the most effective means of reducing cancer-specific mortality is early detection via cancer screening; however, Hispanic men continue to have lower colorectal, prostate and skin cancer screening rates than White non-Hispanic men. To combat this disparity and educate men and women aged 50 and older about the importance of regular colorectal cancer (CRC) screening, the Screen for Life campaign, which included directed intervention materials in Spanish as well as in English, was launched by the Center for Disease Control and Prevention (CDC) in 1999. We hypothesized that CRC screening rates would increase overtime among Hispanics and non-Hispanics as a result of this campaign and that prostate and skin cancer screening would also increase due to screening recommendations and raised awareness and necessity of cancer screening. The objective of this study was to assess whether CRC, as well as prostate and skin cancer screening rates among Hispanic and White non-Hispanic men changed between 2000 and 2005 using the National Health Interview Survey (NHIS) data. Our results showed that Hispanic men were less likely to comply with cancer screening guidelines for these three common malignancies than White non-Hispanic men. However, significant increases in CRC endoscopic screening were observed in both ethnic groups. It increased 2.1-fold and 2.4-fold for Hispanic and White non-Hispanic men, respectively (P&amp;lt;0.05). In contrast, the use of home fecal occult blood tests remained stable among Hispanics and decreased significantly among White non-Hispanics. PSA screening remained stable, while the use of skin cancer screening tended to increase among both ethnic groups. Our study suggests that a targeted public education program that is culturally sensitive and linguistically appropriate may be effective in increasing CRC screening rates. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr LB-434.