Lower Colorectal Cancer Screening Rates Research Articles

Colorectal Cancer Screening Rates at Federally Qualified Health Centers From 2014 to 2022: Incomplete Recovery From COVID-19 and Worsening Disparities.

Federally Qualified Health Centers (FQHC) provide preventive health services such as colorectal cancer (CRC) screening to low-income and underinsured individuals. Overall CRC screening participation in the United States declined during the COVID-19 pandemic and recovered by 2021; however, trends in underresourced settings are unknown. Using Uniform Data System data from 2014 to 2022, we assessed trends in FQHC CRC screening rates nationally, in California, and in Los Angeles County and determined clinic-level factors associated with recent screening rate changes. For each FQHC, we calculated the screening rate change from 2019 to 2020, 2020 to 2021, and 2020 to 2022. We used mixed-effects linear regression to determine clinic-level characteristics associated with each screening rate change. Across all FQHC (n = 1,281), 7,016,181 patients were eligible for CRC screening in 2022. Across the United States and in California, median screening rates increased from 2014 to 2019, severely declined in 2020, and failed to return to prepandemic levels by 2022. Both nationally and in California, CRC screening declined most dramatically from 2019 to 2020 in FQHC serving majority Hispanic/Latino patients or a high proportion of patients experiencing homelessness. From 2020 to 2022, screening rates did not recover completely in US FQHC, with disproportionate recovery among FQHC serving majority non-Hispanic Black patients. CRC screening rates at FQHC did not return to prepandemic levels by 2022, and recovery varied by FQHC patient characteristics. Tailored interventions addressing low and decreasing CRC screening rates in FQHC are urgently needed to mitigate worsening CRC disparities.

Black-White disparities in colorectal cancer outcomes: a simulation study of screening benefit.

The US Black population has higher colorectal cancer (CRC) incidence rates and worse CRC survival than the US White population, as well as historically lower rates of CRC screening. The Surveillance, Epidemiology, and End Results incidence rate data in people diagnosed between the ages of 20 and 45 years, before routine CRC screening is recommended, were analyzed to estimate temporal changes in CRC risk in Black and White populations. There was a rapid rise in rectal and distal colon cancer incidence in the White population but not the Black population, and little change in proximal colon cancer incidence for both groups. In 2014-2018, CRC incidence per 100 000 was 17.5 (95% confidence interval [CI] = 15.3 to 19.9) among Black individuals aged 40-44 years and 16.6 (95% CI = 15.6 to 17.6) among White individuals aged 40-44 years; 42.3% of CRCs diagnosed in Black patients were proximal colon cancer, and 41.1% of CRCs diagnosed in White patients were rectal cancer. Analyses used a race-specific microsimulation model to project screening benefits, based on life-years gained and lifetime reduction in CRC incidence, assuming these Black-White differences in CRC risk and location. The projected benefits of screening (via either colonoscopy or fecal immunochemical testing) were greater in the Black population, suggesting that observed Black-White differences in CRC incidence are not driven by differences in risk. Projected screening benefits were sensitive to survival assumptions made for Black populations. Building racial disparities in survival into the model reduced projected screening benefits, which can bias policy decisions.

The impact of food insecurity on county-level colorectal cancer screening rates.

e22519 Background: Colorectal cancer screening has been associated with a marked reduction in cancer- related mortality, and the achievement of screening targets has been identified as a national objective by the Healthy People 2030 initiative. Although various social determinants of health (SDoH) have been demonstrated to impact healthcare access, the association between food insecurity (FI) and colorectal screening rates (CSR) remains unexplored. As such, we sought to assess the impact of FI on county-level colorectal screening rates (CSR). Methods: Data on county-level colorectal cancer screening and food insecurity rates in 2018 were extracted from the Centers for Disease Control (CDC) PLACES and County Health Rankings & Roadmaps databases, respectively. Notably, FI and CSR were categorized as low (lowest quartile), intermediate (middle two quartiles) and high (highest quartile). Multivariable logistic regression analyses were used to evaluate the association between FI and CSR. Results: Among 3,106 counties, the median CSR was 62.1% (IQR 58.9%–65.2%) and ranged from 39.8% (Kusilvak, Alaska) to 74.4% (Newport, Rhode Island). A majority of counties were urban (Metropolitan: n = 790, 25.4% vs. Urban: n = 1,671, 53.8% vs. Rural: n = 645, 20.8%). Overall, a fourth of counties had high screening rates (Low CSR : n = 788, 25.4% vs. Intermediate CSR : n = 1,545, 49.7% vs. High CSR : n = 773, 24.9%). Similarly, 25.0% of counties demonstrated high FI (Low FI : n = 777, 25.0% vs. Intermediate FI : n = 1,552, 50.0% vs. High FI: n = 777, 25.0%). Notably, counties with increasing FI were markedly less likely to have High CSR (Low FI : n = 353, 45.4% vs. Intermediate FI: n = 370, 23.8% vs. High FI: n = 50, 6.4%)(p<0.001). After adjusting for county-level rurality, population-to-primary care physician ratio, household income, unemployment, race/ethnicity, education and uninsurance, intermediate and high FI was associated with an incrementally lower likelihood of having High CSR compared with low FI counties (ref: Low FI ; Intermediate FI : OR 0.61, 95%CI 0.47–0.80; High FI : OR 0.31, 95%CI 0.20–0.50). Conclusions: Increasing county-level FI was independently associated with markedly lower colorectal cancer screening rates, indicating that FI may play a key role in driving disparities in access to cancer care. As such, policies targeted at vulnerable communities characterized by high food insecurity and social deprivation are critically needed to ensure equitable access to preventive cancer care measures such as colorectal cancer screening.

Abstract 4181: Geospatial heterogeneity in colorectal cancer screening among Hispanic subgroups

Abstract The U.S. Hispanic population has significantly lower colorectal cancer (CRC) screening rates than any other racial/ethnic group, resulting in unchanged incidence and mortality rates over recent decades. Recent studies have identified geographic variation in Hispanic CRC screening rates, but little is known about patterns among Hispanic subgroups. Here, we examine statistical and geographic relationships between broadly defined racial groups, Hispanic subgroups, and nationwide CRC screening rates. USPSTF guideline-adherent CRC screening rates for census tracts were obtained from 2018 CDC Places. Tract race/ethnicity %s, including non-Hispanic White (NHW), non-Hispanic Black (NHB), Asian, and Hispanic subgroups (Mexican, Cuban, Puerto Rican (PR), Dominican, Central/South American (CSAm), and other Hispanic), female %, and area deprivation index (ADI) were obtained from 2015-2019 American Community Survey 5-year estimates. Race/ethnicity %s were transformed using additive log ratios to account for the compositional nature of racial categories. A linear model and geographically weighted regression (GWR) were fit with CRC screening rate as the outcome. The mean CRC screening rate for 72,117 U.S. census tracts (99% of tracts) was 63.7% (SD=7.0). Linear modeling (R2=0.68) showed significant positive linear associations between CRC screening and female % (p&lt0.001), NHW % (p&lt0.001), NHB % (p&lt0.001), and Asian % (p=0.002), and significant negative associations between screening and ADI (p&lt0.001) and all Hispanic subgroups (p&lt0.001). Mexican, Cuban, PR, Dominican, and CSAm subgroups had significant screening rate drops of -1.48%, -0.26%, -0.15%, -0.30%, and -0.52%, respectively, per 1 unit increase in subgroup %. ADI had strong effects on all screening-race associations, with a flip in directionality for NHB% (negative to positive) and weakening of slopes for all other racial categories after adding ADI in the final adjusted model. GWR results (R2=0.94) displayed spatial heterogeneity in local coefficients of all predictor variables, with distinct regional patterns in relationships between screening and ADI (strongly negative local coefficients in OH and OK), Mexican % (strongly negative in TX, AZ, NV, and CA), and NHB % (strongly negative in FL, GA, MS and WI; positive in SC and NC). This work suggests Mexican, CSAm, and Dominican subpopulations may be driving the low CRC screening rates among Hispanics overall. Local variability suggested the importance of where subpopulations live in determining guideline-concordant screening. ADI strongly altered screening-race relationships, with directionality changing for NHB %, further displaying the importance of area deprivation in CRC screening. Future work should explore micro-level drivers of spatial heterogeneity in screening rates across both broadly defined racial groups and Hispanic subgroups in the U.S. Citation Format: Robert Blake Buchalter, Johnie Rose, Mariana C. Stern, Jane C. Figueiredo, Stephanie L. Schmit. Geospatial heterogeneity in colorectal cancer screening among Hispanic subgroups. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4181.

Barriers to Colorectal Cancer Screening Among Russian-speaking Immigrants: The Importance of Culture and Home Country Experiences.

There is potential to improve low colorectal cancer screening rates, reduce mortality, and narrow health disparities, if the distinctive screening barriers among Russian-speaking immigrants were better understood. However, there is little relevant research about the topic. To address this gap, this study aimed to identify barriers to timely colorectal cancer screening, especially colonoscopies, among Russian-speakers in New York City. Thirteen key informant interviews were performed with providers, community leaders, and academics. Eight focus groups were then conducted with 81 Russian-speaking individuals, age 50-75, who had not had a timely colonoscopy. Results were translated, transcribed, coded and analyzed. Barriers identified included individual, communal, and structural issues. Distinctive barriers, such as those related to culture and to the experiences of living under the Soviet system, were uncovered. Barriers identified can potentially be reduced through interventions suggested by the research, including more education and more effective provider recommendations.

S3257 Addressing Disparities in Colorectal Cancer Screening

Introduction: Colorectal cancer (CRC) screening rates are significantly lower in low-income, minority populations nationally. Health system data from a large academic medical center revealed a 3% lower CRC screening rate amongst black patients and a 14% lower rate of CRC screening in the resident patient panels, which contain a greater percentage of high-risk, low-income patients. This novel resident-led quality improvement (QI) work identified causes for disparities in CRC screening, then implemented a resident-driven population health based protocol. Methods: Analysis was conducted across two academic primary care clinics at a single institution. Residents conducted chart reviews and targeted interviews of key stakeholders in the CRC screening process, including patients, physicians, and staff. An EMR-based dashboard was used to collect demographic data and CRC screening rates for colonoscopy and FIT tests for the patient panels for the year 2020. A population health protocol was then developed and implemented by residents during dedicated outpatient blocks. Results: Twenty-two structured interviews revealed scheduling algorithms, limited time during clinical encounters and patient and provider knowledge deficits as the top contributors to low CRC screening rates. Data generated from a central database revealed colonoscopy compliance rates to be 76% for attending panels versus 62% for resident panels, and compliance for FIT to be on average 15% higher than colonoscopies. An established navigator program for improving CRC screening was only effective in 30% of patients. Based on these results, a population health protocol was developed for residents to outreach patients with lapsed CRC screening outside the office visit and streamline referrals to the navigator program for high-risk patients. Thus far, 18 residents have implemented the protocol and 266 patients have been outreached. Conclusion: Multiple factors lead to disparities in CRC screening including intricacies within the health system but also experience in practice. Interventions are being studied to counteract such factors and improve disparities that disproportionately impact minority patients. This QI initiative demonstrates that a resident-led intervention outside the clinical visit can reach a significant number of high-risk patients. In the next phase of data collection, we will examine the impact of our protocol on the number of additional colonoscopies and FIT tests completed.

S0306 A Team-Based Approach Is Effective in Improving Colorectal Cancer Screening Rates in a Community-Based Resident Clinic

INTRODUCTION: Colorectal cancer (CRC) is the second leading cause to cancer-related mortality. This has resulted in increased utilization of screening modalities including fecal immunochemical test (FIT), multi-target stool DNA test (MT-sDNA) and colonoscopy. In 2016, 67.2% of the US population who are 50–75 years old were up-to-date on their CRC screening. Comparatively, CRC screening rates at our academic Internal Medicine resident-based clinic were 42.5%. Therefore, we established a team-based approach to improve the CRC screening program at our community-based clinic. The aim was to achieve a 3% increase in screening rates over the year 2019 which aligns with our organization goal. METHODS: Institute of Healthcare model for improvement was used as a framework for this quality improvement project. Initially, a team was assembled, comprised of resident physicians, practice manager (PM) and patient navigators [nurses and medical assistants (MAs)]. Afterwards, a root-cause analysis was performed to identify contributing factors to our low CRC screening rates and explore areas for improvement (Figure 1). Interventions were implemented across three cycles of improvement (Figure 2). This comprised of providing appropriate CRC screening education to the providers and clinic staff. Personal dashboards were then distributed to residents with the list of patients due for screening from their own panel. This was followed by identification of patients due for CRC screening as part of pre-visit planning and during daily inter-professional staff huddles. Furthermore, an educational brochure comparing the different screening modalities was given to eligible patients by MAs prior to seeing the provider. Choice of a screening method was recommended by the provider based on the patient’s CRC risk. Screening tests results were closely tracked and updated by MAs. Patients with incomplete orders after 30 days were followed by a phone call conducted by a resident physician. CRC screening registry was updated on monthly basis by the PM. RESULTS: There was a steady increase in CRC screening rates from a pre-intervention median of 42.5% to 48.5% by the end of December, 2019. Using run chart rules, this change is significant for a positive shift (Figure 3). CONCLUSION: A team-based approach is an effective method to improve CRC screening rates in a resident-based clinic. We anticipate that our intervention will show more measurable outcomes in the future through continuous cycles of improvement.Figure 1.: Root-Cause Analysis for low CRC screening rates. Abbreviations: CRC-Colorectal Cancer, FIT-Fecal Immunochemical Test, MT-sDNA-Multitarget stool DNA, EMRs-Electronic Medical Records.Figure 2.: PDSA cycles of improvement. Abbreviations: PDSA- Plan-Do-Study-Act.Figure 3.: Run chart graph detailing the exact times for the interventions during the year 2019. A positive Shift can be seen by having six consecutive points above the pre-intervention median. Abbreviations: PDSA- Plan-Do-Study-Act **The red central line reflects the pre-intervention median for the values from June, 2018 to January, 2019.

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

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

Abstract B029: Community-based colorectal cancer screening initiative to address colorectal cancer disparities among African Americans and sexual and gender minorities on the Southside of Chicago

Abstract Background Colorectal cancer (CRC) persists as the second leading cause of cancer death and African Americans (AA) carry a disproportionate burden of CRC, having the highest incidence and mortality. Although CRC is one of the few cancers where screening can be prevention, AAs have lower uptake of CRC screening. Additionally, sexual and gender minorities (LGBTQ) are another population with growing CRC disparities. To date, few initiatives address CRC among LGBTQ populations. Factors impacting screening uptake among AA and LGBTQ populations are multi-factorial including access, awareness, and stigma. To attenuate low rates of CRC screening, the University of Illinois Cancer Center through funding from the Bristol-Myer Squibb Foundation has developed the UI CAAN (Cancer Screening; Access; Awareness; Navigation) Project. UI CAAN is a community focused cancer education, prevention, screening and navigation program aimed at addressing the elevated burden of CRC within the UI Cancer Center catchment population targeting 200 AA per year for three years. Methods Building upon the Center for Disease Control and Prevention socio-ecological model, UI CAAN will address multi-level barriers impacting CRC screening. The American Cancer Society recommends screening starting at age 45 using Fecal immunochemical tests (FITs). Community Lay navigators will work with barber shops, beauty/nail salons and venues frequented by members of the LGBTQ community to provide education and free FIT kits to AA on the Southside of Chicago. Participants who return their FIT kit will be compensated with a $25 Certificate for the barber or beauty salon or $25 gift card for those engaged through community venues. The project will partner with a Federally Qualified Health Center (FQHC) on the Southside of Chicago to support navigation for follow up. Results Year I is devoted to planning, priority setting and community engagement. The key community stakeholder for UI CAAN is Project Brotherhood, a non-profit community based organization with over two decades of successful engagement of AA communities. To date the project has identified a) A community health worker/lay patient navigator from the targeted community; b) identified and trained one barber and one beautician; c) identified and trained a community health psychologist to assist with program design and implementation and d) has identified two Community Health workers from the LGBTQ community in the target area. IRB approval has been obtained. Conclusion Completion of planning and priority setting of the UI CAAN Project to improve CRC screening among AA and LGBTQ populations on the Southside of Chicago demonstrate the feasibility of community engagement to plan and implement a community based CRC screening initiative. Phase II of Year I will begin August 2019 with screening and recruitment from a barber shop, beauty salon and key community events on the Southside of Chicago with navigation to a local FQHC. Citation Format: Karriem S Watson, Vida Henderson, Jessica Madrigal, Jeanette Gonzalez, Erica Martinez, Nasima Mannan, Tonya Roberson, Marcus Murray, Katherine Tossas-Milligna, Robert A Winn. Community-based colorectal cancer screening initiative to address colorectal cancer disparities among African Americans and sexual and gender minorities on the Southside of Chicago [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 B029.

Abstract A011: Opportunities for connection: A scoping review of telemedicine interventions in colorectal cancer screening in rural and nonrural settings

Abstract Introduction: The relative dearth of financial and human resources in rural areas complicates the delivery of timely medical expertise and treatment to its inhabitants. Travel distances between patients and their providers pose transportation barriers that contribute to low colorectal cancer screening rates in rural areas. Increasing applications of telemedicine technologies in health care may reduce or mitigate problems associated with transportation and insufficient availability of local providers. The objective of this study was to conduct a scoping review to compare types of telemedicine interventions for colorectal cancer screening in rural areas to those that have been studied more broadly, evaluate the quality of existing evidence, and suggest opportune areas for further investigation and application. Methods: Searches were conducted in Ovid Medline, EMBASE, and Cochrane databases with the guidance of a librarian. We included peer-reviewed full text articles in English and Spanish about telemedicine interventions in CRC screening. Telemedicine interventions for CRC screening were operationally defined as the use of telephone and Internet-based technologies to aid patient decision making, reduce transportation barriers, and circumvent lack of local human resources from the first moment of screening awareness through cancer diagnosis. We did not exclude articles based on study design type. Risk of bias was assessed through measures including randomization, blinding, and incomplete outcome reporting. Quality was defined by factors such as risk of bias and representativeness of sampled populations. Results: Of 2223 non-duplicate studies, 167 articles fell into the following intervention categories: feasibility and logistics, decision aids, reminders, motivational interviewing, and remote expert evaluation. Reminders were the most robust area of the literature, with more RCTs and large-scale studies conducted. Many studies compared the efficacy of automated screening reminders with those performed by staff. Common outcomes that were measured in all categories except remote expert evaluation were patient acceptability and CRC screening completion within designated time frames. Articles about decision aids exhibited heterogeneity of dissemination method and types of informational materials included. Studies on remote expert evaluation were variable in scope and reported results for interobserver reliability and sensitivity. Of the studies included, nine took place or were targeted for application in rural or remote areas. Of those nine studies, five were about reminders, reflecting trends in the wider literature. Discussion: Given the paucity of CRC screening interventions that were studied in rural areas, further investigation is needed to determine whether broadly studied telemedicine interventions are applicable, particularly since underserved populations in rural areas stand to benefit disproportionately from evidence-based telemedicine interventions. Citation Format: Chanelle Y. Chua, Carolyn Stoll, Julia Maki, Graham Colditz, Aimee James. Opportunities for connection: A scoping review of telemedicine interventions in colorectal cancer screening in rural and nonrural settings [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A011.

Mo1676 COST EFFECTIVENESS OF MULTI-TARGET STOOL DNA TEST VERSUS COLONOSCOPY OR FECAL IMMUNOCHEMICAL TEST FOR COLORECTAL CANCER SCREENING AMONG ALASKA NATIVE PEOPLE

Alaska Native people have higher incidence and mortality from colorectal cancer (CRC) and lower CRC screening rates than U.S. whites. Alaska’s large and predominately roadless geography presents CRC screening challenges, particularly for endoscopy. The objective of this study was to estimate the cost-effectiveness of the multi-target stool DNA test (MT-sDNA) compared with colonoscopy and fecal immunochemical test (FIT) for Alaska Native people. A Markov model was used to evaluate effects of three CRC screening strategies for Alaska Native adults aged 40-75: colonoscopy every 10 years, annual FIT, or MT-sDNA testing every three years, over a 40-year period. An Alaska Native health-system perspective and Alaska Native-specific and national data were updated from previous models to incorporate new evidence on test performance; probabilistic sensitivity analyses explored perfect and imperfect screening adherence. The main outcome measures were CRC incidence and mortality; cost; quality-adjusted life years (QALYs); and incremental cost-effectiveness ratio (ICER). With perfect adherence, CRC incidence was reduced by 51.7% (95% CI: 46.3%-55.9%) using colonoscopy, 60.7% (95% CI: 56.5%-64.2%) using annual FIT, and 65.7% (95% CI: 62.9%-68.3%) using MT-sDNA. Compared with no screening, perfect adherence screening extends life by 0.15 QALYs per person with colonoscopy, 0.17 QALYs per person with FIT, and 0.19 QALYs per person with MT-sDNA. Screening by colonoscopy at ten-year intervals is the most expensive strategy, about $110M more than MT-sDNA and $127M more than FIT. With imperfect adherence (best case), MT-sDNA resulted in 0.12 QALYs/person vs. 0.05 QALYS/person by FIT and 0.06 QALYS/person by colonoscopy. Probabilistic sensitivity analyses supported the findings of the base-case analysis. Under perfect and imperfect adherence scenarios, MT-sDNA either dominates or is cost-effective (ICERs range from $1,740 to $75,868 per QALY saved) as compared with FIT and colonoscopy. Each strategy reduced costs and increased QALYs in comparison with no screening. Screening by MT-sDNA results in the largest savings of QALYs, in all adherence scenarios. In a Markov model analysis, we found that screening by MT-sDNA in the Alaska Native population is cost-effective as compared to screening by colonoscopy and FIT, for a wide range of adherence scenarios.

Abstract B009: ¡Salud!, por la Vida, an educational intervention to increase colorectal cancer screening in Puerto Ricans

Abstract From 2010-2014, colorectal cancer (CRC) was the second highest incident cancer and leading cause of cancer-related deaths in Puerto Rico (PR). Although preventable through screening and treatment, colorectal cancer screening (CRCS) using fecal occult blood test (FOBT) or colonoscopy remains low for adults in PR. Data from the 2016 Behavioral Risk Factor Surveillance System indicated that 18.0% of the PR population aged 50 to 75 had undergone an FOBT within the past year compared to 8.0% in the United States (US). Additionally, 50.1% of age-eligible Puerto Ricans report ever having a colonoscopy in the past 10 years compared to 63.5% in the US. Given the higher burden of CRC and the low CRCS rates in PR, we developed ¡Salud!, por la Vida (SPLV), an educational program which aims to increase CRCS in non-adherent men and women aged 50 and 75 who attend Federally Qualified Health Clinics (FQHCs) in PR. We used Intervention Mapping (IM) as framework to develop an educational intervention that is theoretically sound and grounded in evidence. For the development of SPLV, steps 1 to 4 of IM were completed. Step 1: a needs assessment conducted through focus groups and key informant interviews to gather quantitative and qualitative data for the development of the logic model and the program; step 2: development of a logic model of change and matrices of change objectives; step 3: selection of theory and evidence-based methods and strategies; and step 4: program production, components, and materials. Step 1 revealed 5 main themes: (1) lack of knowledge about CRC and CRCS practices; (2) patient’s fear of the CRC test results; (3) low risk perception of CRC; (4) lack of provider CRCS recommendation; and (5) the importance of social support. Interviews revealed that the majority of clinics offer FOBT as part of their CRCS protocol; where 74.0% of these had a clinical laboratory on-site. Over half (53.0%) had implemented electronic medical records and 82.0% had health educators on staff. A logic model was developed by combining personal behaviors with behavioral determinants and identifying beliefs targeted by the intervention (step 2). Tailored interactive multimedia intervention (TIMI) and small media were selected as the practical application to deliver the intervention (step 3). Development of the program included 5 components: script development; testimonials; animations; written materials; and newsletter. Pre-testing was conducted to evaluate the usability of the program. Our educational program, SPLV, is completed and currently being implemented, using a randomized trial. Trial is being conducted in 10 FQHCs and will recruit 710 participants aged 50 to 75 who have no prior history of CRC and are not adherent to CRCS guidelines. Clinics are randomized to either the intervention group (TIMI) or the control group (usual care). We aim that this intervention will significantly increase CRCS rates and provide evidence to disseminate this educational effort to FQHCs in PR. Citation Format: Vivian Colón-López, Camille Vélez-Alamo, Adrianna Acevedo-Fontanez, Marievelisse Soto-Salgado, Jorge L Rodríguez-Lebrón, Josheili Y Llavona-Ortiz, Yolanda Serra-Martínez, Ileska Valencia-Torres, María Fernández. ¡Salud!, por la Vida, an educational intervention to increase colorectal cancer screening in Puerto Ricans [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 B009.

Tu1116 DISPARITIES IN HEALTH: LOWER COLORECTAL CANCER SCREENING RATES AMONG LGBTQ PATIENTS

Colorectal cancer (CRC) screening via colonoscopy can prevent CRC. Socially neglected populations such as ethnic and racial minorities have consistently lower CRC screening rates when compared to the general population. While lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients represent a population who are at risk for CRC screening disparities, an estimate of the existence and magnitude of the disparity remains unknown. The aim of this study is to analyze the rate of CRC screening between the LGBTQ population and the general population to determine if a disparity exists along with the possible magnitude. Data was extracted from our tertiary care medical center’s de-identified patient database (SD) between 2014 and 2018. Search terms for the LGBTQ population included self-identification in the EMR as “lesbian”, “gay”, “bisexual”, “transgender”, “transsexual”, “queer”, “questioning”, or “intersex” or had an associated ICD 9 or 10 code. The 2008 USPSTF criteria for CRC screening were utilized for identification of patients eligible for screening. Search terms for average risk CRC screening included “colonoscopy”, “FOBT”, “FIT”, “flexible sigmoidoscopy”, and ICD 9/10 codes v76.51, v76.41, z12.11, and z12.12. Patients considered as increased risk for CRC were excluded (family history of CRC or advanced polyp; personal history of IBD). Based on the magnitude of data for the general population, the Center for Disease Control (CDC) and Prevention database for our state was utilized in publication years to calculate the CRC screening rate of the state-wide population. Students t-test for was utilized to assess for differences between the groups. A total of 117 LGBTQ patients were found in the SD. 15% were lesbian, 44% gay, 18% bisexual, 23% transgender, and 0% queer/questioning or intersex with a mean age of 58 [50-76] years-old. 85% were Caucasian (90% non-Hispanic; 3% Hispanic; 7% not identified), 11% African-American, 0% Asian, and 4% unknown. Of the LGBTQ patients identified, 35 met 2008 USPSTF eligibility criteria for average risk CRC screening. The LGBTQ CRC screening rate compared to the state population rate was 29.3% v. 64.9% (p<0.01) in 2014, 34.8% v. 66.4% (p<0.01) in 2016, and 29.9% v. 69.1% (p<0.01) in 2018. Despite increased CRC screening rates for the state population over the years of the study, the rate among the LGBTQ population remained low. Although this is a single center study, our data may serve to highlight low CRC screening rates among the LGBTQ population. Future studies to evaluate the etiology of the low rate, barriers to screening in this marginalized population, and implementation of strategies to improve screening rates are underway.

Colorectal cancer screening among Hispanics in the United States: Disparities, modalities, predictors, and regional variation

Hispanics represent the largest and one of the fastest growing minority populations in the U.S. and have lower survival from colorectal cancer (CRC) than non-Hispanic Whites (NHW). We aimed to examine screening modalities, predictors, and regional disparities among Hispanics and NHW in the U.S. by conducting a cross-sectional analysis of Hispanic participants age 50 to 75 from the 2016 Behavioral Risk Factor Surveillance System (BRFSS) survey. The primary outcome was self-reported CRC screening status. We used the Rao-Scott Chi-square test to compare screening rates and modalities in NHWs and Hispanics. We also used univariable and multivariable logistic regression to determine predictors of screening among Hispanics and calculated Hispanic-NHW screening rate differences for each U.S. state/territory as a measure of regional screening disparities. The screening rate was 53.4% for Hispanics (N = 12,395), compared to 70.4% for NHWs (N = 186,331) (p < 0.001). Among Hispanics, colonoscopy was most common (75.9%). Uninsured status (aOR = 0.51; 95% CI = 0.38–0.70) and limited access to medical care (aOR = 0.38; 95% CI = 0.29–0.49) predicted lack of screening. States/territories with the largest screening disparities were North Carolina (33.9%), Texas (28.3%), California (25.1%), and Nebraska (25.6%). Disparities were smallest in New York (2.6%), Indiana (3.1%), and Delaware (4.0%). In Ohio and Guam, Hispanics had higher screening rates than NHWs. In conclusion, Hispanics have lower CRC screening rates than NHWs across most U.S. states/territories; however, the disparity varies by region. Future efforts must address multi-level barriers to screening among Hispanics and target regions with low rates to improve CRC outcomes in this growing population.

Preliminary Evaluation of Educational Outreach to Promote Colorectal Cancer Screening Among South Asians in the San Francisco Bay Area

Culturally-tailored interventions increase rates of colorectal cancer (CRC) screening in diverse populations. South Asian Americans have very low rates of CRC screening. Targeted interventions may improve community awareness and likelihood of undergoing screening. We identified and recruited multiple South Asian-serving community and religious centers to conduct South Asian physician-led presentations about CRC screening. A post-presentation survey tool was used to evaluate CRC screening history, intent to screen, and acceptance of a tailored brochure. In a convenience sample of 103 surveys, many participants had not undergone screening in the past (48%), and intent to screen after the presentation was high in those previously not screened (87%). Those who took a culturally-tailored brochure said they would share materials with family and friends (95% and 39% respectively). Our results support earlier findings of success in culturally-tailored interventions and indicate acceptance of culturally-tailored CRC screening outreach in community sites.

Personal and Neighborhood Attributes Associated with Cervical and Colorectal Cancer Screening in an Urban African American Population.

IntroductionAssessing individual social determinants of health in primary care might be complemented by consideration of population attributes in patients’ neighborhoods. We studied associations between cervical and colorectal cancer screening and neighborhood attributes among an African American population in Philadelphia.MethodsWe abstracted demographic and cancer screening information from records of patients seen during 2006 at 3 federally qualified health centers and characterized patients’ census tracts of residence by using census, survey, and other data to define population metrics for poverty, racial segregation, educational attainment, social capital, neighborhood safety, and violent crime. We used generalized estimating equations to obtain adjusted relative risks of screening associated with individual and census tract attributes.ResultsAmong 1,708 patients for whom colorectal cancer screening was recommended, screening was up to date for 41%, and among 4,995 women for whom cervical cancer screening was recommended, screening was up to date for 75%. After controlling for age, sex (for colorectal cancer screening), insurance coverage, and clinic site, people living in the most racially segregated neighborhoods were nearly 10% more likely than others to be unscreened for colorectal cancer. Other census tract population attributes were not associated with differences in screening levels for either cancer.ConclusionsThe association between lower rates of colorectal cancer screening and neighborhood racial segregation is consistent with known barriers to colonoscopy among African Americans combined with effects of segregation on health-related behaviors. Recognition of the association between segregation and lower colorectal cancer screening rates might be useful in informing and targeting community outreach to improve screening.

Colorectal Cancer Screening and Access to Healthcare in New York City Taxi Drivers.

This study examined differences in colorectal cancer screening across sociodemographic, migration, occupational, and health-related factors in a sample of male taxi drivers. Male drivers eligible for colorectal cancer screening (CRCS) (≥ 50years old) were recruited in 55 community-based health fairs conducted during November 2015 to February 2017 in 16 taxi garages or community locations located in Queens, Brooklyn, Manhattan and Bronx. Participants completed a survey that included sociodemographic, migration, occupational, health-related, and cancer screening practices. For this study 33 questions were analyzed. The sample consisted of 137 male drivers, 27% of them had undergone CRCS. Occupation-related factors, including night shifts and driving high numbers of weekly hours, were associated with lower CRCS rates; having a family history of cancer, health insurance, a regular source of primary care, and a routine check-up in the last year, were associated with higher CRCS rates. The findings suggest that drivers with health insurance and better access to primary care are more likely to be up-to-date with CRCS. The results provide important information that can inform occupation-based public health interventions.

Effectiveness of a Tailored Colorectal Cancer Educational Seminar in Enhancing the Awareness, Knowledge, and Behavior of Korean Americans Living in the Los Angeles Koreatown Area.

Improving rates of colorectal cancer (CRC) screening can reduce CRC-related mortality, which is estimated to cause about 50,630 deaths in the U.S. by the end of 2018. There is a noted increasing prevalence of CRC among Korean Americans. Although CRC screening has been widely implemented, Korean Americans over the age of 50 have the lowest rates of proper CRC screening, compared to those of other Asian ethnicities. Barriers, such as language and culture, may be making participation in screening procedures difficult for those with immigrant backgrounds. Thus, this study aimed to determine whether proper CRC education can enhance awareness, knowledge, and behavior in screening among Korean Americans living in the Los Angeles Koreatown area. This study was conducted among 100 self-identified Korean Americans between the ages of 45-75, who voluntarily participated in this study through local community outreach from January to June 2018. Educational brochures were provided for those in the control group, while those in the intervention group attended an additional short educational seminar. All participants were asked to complete a questionnaire after, and data were collected on site. We found that intervention had a significant effect on awareness regarding colorectal polyps (OR (odds ratio): 22.47; 95% CI: 6.42-78.62; p-value <0.001) and fecal occult blood tests (FOBTs)/stool blood test (OR, 245.37; 95% CI: 34.55-1742.75; p-value <0.001). Willingness for CRC screening in following 6 months significantly increased (OR: 87.17; 95% CI: 19.01-399.63; p-value <0.001). Knowledge on options for CRC screening (OR: 126.63; 95% CI: 23.61-679.07; p-value <0.001) and stool blood tests (OR: 157.17; 95% CI: 18.02-1370.41; p-value <0.001) were significantly enhanced. In additional univariate analysis, we found that Korean Americans with higher level of education, birthplace in US or better general health showed better CRC awareness or knowledge. There is a significant gap in our knowledge and understanding of the contributing factors that may be leading to low CRC screening rates in Korean Americans. This study suggests that well-tailored educational seminars can overcome certain barriers to screening and improve CRC knowledge and awareness, which is critical to achieving greater screening compliance. Our findings provide important references for designing effective strategies to increasing CRC screening rates among Korean Americans.

Abstract B24: Salud!, por la Vida, an educational intervention to increasing colorectal cancer screening in Puerto Ricans

Abstract Introduction: Colorectal cancer (CRC) represents the second highest incidence in both men and women in Puerto Rico (PR). This cancer is the leading cause of death in PR. Although largely preventable through screening and treatment of precancerous polyps, colorectal cancer screening (CRCS) using fecal occult blood test (FOBT), sigmoidoscopy, or colonoscopy remains low for adults in PR. Data from the 2014 Behavioral Risk Factor Surveillance System indicate that only 18.5% of the PR population 50+ years has undergone an FOBT within the past two years compared to 12.8% in the United States of America (USA). Additionally, only 50.6% of age-eligible Puerto Ricans report ever having a sigmoidoscopy or colonoscopy compared to 68.8% in the USA. Therefore, given the higher burden of CRC and the low CRCS rates in the island, we developed ¡Salud!, por la Vida (SLPV), an educational program that aims to increase CRCS in nonadherent men and women 50 years and older who attend Federally Qualified Health Clinics (FQHCs) in PR. Methods: Intervention mapping (IM) was used as the guiding framework to develop an educational intervention that is theoretically sound and grounded in evidence. For the development of SPLV, steps 1 to 4 of IM were completed: step 1: a needs assessment conducted through focus groups and face-to-face interviews with patients, medical directors, and other key informants from the FQHCs to gather quantitative and qualitative data for the development of the logic model and the program; step 2: development of a logic model of change and matrices of change objectives; step 3: selection of theory and evidence-based methods and strategies; and step 4: program production, components, and materials of a CRCS patient-education intervention. Results: The needs assessment (step 1) data revealed five main themes: (1) limited knowledge about CRC and CRCS practices; (2) patients' fear of the CRC test results; (3) low risk perception of CRC; (4) reporting not having received a provider recommendation regarding the screening test; and (5) the importance of social support in making the decision of getting screened for CRC. Key informant interviews showed that the vast majority of the clinics offer FOBT as part of the CRCS protocol, with 74.0% of these having a clinical laboratory at their facilities. Over one half (53.0%) had already implemented electronic medical records (EMR) and 82.0% had health educators as part of their full-time staff. A logic model was developed by combining personal behaviors with behavioral determinants and identifying beliefs targeted by the intervention (step 2). Tailored interactive multimedia intervention (TIMI) and small media were selected as the practical application to deliver the intervention (step 3). Development of the program included 5 components: (1) script development for fictional videos; (2) testimonials; (3) animations; (4) written materials; and (5) newsletter. After all five components were developed, the team completed a pretesting to evaluate the usability of the program. Pretesting assessment conducted with 9 participants showed that the program was easy to use and that they understood the commands of the interactive platform. Conclusion: Our educational program, !Salud!, por la Vida is completed and currently in implementation phase, using a randomized trial. This trial will be conducted in 10 FQHCs and is expected to recruit 710 participants between the ages of 50-75 who have no prior history of CRC and who are not adherent to CRCS guidelines. The randomization of this study is at the clinic level, in which we randomly allocated each clinic to either the intervention group (TIMI) or the control group (usual care). We aim for this intervention to significantly increase CRCS rates and provide evidence to disseminate this educational effort to FQHCs island wide. Note: This abstract was not presented at the conference. Citation Format: Vivian Colon-Lopez, Camille Velez-Alamo, Adrianna Acevedo-Fontanez, Marievelisse Soto-Salgado, Yolanda Serra-Martinez, Ileska Valencia-Torres, Maria E. Fernandez. Salud!, por la Vida, an educational intervention to increasing colorectal cancer screening in Puerto Ricans [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr B24.

Abstract C38: Increasing colorectal cancer screening in rural populations: A systematic literature review

Abstract Background: Research demonstrates that early detection through recommended screening for colorectal cancer (CRC) yields favorable treatment outcomes; however, screening rates remain low, particularly in rural communities. Residents of rural communities have unique barriers to health care that often result in poorer health outcomes. Targeted interventions to increase CRC screening are needed to tackle barriers to preventive health behaviors among individuals in rural communities. Methods: A systematic literature search of PubMed/Medline was performed to identify CRC screening interventions conducted in rural communities. English language articles from peer-reviewed journals published from January 2006 to December 2016 were included if they reported results for CRC screening interventions in rural communities in the United States. Results: Of the 358 articles abstracted, 29 met the inclusion criteria. The studies detailed interventions in rural settings, particularly among populations with low CRC screening rates including American Indians/Alaska Natives, African Americans, and uninsured individuals. Studies varied in design and mode of intervention delivery; however, interventions emphasizing community-based participatory research principles yielded improved CRC screening adherence. Interventions to increase CRC screening included communication campaigns, home-based screening, and patient navigation. Few interventions included a theoretical foundation or information on cost-effectiveness. Conclusions: More research is needed to examine the theoretical framework, design, delivery, and cost-effectiveness of CRC screening interventions for rural populations. Additional assessment is needed to determine how effectively these interventions can be translated to different types of rural settings. Synthesis of this literature may inform efforts to develop targeted interventions to increase CRC screening in rural populations. Citation Format: Joelle Atere-Roberts, Ingrid J. Hall, Judith Lee Smith. Increasing colorectal cancer screening in rural populations: A systematic literature review [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C38.