Challenges and possible solutions to colorectal cancer screening for the underserved

Abstract

Colorectal cancer (CRC) is a leading cause of cancer mortality worldwide. CRC incidence and mortality can be reduced through screening. However, in the United States, screening participation remains suboptimal, particularly among underserved populations such as the uninsured, recent immigrants, and racial/ethnic minority groups. Increasing screening rates among underserved populations will reduce the US burden of CRC. In this commentary focusing on underserved populations, we highlight the public health impact of CRC screening, list key challenges to screening the underserved, and review promising approaches to boost screening rates. We identify four key policy and research priorities to increase screening among underserved populations: 1) actively promote the message, "the best test is the one that gets done"; 2) develop and implement methods to identify unscreened individuals within underserved population groups for screening interventions; 3) develop and implement approaches for organized screening delivery; and 4) fund and enhance programs and policies that provide access to screening, diagnostic follow-up, and CRC treatment for underserved populations. This commentary represents the consensus of a diverse group of experts in cancer control and prevention, epidemiology, gastroenterology, and primary care from across the country who formed the Coalition to Boost Screening among the Underserved in the United States. The group was organized and held its first annual working group meeting in conjunction with the World Endoscopy Organization's annual Colorectal Cancer Screening Committee meeting during Digestive Disease Week 2012 in San Diego, California.

Figure 1.

Colorectal cancer screening rates by race, ethnicity, insurance, age, education, and income based on the National Health Interview Survey (NHIS). Rates rounded for presentation. Screen up-to-date is defined by having a fecal occult blood test in the last year, sigmoidoscopy in the last 5 years, or colonoscopy in the last 10 years. Income is estimated as percentage of federal poverty level. HP 2020, Healthy People 2020 (9). *NHIS 2010 data (11). †NHIS 2008 data (12).

Figure 2.

Potential multilevel impact of recommendations for increasing colorectal cancer (CRC) screening among the underserved. The figure follows the Quality in the Continuum of Cancer Care framework of potential multilevel influences in the cancer care continuum, including screening (44–46). We have highlighted that challenges to screening underserved populations operate at multiple population levels of influence and that our four recommendations have multilevel characteristics that can address this complexity. The figure was adapted, with permission, from work by Zapka et al. (46). EHR = electronic health record; FIT = fecal immunochemical test; USPSTF = US Preventive Services Task Force.