Colorectal cancer (CRC) is the third leading cause of cancer-related deaths in the United States, with a predicted 52,550 CRC-related deaths in 2023.
Patients who receive a recommendation for CRC screening from their HCP are more likely to be screened. Screening can lead to pre-cancerous polyp removals and early diagnosis, but only a quarter of patients are being recommended for CRC screening.
CRC screenings were lower for non-Hispanic Asian, non-Hispanic Black, and Hispanic adults than for non-Hispanic White adults. They were also lower for the uninsured and for those with lower education levels.
Only about a quarter of Americans overdue for colorectal cancer (CRC) screening report that their healthcare providers recommended CRC screening, according to new research published by the Annals of Internal Medicine.
CRC is the third leading cause of cancer-related deaths in the United States. The American Cancer Society estimates that CRC will cause approximately 52,550 deaths during 2023. However, CRC is possibly preventable when patients are regularly screened. The Society says that CRC-related deaths have been lower in recent years due to patients being regularly screened (leading to pre-cancerous polyp removals), early diagnosis (resulting in better outcomes), and improved treatment.
“Receiving a clinician recommendation is the strongest and most consistent determinant of CRC screening participation. Lack of clinician recommendation may contribute to low uptake of CRC screening, but the magnitude of this problem is unknown,” the authors of the research write.
To investigate further, the research team assessed the prevalence of screening recommendations for under-screened US adults overall and by demographic, socioeconomic status, and healthcare access.
The researchers used nationally representative data from the 2019 and 2021 National Health Interview Survey, looking specifically for underscreened adults—as defined by the U.S. Preventive Services Task Force guidelines) who reported having visited their doctor in the past year.
The team looked for the dependent variable—a “yes” or “no” answer to the following question: “In the past 12 months, did a doctor or other health professional recommend that you be tested to look for problems in your colon or rectum?” This question was asked only of patients who did not report guideline-defined CRC screening.
Of 5,022 adults overdue (and eligible) for CRC screening, only about a quarter (26.8%) reported that their HCP recommended CRC screening. In individuals whose family income was 400% above the federal poverty line, that percentage was around 32%. Less than 10% of people without a usual source of care were given a recommendation.
Recommendations for CRC screenings were lower for non-Hispanic Asian, non-Hispanic Black, and Hispanic adults than non-Hispanic White adults. They were even lower for those with less than a high school education and uninsured adults than those with private insurance.
These findings, the authors say, are consistent with historical disparities and contemporary patterns of CRC screening participation. The authors also note that while HCPs “overwhelmingly” report that they recommend CRC screening to their average-risk patients, there’s very limited data to back this up.
The authors note that recall bias could be a barrier to the accuracy of collected information—especially among patients with lower health literacy—another limitation. Also, the absence of HCP- and practice-level measures. There may be reasons why screening isn’t recommended, they also say, including time and resource constraints, prioritization of acute care needs, and clinician preference for colonoscopy over alternative methods.
What this means for you and your practice
According to corresponding author Jordan Baeker Bispo, PhD, MPH, a principal scientist of Cancer Disparity Research at the American Cancer Society, MDs can close the gap in CRC screening by “engaging patients in shared decision-making based on patient risk factors and patient preferences is critical for encouraging screening participation.”
Bispo provides an example of how to do this: “Patients may prefer colonoscopy, as it needs to be performed just once every 10 years, whereas others may prefer the convenience and ease of annual home stool testing using FIT or FOBT. These preferences should be discussed during the clinical encounter and incorporated into clinician screening recommendations.” The American College of Physicians (ACP) recently updated its CRC screening guidance for asymptomatic, average-risk adults. The new guidelines state that HCPs should start screening patients at age 50 if they are asymptomatic and at average risk.
The ACP recommends a few options for screening: either a fecal immunochemical or high-sensitivity guaiac fecal occult blood test every two years, a colonoscopy every 10 years, or a flexible sigmoidoscopy every 10 years, and a fecal immunochemical test every two years. A colonoscopy every 15 years for patients between the ages of 50 and 60 who prefer less frequent screenings may be reasonable. The ACP also recommends against “stool DNA, computed tomography colonography, capsule endoscopy, urine, or serum screening tests.”
Bispo notes that at the practice level, there needs to be a robust system in place for identifying which patients are due for—or need first-time—CRC screening. “For many clinics, it may be feasible to leverage electronic health data to develop point-of-care prompts that alert clinicians when a patient is due for screening,” Bispo says.Related: Start checking average-risk, asymptomatic adults at 50, says new guidance for colorectal cancer screening
When it comes to ensuring that patients of all backgrounds are informed, Bispo says HCPs should make sure that their clinics or practices have informational materials available in several languages and at an appropriate literacy level, “especially where there is a high volume of patients with limited health literacy and/or patients best served in languages other than English.”.
“Finally, involving patient navigators who assist with patient education and provide follow-up reminders can also bolster colorectal cancer screening efforts at a clinic,” she notes.