Overcoming patients’ barriers to colorectal cancer screening

By Samar Mahmoud, PhD | Fact-checked by Barbara Bekiesz
Published January 31, 2023

Key Takeaways

  • While national rates of colorectal cancer incidence and mortality have been decreasing, colorectal cancer remains a major cause of cancer-related death. Early detection is essential for preventing these deaths.

  • Top barriers to colorectal cancer screening include fear or anxiety about the screening procedure, lack of recommendations from healthcare professionals (HCPs), financial difficulties, and logistical challenges.

  • HCPs can help overcome these barriers by providing recommendations for patients through shared decision-making and by better understanding patients’ risk factors and individual preferences.

Colorectal cancer is a leading cause of cancer-related mortality among men and women in the US, yet only about 60% of adults actually get screened for this form of cancer, according to a study published by Preventive Medicine Reports.[]

Since early detection is critical for preventing colon cancer–related deaths, it's essential to understand why some patients are reluctant to undergo colorectal cancer screening and diagnosis. 

Barriers to colorectal cancer screening

Due to increased screening, national rates of colorectal cancer diagnosis and death have steadily decreased since the mid-1980s, according to a Healthcare Journal of Arkansas report.[]

Why don’t more patients take advantage of screening?

To find out, the authors of the Preventive Medicine Reports study recruited 483 patients from primary care sites who were asked to complete self-report surveys that assessed barriers to colorectal cancer screening.

Overall, 65.2% reported being screened for colorectal cancer at some point, but only 46.4% were considered current, ie, with either a fecal occult blood test (FOBT) within the last year or a sigmoidoscopy/colonoscopy within the last 5 years.

The study authors identified the top four self-reported barriers to colorectal cancer screenings:

1. Fear or worry

Anxiety or fear was the most common self-reported barrier to colorectal cancer screening, affecting 29.5% of study participants. Some reported feeling concerns about certain aspects of the screening procedure, such as worries about the anesthesia. Others were concerned about the procedure’s potential negative outcomes, such as getting a cancer diagnosis.

2. Lack of provider referral or recommendation

Out of the 198 patients who reported barriers, 22.9% said they were not due for a screening, or their clinician had not recommended colorectal cancer screening.

Physicians do play a critical role in ensuring that patients get screened for colorectal cancer. A market research study conducted by the National Colorectal Cancer Roundtable found that the top six sources of trusted information about colorectal cancer screening were a personal doctor (68%), most doctors (48%), most medical professionals (40%), national health organizations (31%), government health organizations (25%), and family (20%).[]

3. Financial difficulties

A quarter of the study participants reported that finances constituted a barrier to colorectal cancer screening. Some lacked health insurance and were not able to afford the cost of screening. Others reported a lack of access to assistance programs.

Citing financial difficulties as a barrier was significantly correlated with having an income below $1,200 a month and being uninsured.

4. Logistical challenges

Other self-reported obstacles to screenings included logistical challenges, which affected 19.1% of those who reported barriers. These challenges included difficulty finding transportation or not having someone available to accompany them to their screening appointment. Participants also reported not having the time to schedule and attend an appointment.

Disparities in screening, outcomes

The decline in the rates of colorectal cancer diagnosis and mortality, while positive, can belie the fact that there are significant disparities that exist in screening and outcomes.

Between 2014 and 2018, the prevalence of colorectal cancer was highest among Black people in the US compared with any other racial or ethnic group, according to a report published by the American Association for Cancer Research (AACR).[]

The incidence of colorectal cancer was approximately 15% higher in Black people than in White individuals. The research also found that Black and Hispanic patients with colorectal cancer were at increased risk of being undertreated compared with White patients.

There are also disparities between Black and White populations in terms of colorectal cancer–related death rates, which are 44% higher in Black men compared with White men. For Black women, the mortality rate is 31% higher than for White women.

Demographics—such as living in a rural vs an urban area—can affect the likelihood of colorectal cancer screening. One study showed that women living in rural areas between 2017–2020 were 19% less likely to be current with colorectal cancer screening than those living in urban areas.

The role of HCPS

Various studies suggest that the most important factor that influences a patient’s screening behavior is a recommendation from a PCP or someone on their team. Because of this, the onus is on HCPs to remain up to date on colorectal cancer screening guidelines and to ensure that patients are aware of their colorectal screening options.

HCPs should also understand the benefits of presenting multiple screening options to patients. In a survey of 180 clinicians cited by the National Colorectal Cancer Roundtable, the majority of participants (92%) viewed colonoscopies as “highly effective.”

However, only 25% felt the same about the fecal immunochemical test (FIT), and less than 10% viewed guaiac FOBT (gFOBT) as “highly effective.” The surveyed clinicians still favored colonoscopies, even when 51% reported that this option was not readily available to their patients, and 82% acknowledged that their patients could not afford a colonoscopy.

Keep in mind that patients with an average risk of developing colorectal cancer are more likely to get screened when given a choice, according to the NCCRT. Being offered a stool test over a colonoscopy can significantly nudge patients into getting screened, especially if they can take the test in the comfort of their own home.

The key to providing a screening recommendation that a patient will accept is to use shared decision-making, taking into consideration the patient’s risk factors as well as their individual preferences.

By avoiding medical jargon and highlighting the benefits, clinicians can help patients buy into their recommendations.

What this means for you 

Clinicians can play an instrumental role in helping overcome the barriers to early colorectal cancer detection. Strive to remain up to date on the latest screening guidelines, and discuss them with your patients in terms that relate to them. The agreed-upon recommendation should be a shared decision with the patient that offers a range of options, as appropriate. HCPs should also be cognizant of the significant racial and ethnic disparities that exist in colorectal cancer screening.

Read Next: Partnering with patients in colon cancer screening decisions
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