Our study reveals that there are vulnerable patients among the population who visit rural primary care practices: those who aren’t already up to date with CRC screening do not intend to be screened in the future, even when they have access to the means to do so. Therefore, simply advising patients to go see their doctors for information regarding screening may not be enough to further increase CRC screening rates.
Many screening modalities for CRC exist. Guidelines for CRC screening include either FOBT, flexible sigmoidoscopy, colonoscopy, or barium enema, each at specific intervals.14–16
In this study colonoscopy is a common modality used for CRC screening, and most people who have had colonoscopy are up to date with it. Meanwhile, most patients who report having an FOBT are not up to date with it. This is telling, as FOBT is less invasive and theoretically more acceptable for patients.
An important finding in this study is that when patients feel like they are in control of their health, they are more likely to participate in recommended CRC screening practices. Patients are also more likely to be up to date with screening when they believe that CRC is a severe, preventable problem. Knowing that their provider recommends regular testing for CRC appears to be a motivating factor for intending to get tested. This should encourage providers to have targeted discussions with their patients regarding CRC screening. The physician-patient interaction that occurs at a primary care visit should be an ideal opportunity to reinforce such knowledge.
This study also confirms that a lack of symptoms can act as a barrier both for past screening behavior (being up to date) and future screening behavior (intending to get tested). Therefore, it is vital that patients be aware of the potential of lack of symptoms associated with CRC—even in advanced stages—or pre-cancerous colon polyps, and that they not wait until symptoms develop to begin testing.
One of the strengths of this study is that participation among the practices in the High Plains Research Network (HPRN)—the health-care providers for the rural communities in northeast Colorado—was very high. This extensive participation provides a fairly complete snapshot of how CRC screening is being utilized in primary care practices in rural northeastern Colorado.
We were limited in our ability to examine the effect of insurance or other financial factors on decisions to get CRC screening tests because of small sample sizes. Though a lack of having insurance showed a trend towards not being up to date with CRC testing, and towards a negative influence on intention to get tested for CRC, these trends were not statistically significant and could not be explored in further detail. Furthermore, patients self-reported their recollection of undergoing CRC tests. We did not conduct chart abstraction or medical record review to confirm the dates of having tests done. This may have influenced the categorization of patients as being up to date or not up to date; however, others have found that patient self-report of colon cancer screening behavior can be reliably used as an endpoint for intervention trials.17
This study was developed to provide information for a 4-year project in which community-based participatory methods were used to develop messages to promote colon cancer screening in rural communities. Through the formation of a Community Advisory Council (C.A.C.), community members with different backgrounds have had a voice in identifying pertinent research priorities and patient needs. Because the C.A.C. has recognized the need to learn more about CRC screening, the uptake of any health promotion efforts may be more likely to be supported. This could have influenced the observed outcomes. However, by being involved in the research process, community members can identify resources to deliver important health messages and aid in intervention efforts. In this instance, the goal is to further increase CRC screening rates.
Because CRC is a preventable cancer, it is critical that health-care providers strive to increase awareness of the disease and increase screening rates even further. A reasonable public health goal is to increase CRC screening rates to levels on par with breast, prostate, and cervical cancer screening rates. The clinic visit provides an ideal opportunity for such education to occur. Patients not tested or not up to date with CRC testing represent a particularly vulnerable population in this regard; only about one in ten patients in this study who have never been tested declared any intention to get tested in the future. This is significant because these are patients who already have a medical home. In a population-based survey study of members in the same HPRN counties as our clinic-based study,11
the prevalence of being up to date with any screening appeared to be slightly higher for those in the community than the population in our study who were seen in a clinic (58% vs. 52%, data not presented). This trend was true for every modality except for colonoscopy (37% vs. 44%). This comparison suggests that it may not be enough to simply get patients in to their health-care providers. If we are going to reduce the morbidity and mortality from colorectal cancer, we need to engage patients more actively.