As the third most common and second deadliest cancer in the U.S., colorectal cancer (CRC) remains one of the most preventable cancers by appropriate screening.1 Because CRC starts from an adenomatous polyp that develops over a period of years into a cancer, this extended timeframe provides an ideal window of opportunity for detection, removal, and prevention. Despite this, nearly one-third of eligible candidates remain unscreened.2 As the recommended age to start CRC screening has been lowered to age 45, that percentage may increase.3
As unfortunate as these numbers are, they’re even worse when we zoom in on minorities in the U.S. For example, the incidence of CRC in Black Americans is 20% higher than White Americans, and the mortality rate from CRC is 40% higher.4 CRC is 40% more common in those with a lower socioeconomic status than those of a higher socioeconomic status. Forty-four percent of this racial healthcare disparity is attributed to differences in screening rates, according to the American Cancer Society.5 This is one healthcare disparity that radiologists can work to improve through promoting increased uptake of CRC screening within minority communities.
The most prevalent CRC screening method currently in use is called optical colonoscopy (OC). Although OC is the most well-known CRC screening exam, it presents significant challenges for uptake among minority groups. For instance, the use of anesthesia requires a driver post-procedure. Undergoing OC also often requires patients to take a day off from work, which can be a challenge for those in underserved populations. The anesthesia involved with OC also evokes fear in some cultural and ethnic minority groups.6 Furthermore, access to OC continues to be limited by the number of available gastroenterologists to perform the exam and the lower number of gastroenterologist practices in locations convenient for minority screening candidates.7
By comparison, although less widely used than OC, CT colonography (CTC) presents fewer barriers to adoption in underserved communities. Despite the recommendations of the U.S. Preventive Services Task Force (USPSTF) to make CTC screening widely available to all eligible screening candidates, CMS does not currently reimburse for screening CTC unless the patient meets very specific criteria.8 In practice, however, this “one-size-fits-all” approach does not facilitate access to minority screening candidates and contributes to the healthcare disparities we are trying to overcome in the medical community.
Although CTC still requires bowel prep, CTC helps overcome many barriers to resistance. First, CTC does not require anesthesia. Second, the procedure takes approximately 20 minutes to perform, and screening candidates can resume normal activities or work immediately afterwards. Plus, CT scanners are widely available to a variety of patients regardless of zip code. For these reasons, CTC has been shown to increase screening percentages for some groups who are offered this option.6–8 Establishing a CTC program to optimize access has realistic potential to impact both CRC incidence and mortality disparities.
Optimizing the EHR
One tool that radiologists can enlist in their effort to improve access to CRC screening is the EHR system. Results from a 2017 survey indicated that 99% of hospitals and healthcare systems use EHRs.9 Many EHR systems can be programmed to identify patients who have not been screened for colon cancer when they present to a healthcare provider. Once identified, communication tools can educate and encourage minority screening candidates to schedule CRC screening via CTC.
Similarly, patient letters, email, or electronic patient portal messages have been used with some success in reaching minority breast cancer screening candidates.10 Building on this success, many healthcare systems are now consolidating these communication channels into centralized systems for health maintenance. The use of automated reminders to “nudge” physicians to order timely CRC screening for minority candidates has been shown to decrease the bias previously seen as a disparity in physician ordering practices.11
Radiologists can play a vital role in decreasing health disparities by extending access to CTC for minorities.
Also in line with breast and lung cancer screening programs, CTC makes use of evidence-based dedicated screening intervals and standardized follow-up strategies when it comes to handling abnormal results. Utilizing either established health maintenance modules or working with IT departments to build similar workflows to identify and contact unscreened candidates is possible with a modicum of effort.12
One major advantage of enlisting the EHR in these communications efforts is that if the proper permissions can be approved, the primary care provider (PCP) does not need to activate the screening visit. It is, however, always important to keep the PCP informed of findings and next actions. A recent article indicated that high patient satisfaction scores can be achieved by healthcare systems with automated navigation of patients for preventive oncology screening as opposed to direct involvement of a patient’s frequently over-taxed PCPs.13
Involving Patient Navigators
Although the EHR is an important tool in identifying eligible minority CRC screening candidates, its value can be accentuated when used in tandem with nurses, medical assistants, or even community health volunteers — also known as healthcare navigators — who bring a human element to shoring up healthcare disparities. For example, navigators can increase CRC screening uptake among underserved communities by calling unscreened candidates to schedule initial screens. This same approach can work for contacting patients to schedule follow-up appointments for abnormal screening results. Follow-up of abnormal results is another key step to decreasing CRC mortality.
Multiple studies have demonstrated success in achieving higher screening rates among minorities with the use of navigators. Surveys indicate that patients are satisfied, are better informed on expectations for follow-up visits, and have increased compliance with follow-up instructions.14 Several studies involving cancer screening have shown that employing patient navigators is an effective way to reduce the number of missed care opportunities and improve patient compliance with both initial screenings and follow-up care.15–17 Although navigators can prove relatively expensive, implementing a strategy to target candidates with higher rates of missed care opportunities can result in cost-effective savings for health systems focused on achieving a healthier population of “covered lives.”18
Beyond enlisting the help of navigators in the clinical setting, the use of community health volunteers as navigators may provide an additional opportunity to address the cultural fears and obstacles unique to specific minority populations. Barriers to CRC screening for minorities have included affected groups being less informed about options and lacking trust in healthcare systems in light of past injustices, such as the Tuskegee Study of untreated syphilis and the forced sterilization of Black patients.19–25 Community navigators may have already established trust with patients within their own communities and can prove vital to extending a CRC screening program’s reach.26
Despite having made great inroads, CTC is still not a widely used alternative for CRC screening. While this can be seen as suboptimal, it also presents an opportunity. Social media announcements, radio spots, church events, and other communication avenues can be used to educate both providers and minority communities about this option for CRC screening. In addition, the ACR offers an online locator tool (bit.ly/CTCFind) to help providers and patients find a nearby site offering CTC.
Radiologists can play a vital role in decreasing health disparities by extending access to CTC for minorities. As radiologists, most of us want to help ensure quality care across the board but have found it challenging to do so given that we don’t often interface directly with patients. This is one way to rewrite the script we’ve been given and help those most in need.