Addressing Barriers to Colorectal Cancer Screening in Rural Populations

Dr. Buch:

This is Clinician’s Roundtable on ReachMD. I’m Dr. Peter Buch, and joining me to discuss strategies for improving colorectal cancer screening rates in rural populations is Dr. Michael Dougherty. He’s an Adjunct Assistant Professor in the Division of Gastroenterology and Hepatology at the University of North Carolina School of Medicine. Dr. Dougherty, welcome to the program. 

Dr. Dougherty:

Thanks for having me, Dr. Buch. Glad to be here. 

Dr. Buch:

Let’s dive right in, Dr. Dougherty. What barriers do patients in rural communities face when considering colorectal cancer screening? 

Dr. Dougherty: 

Some communities tend to be poorer and not be able to afford expensive tests like colonoscopy, especially if they’re uninsured. And the distance that folks have to travel to get a procedure like colonoscopy—or even see their providers—and less provider density per capita are probably the biggest barriers. There may be lower levels of education and a variety of other factors. 

Dr. Buch: 

And how has mailed fecal immunochemical testing, or FIT, outreach improved screening rates? 

Dr. Dougherty: 

The way that it improves screening rates is it takes screening from being opportunistic to being programmatic and reaching people despite the fact that they don’t have to come into the office. So it has, in meta-analyses, between two to three times increased the rate of completing a colon cancer screening test. It’s a relative increase, and that’s pretty well established. And so it reaches people who don’t come into the office and inquire about screening or their provider doesn’t necessarily offer it when they’re there. It allows them to do it in their home rather than come to a facility. 

Dr. Buch: 

So from my understanding, if a patient does receive a positive result from the FIT test, they may come across challenges when seeking follow-up care. Could you break those down for us?

Dr. Dougherty: 

Yeah, absolutely. So I think it gets people in the door and reaches more people who either may not have done a colonoscopy for some real financial barrier or maybe a preference. There’s definitely people who prefer stool-based tests. But it is a two-step screening test, so if you just do the stool-based test and it’s positive, that’s not actually a completed screening cascade as we like to call it. So you have to get the follow-up definitive test, which is usually a colonoscopy, and that’s generally the tougher thing to do.

Now, the benefit of doing a stool-based outreach is that you reach a broader number of people, and then you select down this higher-risk group of the positives that are more likely to have something and are worth investing more resources in to get to a full colonoscopy. So as most of us know, it can be a little bit of a burden to do a colonoscopy. You’ve got the prep, which if patients are not familiar with, they may be thrown off by having to drink that solution and have all those bowel movements. Then, you have to have transportation generally for sedated colonoscopy, including maybe another person who has to take off work to do that, and then find the center, get there on time, and all sorts of things that end up being obstacles for specific patients. So the journey only begins with the mailed test, and there’s a lot to do on the back end, but it’s probably worth it for somebody who has had a positive test. 

Dr. Buch: 

For those just tuning in, you’re listening to Clinician’s Roundtable on ReachMD. I’m Dr. Peter Buch, and I’m speaking with Dr. Michael Dougherty about how we can improve colorectal cancer screening adherence in rural communities.

So Dr. Dougherty, let’s talk for a moment about patient navigation. How can it help address challenges with follow-up care? 

Dr. Dougherty: 

Well, the benefit of patient navigation is there’s a couple programs that have tried to use AI and automated ways to do “navigation,” but traditionally, it’s thought of as a personal outreach that’s tailored to the patient and their specific barriers, and it’s trying to address multiple barriers. And so all those things that we discussed—questions with the prep, questions with the diet before colonoscopy, questions with medications, addressing the transport barrier, how to get to the procedure—all those things that come up so often are proactively addressed by a navigator. So we have a lot of no-shows or cancellations to colonoscopies because patients say, “Well, I never got the prep,” or “I forgot about it,” or “It didn’t work out,” or “I didn’t have a ride.” And so if you have a known hard-to-reach population that you know you’re going to have a lot of these issues come up, you can have a navigator for those patients to actually get to the procedure, especially if it’s the population of positive FITs who you really want to get to this procedure. They go ahead and address those proactively.

And also educationally, understanding, “Why are you doing this?” We’re trying to prevent colon cancer by removing polyps or detecting it early, and there’s a lot of fear. Is it going to hurt? It’s a sensitive area. There’s denial, other barriers, and even mental barriers that patients have to get over. Trained navigators can navigate those obstacles, provide education, and provide resources to get the patient to complete the screening. And it’s just more important for populations that have more of those barriers, don’t live right next to a center, and have a lot of financial resources to get there. 

Dr. Buch: 

Thank you. As we come to the end of our program, Dr. Dougherty, what future research directions or interventions should we keep an eye out for? 

Dr. Dougherty: 

Things that make colon cancer screening easier are always welcome. And in this specific space, improving colonoscopy access—especially for these higher-yield patients, like with positive stool tests—refining navigation interventions to define the populations who most benefit, and also defining the interventions that are most efficient use of our precious human resources in healthcare are some questions that still need some work. And then not necessarily research but just policy changes to get these programs funded and implemented. 

Dr. Buch: 

I’d like to thank my guest, Dr. Michael Dougherty, for joining me to discuss strategies for enhancing colorectal cancer screening in rural populations. Dr. Dougherty, it was great having you here with us today. 

Dr. Dougherty: 

It was great to be here.

Dr. Buch: 

For ReachMD, I’m Dr. Peter Buch. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening.