Sherri Sheinfeld Gorin, PhD, FSBM
This recent systematic review of interventions to increase stool blood colorectal cancer screening in African Americans raises some important clinical implications for primary care. The adage that the “best cancer screening test is the one that the patient will complete” is relevant to their findings about the continued uptake of the fecal occult blood test among African Americans.
While colonoscopy remains the gold standard for diagnosis, it is only one of several robust routine screening tests recommended by the USPSTF. However, colonoscopy is often not accessible as first-line screening; it requires bowel preparation, access to in-person specialists and sedation procedures that are not equally distributed across communities; the screening may be expensive and can lead to complications. Also, in-office preventive visits can be markedly reduced (or stopped) during pandemics like COVID-19, and patients may be too afraid of the infection risks to make appointments for care. We have found that, even during the pandemic, patients continued to use home-based colorectal cancer screening tests, however. Home stool tests, including the fecal occult blood test (gFOBT) fecal immunochemical test (FIT) and fecal immunochemical test-DNA (FIT-DNA) should remain first-line screening tests. In under-resourced communities, where completing cancer screening competes with daily challenges of food and housing insecurity, increasing access to colorectal screening by using home-based approaches becomes critical. Further, screening interventions are more effective, particularly in under-resourced communities, when they target barriers at the patient, provider and health system levels.
In my research team’s studies of colorectal cancer screening among racially/ethnically diverse urban residents in under-resourced communities, we have implemented multi-component interventions that educate primary care physicians and their staff, as well as provide audit and feedback on patient screening uptake. Our interventions have increased colorectal cancer screening. As a tailored educational approach to the physicians, we have used academic detailing with brief, tailored, repeated messages that are designed to overcome the barriers to screening uptake. We have worked with offices to alter workflow processes to increase patient screening uptake; for example, through electronic and chart prompts, and mailed reminders to patients. We have helped office staff to develop and share targeted educational materials for patients, as well as to identify gastroenterologists who accept Medicare in the local community, among other intervention components. In addition, patient navigation has been implemented in some of the primary care offices that we have studied.
Prompt diagnosis and follow-up after a positive screen for colorectal cancer is a crucial step in reducing morbidity and mortality, notably among African Americans. While the physicians’ office is a common focus of efforts to reduce diagnostic delay, the patient, too, could be prompted (with an app, for example) for follow-up. Recently, I wrote in Annals of Family Medicine about some important policy approaches, including implementing standards across health care systems to reduce total diagnostic delay to 90 days or less. These approaches, when combined with multi-level physician/provider team and patient-directed interventions to increase screening and follow-up, could begin to reduce the scourge of this largely preventable cancer.
References:
Sherri Sheinfeld Gorin, PhD, FSBM
Research professor, department of family medicine
The University of Michigan School of Medicine
Member, Rogel Cancer Center
University of Michigan
Director, New York Physicians Against Cancer (NYPAC)
Disclosures: Gorin reports no relevant financial disclosures.
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Mailed tests, follow-up calls increase colorectal cancer screening among African Americans - Healio
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