Moshe Shike

Lecture Abstract

Colorectal Cancer Screening in a Poor, Underserved, Minority Population

In spite of the proven efficacy of colorectal cancer screening (CRCS), no more than 50% of the United States population undergoes screening,1 in contrast to screenings for breast and cervical cancer which are utilized by a high percentage of women.2-3  Inadequate screening for colon cancer is even more pronounced in minority communities such as Harlem, NY, where the 5-year survival rate of CRC patients has been reported to be as low as 20%4 compared with the national average of 47-62%.5   This decreased survival rate is attributed to low rate of screening and late diagnosis.6  While women in general are more likely to participate in preventive healthcare, CRCS is still suboptimal in this group and far below the screening rates for cervical and breast cancer.  A random survey of New York's Harlem households from 1992-1994 showed that 80% of women age 50 to 65 have had a mammogram.3   A recent meta-analysis7 of interventions to promote screening mammography in populations with historically low rates of screening demonstrates that individualized, directed strategies (i.e., one-to-one counseling) in a healthcare setting resulted in a significant increase in utilization.  Similar findings were reported in CRCS.8 

We performed a study to determine the feasibility of offering CRCS to women at the time of mammography, thus eliminating the need for referral by a physician, and thereby removing a major barrier to CRCS.  The study was performed at the Breast Examination Center of Harlem, a community mammography center.  Women attending the community center for mammography were approached and offered the study which included an explanation about CRCS and facilitation in appointments for a colonoscopy.  The aims of the study were: 1) to determine the feasibility of using a community screening mammography center to recruit minority women from a low income community to undergo CRCS; 2) to identify individual level barriers (demographic, financial, psychosocial, awareness, and a lack of ability to navigate the medical system) to CRCS among minority women who are already participating in screening for another cancer (breast); 3) to determine the stage and pathology of neoplastic lesions found during screening colonoscopy among minority women recruited for CRCS at time of mammography.  

Of the 611 women who participated in this study, 92% were black or Hispanic, and 337 women (55%) proceeded to undergo screening colonoscopy. Many of these women were unlikely to undergo CRCS, given that most of them lacked medical insurance and access to routine medical care. Introducing them to CRCS through the mammography center and without a doctor's referral was effective. This approach is viable for similar women in the general population, since many women undergo mammography even in the absence of regular medical insurance.9    After a simple, short explanation of screening colonoscopy given by a nonprofessional (in this case a study assistant), women became interested in the procedure even in the absence of a doctor's referral. The most common barrier to CRCS was lack of medical insurance.  Alternatives to traditional medical insurance are needed for the uninsured.  The process of arranging the appointments for medical evaluation and colonoscopy clearly facilitated CRCS and increased participation.  The findings on screening colonoscopy were similar to those found in non-minority women.  Future programs designed in the context of this medical environment will enhance the participation of minorities in CRCS.

1. Increased use of colorectal cancer tests - United States, 2002 and 2004. MMWR. 2006:55(11):308-311.
2. Blackman DK, Bennett EM, Miller DS. Trends in self-reported use of mammograms (1989-1997) and Papanicolau tests (1991-1997)-Behavioral Risk Factor Surveillance System. MMWR. 1999;48(SS-6): 1-21.
3. Fullilove RE, Fullilove MT, Northridge ME, et al. Risk factors for excess mortality in Harlem. Findings from the Harlem Household Survey. Am J Prev Med. 1999;16 (3S): 22-28.
4. Freeman HP, Alshafie TA. Colorectal carcinoma in poor blacks. Cancer 2002;94:2327-2332.
5. Surveillance, Epidemiology, and End Results-National Cancer Institute. SEER Cancer Statistics Review 1973-1998 Colon and Rectum. www.seer.cancer.gov/publications.
6. Early colorectal cancer screening for African Americans. Lancet. 2009 ; 373 :980.
7. Legler J, Meissner HI, Coyne C, et al. The effectiveness of interventions to promote mammography among women with historically lower rates of screening. Cancer Epidemiol Biomarkers Prev 2002 Jan;11(1):59-71.
8. Chen LA, Santos S, Jandorf L, et al. A program to enhance completion of screening colonoscopy among urban minorities. Clin Gastro Hepato 2008;6:443-450.
9. Tangka FKL, Dalaker J, Chattopadhyay SK, et al. Meeting the mammography screening needs of underserved women: the performance of the National Breast and Cervical Cancer Early Detection Program in 2002-2003 (United States). Cancer Causes and Control. 2006;17:1145-154.

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