Evaluating Barriers to Screening for Alaska Native People
Over the past several years, our research at the Alaska Native Tribal Health Consortium has explored CRC screening and prevention among Alaska Native people. The valuable insights that we have derived from serving this unique population can inform the development of innovative screening solutions for others who live in rural locations.
We recently conducted a cross-sectional survey in which our primary objective was to learn more about patient and provider preferences in CRC screening, specifically those relative to colonoscopy and a multitarget stool-DNA (mt-sDNA) test commercially known as Cologuard®, which is intended for CRC screening use in average-risk adults aged 45 years and older.16 Cologuard is not a replacement for colonoscopy in high-risk patients. We also examined test-specific barriers that impede patient screening.
From July 2017 through September 2017, we surveyed 3 remote Alaska Tribal health regions through a mailed and online survey. A total of 1616 Alaska Native patients (of 8580 patients with valid addresses), aged 40 years to 75 years, participated in the survey. Eighty-seven providers (of 331) also participated.
Our survey of Alaska Native patients yielded the following results:
- One-fifth of screening-eligible patients had never heard of CRC screening tests and had never been screened.14
- Men were more likely than women to report that they did not know where to go to access screening services (21% vs 14%, respectively).14
These results demonstrate the continued need to educate patients about the importance of the early detection of CRC. Open conversations about different CRC screening options may also help to raise awareness and subsequently improve screening rates.
Another outcome of our analysis was to gain insight into the perceived patient and provider barriers to mt-sDNA and colonoscopy. A critical finding from this study was the substantial difference in barriers to screening reported by Alaska Native patients compared with their providers’ perceptions. The providers we surveyed felt that fear of pain and test invasiveness would be the 2 primary factors preventing people from pursuing colonoscopy. Although fear of pain was the third main deterrent listed by patients, the top 2 barriers reported were bowel preparation and travel.14
Applying these survey results may help reduce barriers to CRC screening. By improving providers’ understanding of the hurdles that patients face, we can develop more impactful solutions to help increase screening rates.
Importance of At-Home Screening Options
At-home screening tests may help address the top 3 barriers to screening colonoscopy reported by patients in this study because these tests do not require travel, bowel preparation, or invasive procedures. In our survey of Alaska Native people, more than half (58%) of respondents preferred colonoscopy for CRC screening vs mt-sDNA (36%).Unscreened patients were more likely to prefer the mt-sDNA test compared with those who had been previously screened (42% vs 31%, P <.05). Providers were willing and open to recommending the mt-sDNA test and felt that offering this alternative could improve CRC screening rates in the Alaska Native population.14
According to the 2016 United States Preventive Services Task Force (USPSTF) guidelines, “the best test is the one that gets done.” 6 Presenting patients and providers with options that they feel comfortable completing can improve CRC screening adherence and help us make progress against this disease.6
At-home tests may also improve patient access and minimize travel barriers when made available via telehealth.17 We have seen an encouraging increase in telehealth options for a wide variety of health care needs during the COVID-19 pandemic, and CRC screening may benefit from this growing trend.
Understanding more about the barriers that patients face, as well as the increasing availability of at-home screening tests, can facilitate the provision of tools to improve screening for Alaska Native people and others who live in medical deserts and underserved areas. Everyone deserves access to CRC screening to help reduce the burden of this preventable disease.
See Cologuard.com for important risk information. Available by prescription only.
Diana Redwood, PhD, is a senior epidemiologist at the Alaska Native Tribal Health Consortium. She has consulted previously with Exact Sciences but did not receive any compensation from Exact Sciences for writing this column.
- London JW, Fazio-Eynullayeve E, Palchuk MB, Sankey P, McNair C. Effects of the COVID-19 pandemic on cancer-related patient encounters. JCO Clin Cancer Inform. Published online July 27, 2020. doi:10.1200.CCI.20.00068
- Jones RM, Devers KJ, Kuzel AJ, Woolf SH. Patient-reported barriers to colorectal cancer screening: a mixed-methods analysis. Am J Prev Med. 2010;38(5):508-516. doi:10.1016/j.amepre.2010.01.021
- Wang H, Roy S, Kim J, Farazi PA, Siahpush M, Su D. Barriers of colorectal cancer screening in rural USA: a systematic review. Rural Remote Health. 2019;19(3):5181. doi:10.22605/RRH5181
- Henley SJ, Jemal A. Rural cancer control: bridging the chasm in geographic health inequity. Cancer Epidemiol Biomarkers Prev. 2018;27(11):1248-1251. doi:10.1158/1055-9965.EPI-18-0807
- Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018;68(4):250-281. doi:10.3322/caac.21457
- Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(23):2564-2575. doi:10.1001/jama.2016.5989
- Rex DK, Boland CR, Dominitz JA, et al. Colorectal cancer screening: recommendations for physicians and patients from the U.S. Multi-Society Task Force on colorectal cancer. Am J Gastroenterol. 2017:112(7):1016-1030. doi:10.1038/ajg.2017.174
- National Cancer Institute. SEER Cancer Stat Facts: Colorectal Cancer. https://seer.cancer.gov/statfacts/html/colorect.html. Accessed September 22, 2020.
- ACS. Survival Rates for Colorectal Cancer, by Stage. https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/survival-rates.html. Accessed September 22, 2020.
- Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterol. 1997;112(2):594-642. doi:10.1053/gast.1997.v112.agast970594
- Siegel RL, Miller KD, Goding Sauer A, et al. Colorectal cancer statistics, 2020. CA Cancer J Clin. 2020;70(3):145-164. doi:10.3322/caac.21601
- Sharpless N. COVID 19 and cancer. Science. 2020;6497(368):1290. doi:10.1126/science.abd3377
- ACS. Colorectal cancer facts and figures 2020-2022. Atlanta: American Cancer Society; 2020.
- Redwood DG, Blake ID, Provost EM et al. Alaska Native patient and provider perspectives on the multitarget stool DNA test compared with colonoscopy for colorectal cancer screening. J Prim Care Community Health. 2019;10:2150132719884295. doi:10.1177/2150132719884295
- CDC. Quick facts colorectal cancer (CRC) screening in Alaska. 2016 Behavioral Risk Fact Surveillance System. https://www.cdc.gov/cancer/ncccp/screening-rates/pdf/colorectal-cancer-screening-alaska-508.pdf. Accessed September 10, 2020.
- Cologuard Physician Brochure. Exact Sciences Corporation. Madison, WI.
- Dobrusin A, Hawa F, Gladshteyn M, et al. Gastroenterologists and patients report high satisfaction rates with telehealth services during the novel coronavirus 2019 (COVID-19) pandemic. Clin Gastroenterol Hepatol. 2020;18(11):2393-2397. doi:10.1016/j.cgh.2020.07.014