Addressing Barriers Contributing to Disparities in CRC Screening in Underserved Populations

Denalee O'Malley, PhD

Structural racism, income inequality, and geographic barriers can all contribute to disparities in colorectal cancer (CRC) screening and care in minority populations, according to Denalee O'Malley, PhD, who added that several strategies can be employed to improve screening rates in these patients, including the provision of resources and support to qualified health centers.

“The barriers are multilevel, but most of them can be resolved with additional resources. At the patient level, there are [barriers to] transportation, time off work, and access to appointments,” O’Malley, an assistant professor of family medicine and community health at Rutgers Robert Wood Johnson Medical School, said. “The centers at the clinic sites need test kits to be able to send to patients for first-line screening. They need personnel to prepare and mail them, postage, staff time to follow-up and coordinate both the abnormal and the positive results, and they need to [be able to] support patients in the transition to oncology [care].”

One strategy that is being used to improve screening rates in underserved communities is ScreenNJ, which partners with organizations like federally qualified health centers and others to provide resources, improve outreach and community education, support provider awareness, and strengthen peer support/patient navigation programming.¹

In a recent interview with OncLive^®, O'Malley, who is also a member of the Cancer Prevention and Control Program and a research member of the Cancer Health Equity Center of Excellence at Rutgers Cancer Institute of New Jersey, shed light on racial and ethnic disparities in CRC screening, and strategies that can be used to address existing barriers in the clinic and beyond.

OncLive^®: Could you discuss the research you are currently conducting in the realm of racial disparities in CRC screening and care?

O’Malley: I am currently working on a project funded by the National Cancer Institute called ‘Optimizing CRC Screening Among Patients with Diabetes in Safety-Net Primary Care Settings,’ to target implementation approaches. This study examines differences in the types of CRC screenings utilized by patients who receive most of their care in the community health-center system, which is the primary care safety net.

The goal is to identify and overcome barriers at multiple levels—the patient, the clinic, and the health system—that can all affect optimal use of CRC screening tests, and then develop strategies that can be implemented based on context-specific needs of clinics.

To expand a little, how can racial disparities affect CRC screening? What are some existing barriers to testing and appropriate care?

There is structural racism embedded in the healthcare delivery system, and the disparities that affect CRC screening are intersectional. Racism, income inequality, geographic disparities, and how healthcare is organized and deliveredall have an effect on CRC screening and care.

Multiple types of CRC screening tests [exist], which makes [this] more complicated, and they have different levels of efficacy and [need to be performed in] different intervals. For example, a FIT test needs to be administered every year. A colonoscopy, if the test comes back normal, has a 10-year interval, based on the current guidelines.

Community health centers are considered the primary care safety net. A little over 20% of community health center patient populations are uninsured, and the largest payer nationally in the community health setting is Medicaid.

When you use a first-line FIT test, there are multiple steps between an abnormal FIT test and a cancer diagnosis and transition to care. There is the screening itself, the cancer detection, the pathology report, and then, the transition to a cancer center or an oncologist. Barriers at the patient level can include not having a reliable telephone to get the [test result] information [returned to them], not being able to take off work to get a colonoscopy if the test is found to be abnormal, the inability to get an appointment that accommodates their schedule, and the need to get transportation if anesthesia is involved.

At the health-system level, there can be an insufficient number of specialists who offer the diagnostic tests at different centers. There can be there can be any constellation of these problems. In the study focused on patients with diabetes, there is also a cumulative risk involved with having another medical condition. Patients who have diabetes have a 27% greater lifetime risk of having CRC. Diabetes disproportionately affects the Hispanic and African-American population, and in the in the community health-center setting, we see a much larger proportion of uncontrolled diabetes than you would in a traditional primary-care setting. What that means in the care space is that if a patient comes in with an acute health need, preventative health needs might take a backseat.

How can some of these barriers be addressed?

Within the medical neighborhood, the resources that the clinics need [include] receptive diagnostic centers and oncology colleagues who they can transition patients to who are in need diagnostic workups or cancer care.

What strategies are needed to help improve CRC screening in high-priority populations to prevent loss of life?

These are contextually bound strategies. The answer lies in partnering with different types of community health centers, seeing what the barriers are, and coming up with strategies that fit the needs of the context. This requires a partnership between researchers, community members, community health-center staff, and clinicians who are the experts on how their organization operates and the barriers that they face.

How can your colleagues in the community work to better address existing disparities to help close the gap?

Awareness about prevention and clear messaging is important. We are living in a time where misinformation is abundantly available. [Ensuring] that we have outlets in the community that can provide patients with reliable information about the benefits of screening is important.

[We also need] to develop creative solutions, based in the community, for the barriers that [these] populations face. [Some of these] can be universal; we [may] see [some of them] across different sites, but others may be different. Some places have an environment that has better transportation, so that may not be an issue in 1 place and a huge barrier in another.

The other piece is to be more mindful about what we accept as a normal course of business and interrogate why we do things the way we do them. [We need to ask ourselves, who] is this intervention benefiting and who is it potentially leaving out? Those are ways that we can do a better job at closing that gap.

How pivotal is screening in terms of diagnosis and outcomes in CRC?

With most prevention, the famous slogan to follow is ‘An ounce of prevention is worth a pound of cure.’ CRC is a clear example of that. If CRC was prevented, such as removing a polyp [prior to diagnosis], the potential life saved would be 6.5 years on average. The main takeaway is that [screening and treatment of CRC] is all connected. Our primary care system and its strength affect what we see later down the road in cancer care.

This is all connected in the sense that a patient who comes in for cancer care comes as a whole person who has other illnesses. Since cancer is generally a condition of the aging, chances of someone coming to a cancer diagnosis with chronic illness matters and affects that journey. We need to be intentional about that earlier in the care pathway because we could be more intentional about preventing what can be more cumulative risks as someone lives longer.

Reference

Exploring racial and ethnic disparities in colorectal cancer screening. Rutgers Cancer Institute of New Jersey website. March 1, 2022. Accessed May 19, 2022. https://bit.ly/3LA8Sam