American Gastroenterological Association - Advancing the Science and Practice of Gastroenterology

Increasing CRC Screening in Minorities and Disadvantaged Populations: Our Success Story

Steven H. Itzkowitz, MD, AGAF, FACP, FACG Professor of Medicine; Director, GI Fellowship Program, Mount Sinai School of Medicine, New York, NY

Lina Jandorf Associate Professor, Department of Oncological Sciences, Mount Sinai School of Medicine, New York, NY

For many different diseases, racial and ethnic minority populations are less likely, compared to non-minorities, to receive equal health care.¹ Indeed, when it comes to colorectal cancer (CRC), disparities have been reported for all aspects of the disease, including screening, incidence and mortality. For example, while CRC mortality has declined by 39 percent among whites since 1960, mortality among African Americans has increased by 28 percent.² This is particularly unfortunate, given how effective CRC screening tests are. By achieving high CRC screening rates among all segments of the population, we should conceivably be able to dramatically lower CRC incidence and mortality rates.

3 However, this progress has not yet eliminated disparities. For example, Doubeni et al. used the Medicare current beneficiary survey of Medicare enrollees aged 65 to 80 years to analyze CRC screening rates for African Americans and whites between 2000 and 2005.⁴ Despite overall improvement in screening rates, disparities persisted over the six-year period, with screening rates among whites versus African Americans reported to be 49 versus 41 percent (in 2000), 52.8 versus 49.6 percent (in 2003) and 56.6 versus 52 percent (in 2005). The overall increase in screening has been partially credited to greater awareness on the part of physicians and patients, as well as the many interventions that have been developed to increase CRC screening.⁵

 

Since 2002, our research group has been developing ways to increase CRC screening (see sidebar) for minority and disadvantaged populations, primarily lowincome African Americans and Latinos living in the East Harlem, New York City urban area served by The Mount Sinai Hospital.^{6, 7} Although several types of CRC screening tests are available, our focus has been on colonoscopy as the preferred screening approach. We began by implementing a direct endoscopy referral system whereby primary care providers could refer patients for screening colonoscopy without an intervening office visit. With this in place, we then hired a patient navigator. At that time, patient navigation had just been introduced as a way of helping women with abnormal breast and cervical cancer screening tests get appropriate care, but not for getting women screened. Given the complexities of preparing for and completing a colonoscopy, we decided to implement patient navigation for screening colonoscopy. Before we introduced patient navigation in our publicly insured population, our colonoscopy completion rate was only 40 percent. By implementing both direct referrals and patient navigation, we achieved a completion rate of 68 percent by 2007.

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In the past several years, we have added a culturally targeted component to our navigation process. This involves both ethnically matching our patient navigators to our patients and specifically addressing cultural issues in both the African American and Latino patients. We now find that our colonoscopy completion rates have increased to almost 80 percent.

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Moreover, our research has demonstrated that we can successfully train lay people from the surrounding community to serve as peer patient navigators (volunteers who are older than 50 years old and have had their own colonoscopies) with excellent results.

 

At the same time that we were pursuing patient navigation at our institution, the New York City Department of Health and Mental Hygiene, under the direction of Health Commissioner Thomas Frieden, MD, launched public campaigns and implemented patient navigation systems in many of the New York City area hospitals in an effort to increase colonoscopy screening rates and reduce racial/ethnic disparities. In 2003, low rates of screening, as well as disparities, were noted, with only 24 percent of Asian and Pacific Islanders, 36 percent of African Americans, 38 percent of Latinos and 48 percent of whites having had a colonoscopy. After this concerted citywide effort to screen all New Yorkers over the age of 50, by 2009, screening colonoscopy rates had increased to approximately 62 percent, with virtual elimination of disparities between all these ethnic groups (although rates among Asian and Pacific Islanders have lagged slightly behind the other groups).⁸

Of course, the best CRC screening test is the one that gets done, and gets done well. No doubt, the factors contributing to CRC screening disparities are complex. Still, each institution must assess its resources and the patient population it serves to determine which approaches are appropriate. For example, in areas where colonoscopy resources are limited, screening with a non-invasive stool-based test may be appropriate. Either way, there is now ample precedence that a concerted effort can increase CRC screening rates and reduce disparities. In this way, we should be able to equalize quality health care for all.

1. Smedley BD, Stith AY, Nelson AR. Unequal Treatment:Confronting Racial and Ethnic Disparities in Healthcare. 2003. Institute of Medicine.

2. Soneji S, Lyer SS, Armstrong K, Asch DA. Racial Disparities in Stage-Specific Colorectal Cancer Mortality:1960-2005. American Journal of Public Health 2010 October;100(10):1912-6.

3. Centers for Disease Control and Prevention. Vital Signs:Colorectal Cancer Screening Among Adults Aged 50--75 Years --- United States, 2008 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm59e0706a1.htm. 2008.

4. Doubeni CA, Laiyemo AO, Reed G, Field TS, Fletchers RH. Socioeconomic and Racial Patterns of Colorectal Cancer Screening among Medicare Enrollees in 2000 to 2005. Cancer Epidemiology Biomarkers & Prevention 2009 August;18(8):2170-5.

5. Pignone M, Lewis C. Improving Colorectal Cancer Screening in 2011:Comment on "Patient Outreach to Promote Colorectal Cancer Screening Among Patients With an Expired Order for Colonoscopy." Archives of Internal Medicine 2011 April 11;171(7):647-8.

6. Chen LA, Santos S, Jandorf L et al. A program to enhance completion of screening colonoscopy among urban minorities. Clinical Gastroenterology and Hepatology 2008 April;6(4):443-50.

7. Jandorf L, Stossel L, Itzkowitz S et al. Implementation of Culturally Targeted Patient Navigation System for Screening Colonoscopy. Medical Care, Under Review 2011.

8. Krauskopf MS. 2009 C5 Summit Presentation. 2009.