Strategies for expanding colorectal cancer screening at community health centers

Community Health Centers' Performance in Cancer Screening and Prevention

INTRODUCTION

Little is known about what clinic-level factors differentiate community health centers that achieve high performance on cancer-preventive care metrics. This study aims to describe the longitudinal trends in the delivery of 3 cancer-preventive care metrics (cervical and colorectal cancer screenings and tobacco-cessation intervention) and define and compare community health centers with high cancer-preventive care performance with those with low cancer-preventive care performance.

METHODS

This observational study used 2012-2019 community health center data (N=933) from the Uniform Data System. High/low performance was based on Healthy People 2020 targets and sample distribution. For each cancer-preventive care metric, the percentage of community health centers that met high (≥70.5% at cervical or colorectal cancer screening or >80% tobacco-cessation intervention) and low thresholds at 1, 2, and all the 3 screenings was estimated. Multivariable generalized estimating equations logistic regression modeling was used to assess the community health center‒level factors associated with screening performance.

RESULTS

The community health centers' performance for tobacco-cessation intervention remained at ≥80%, with a small increase over time. Performance for cervical cancer screening remained unchanged with about 50% of patients screened. Colorectal cancer screening performance increased from around 30% in 2012 to 44% in 2019. Very few community health centers reached high performance (3%) in all the 3 indicators, and 13% of community health centers were high in any 2 of the outcomes in 2019. Higher patient volume, a greater proportion of Hispanic patients, fewer uninsured patients, and community health centers located in the Northeast region were associated with high performance in 2019.

CONCLUSIONS

Very few community health centers meet all Healthy People 2020 goals in cancer screenings and may struggle to achieve the 2030 goals. Very few indicators differentiated high performers from low performers.

Association of Primary and Specialty Care Integration on Physician Communication and Cancer Screening in Safety-Net Clinics

INTRODUCTION

Primary care providers who lack reliable referral relationships with specialists may be less likely than those who do have such relationships to conduct cancer screenings. Community health centers (CHCs), which provide primary care to disadvantaged populations, have historically reported difficulty accessing specialty care for their patients. This study aimed to describe strategies CHCs use to integrate care with specialists and examine whether more strongly integrated CHCs have higher rates of screening for colorectal and cervical cancers and report better communication with specialists.

METHODS

Using a 2017 survey of CHCs in 12 states and the District of Columbia and administrative data, we estimated the association between a composite measure of CHC/specialist integration and 1) colorectal and cervical cancer screening rates, and 2) 4 measures of CHC/specialist communication using multivariate regression models.

RESULTS

Integration strategies commonly reported by CHCs included having specialists deliver care on-site (80%) and establishing referral agreements with specialists (70%). CHCs that were most integrated with specialists had 5.6 and 6.8 percentage-point higher colorectal and cervical cancer screening rates, respectively, than the least integrated CHCs (P < .05). They also had significantly higher rates of knowing that specialist visits happened (67% vs 42%), knowing visit outcomes (65% vs 42%), receiving information after visits (47% vs 21%), and timely receipt of information (44% vs 27%).

CONCLUSION

CHCs use various strategies to integrate primary and specialty care. Efforts to promote CHC/specialist integration may help increase rates of cancer screening.

Impact of COVID-19 on colorectal cancer disparities and the way forward

In response to the coronavirus disease 2019 (COVID-19) pandemic, the U.S. Surgeon General advised all hospitals and ambulatory care centers to delay nonurgent medical procedures and surgeries. This recommendation, echoed by a multigastroenterology society guideline, led to the suspension of colonoscopies for colorectal cancer (CRC) screening and surveillance. Although this temporary suspension was necessary to contain COVID-19 infections, we as gastroenterologists, patient advocates, and CRC researchers have witnessed the downstream impact of COVID-19 and this recommendation on CRC screening, research, and advocacy. These effects are particularly noticeable in medically underserved communities where CRC morbidity and mortality are highest. COVID-19-related pauses in medical care, as well as shifts in resource allocation and workforce deployment, threaten decades worth of work to improve CRC disparities in medically underserved populations. In this perspective, we present the unique challenges COVID-19 poses to health equity in CRC prevention and provide potential solutions as we navigate these uncharted waters.

Feasibility of Patient Navigation and Impact on Adherence to Screening Colonoscopy in a Large Diverse Urban Population

INTRODUCTION

Disparities observed in colorectal cancer (CRC) incidence and mortality among blacks and Hispanics compared with whites may be in part due to lower screening rates. The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) has implemented a patient navigator (PN) program at NYC hospitals serving lower-income patients to promote high adherence by patients referred for screening colonoscopy. A prior study showed this PN program increased adherence at 3 public hospitals. The aim of this study was to determine the feasibility of expanding the PN program to 10 hospital sites by assessing the impact of the PN program on adherence to screening colonoscopy in a large, urban, lower-income population.

METHODS

Data were collected from 2007 through the first quarter of 2012 from PN sites. One site also contributed data from the pilot phase of the project, from 2005 to 2006. Adherence to scheduled screening colonoscopy among those ≥ 50 years was assessed among 10 hospital sites in NYC participating in the colonoscopy PN program.

RESULTS

Among the 37,077 asymptomatic adults ≥ 50 years who were scheduled for a screening colonoscopy from 2005 to the first quarter of 2012, 84.2% (83.2% of black, 84.9% of Hispanic, and 87.5% of white adults) were adherent to scheduled colonoscopy.

CONCLUSIONS

Expansion of PN programs to navigate all patients referred for a colonoscopy was feasible in a large, urban setting. This can be implemented resulting in high overall adherence rates to screening colonoscopies. The program likely did not result in large ethnic disparities.

The National Colorectal Cancer Roundtable: Past Performance, Current and Future Goals

The National Colorectal Cancer Roundtable (NCCRT) is an organization of organizations with staffing, funding and leadership provided by the American Cancer Society (ACS) and guidance and funding by the Centers for Disease Control and Prevention (CDC). In 2014, ACS, CDC, and the NCCRT launched the 80% by 2018 campaign. This highly successful initiative activated hundreds of organizations to prioritize colorectal cancer screening, disseminated smart, evidence-based interventions, and ultimately led to 9.3 million more Americans being up to date with screening compared with the precampaign rate. It's new campaign, 80% in Every Community, is designed to address persistent screening disparities.

A novel plasma based early colorectal cancer screening assay base on methylated SDC2 and SFRP2

BACKGROUND

Methylated SFRP2 was previously reported as a non-invasive biomarker for colorectal cancer (CRC) detection with a relatively low sensitivity for early stage CRC. The purpose of this study was to evaluate the performance of a new plasma based CRC screening assay, SpecColon test, which tested methylated SFRP2 and SDC2 simultaneously in a single qPCR reaction, in detecting CRC and advanced adenomas (AA).

METHOD

One milliliter plasma of 122 CRC patients, 12 AA patients, 93 patients with benign polyps, and 91 normal individuals were collected from the Affiliated Hospital of Xuzhou Medical University, and all samples were examined by SpecColon test.

RESULTS

The sensitivities for detecting AA and CRC by methylated SFRP2 alone were 50.0% (95% CI: 22.2-77.7%) and 63.1% (95% CI: 53.9-71.5%) with a specificity of 90.1% (95% CI: 81.6-95.1%). The sensitivities by methylated SDC2 alone were 33.3% (95% CI: 11.3-64.6%) and 56.6% (95% CI: 47.3-65.4%) with a specificity of 95.6% (95% CI: 88.5-98.6%). However, when methylated SFRP2 and methylated SDC2 were combined, the sensitivities for AA and CRC detection improved to 58.3% (95% CI: 28.6-83.5%) and 76.2% (95% CI: 67.5-83.3%) with a specificity of 87.9% (95% CI: 79.0-93.5%). The positive detection rates of benign polyp group and normal control group showed no significant difference (p > 0.01), whereas AA and CRC groups had significantly higher positive detection rates than normal individual group (p < 0.001).

CONCLUSION

The sensitivities for AA and early stage CRC by combined test of methylated SFRP2 and methylated SDC2, the so called SpecColon test, improved upon those by either biomarker alone without significant impact on the specificity. It has the potential to become a powerful, convenient and highly effective screening tool for early CRC screening.

Race, Poverty, and Mental Health Drive Colorectal Cancer Screening Disparities in the Veterans Health Administration

INTRODUCTION

Colorectal cancer (CRC) is a common but largely preventable malignancy. Screening is recommended for all adults aged 50-75 years; however, screening rates are low nationally and vary by patient factors and across health care systems. It is currently unknown whether there are inequities in CRC screening rates by patient sociodemographic and/or clinical factors in the Veterans Health Administration (VA) where the majority of patients are CRC screening-eligible age and CRC is the third most commonly diagnosed cancer.

METHODS

We performed a retrospective cohort study using VA national clinical performance and quality data to determine the overall CRC screening rate, rates by patient sociodemographic and clinical factors, and predictors of screening adjusting for patient and system factors. We also determined whether disparities in screening exist in VA.

RESULTS

The overall CRC screening rate in VA was 81.5%. Screening rates were lowest among American Indians/Alaska Natives [75.3%; adjusted odds ratio (aOR)=0.77, 95% confidence interval (CI)=0.65-0.90], those with serious mental illness (75.8%; aOR=0.65, 95% CI=0.61-0.69), those with substance abuse (76.9%; aOR=0.76, 95% CI=0.72-0.80), and those in the lowest socioeconomic status quintile (79.5%; aOR=1.10-1.31 for quintiles 2-5 vs. lowest quintile 1). Increasing age, Hispanic ethnicity, black race, Asian race, and high comorbidity were significant predictors of screening uptake.

CONCLUSIONS

Many racial/ethnic disparities in CRC screening documented in non-VA settings do not exist in VA. Nonetheless, overall high VA CRC screening rates have not reached American Indians/Alaska Natives, low socioeconomic status groups, and those with mental illness and substance abuse. These groups might benefit from additional targeted efforts to increase screening uptake.

Correlates of colorectal cancer screening rates in primary care clinics serving low income, medically underserved populations

INTRODUCTION

Screening for colorectal cancer (CRC) is effective in reducing CRC burden. Primary care clinics have an important role in increasing screening. We investigated associations between clinic-level CRC screening rates of the clinics serving low income, medically underserved population, and clinic-level screening interventions, clinic characteristics and community contexts.

METHODS

Using data (2015-16) from the Centers for Disease Control and Prevention's (CDC) Colorectal Cancer Control Program, we linked clinic-level data with county-level contextual data from external sources. Analysis variables included clinic-level CRC screening rates, four different evidence-based interventions (EBIs) intended to increase screening, clinic characteristics, and clinic contexts. In the analysis (2018), we used weighted ordinary least square multiple regression analyses to associate EBIs and other covariates with clinic-level screening rates.

RESULTS

Clinics (N = 581) had an average screening rate of 36.3% (weighted. Client reminders had the highest association (5.6 percentage points) with screening rates followed by reducing structural barriers (4.9 percentage points), provider assessment and feedback (3.2 percentage points), and provider reminders (<1 percentage point). Increases in the number of EBIs was associated with steady increases in the screening rate (5.4 percentage points greater for one EBI). Screening rates were 16.4 percentage points higher in clinics with 4 EBIs vs. no EBI. Clinic characteristics, contexts (e.g. physician density), and context-EBI interactions were also associated with clinic screening rates.

CONCLUSIONS

These results may help clinics, especially those serving low income, medically underserved populations, select individual or combinations of EBIs suitable to their contexts while considering costs.

Genetic variants in SLC22A3 contribute to the susceptibility to colorectal cancer

Previous a genome-wide association study (GWAS) of colorectal cancer in Japanese population has identified a risk region at the chromosome 6q26-q27 associated with colorectal cancer risk. However, the causal gene at this locus remained unclear. In our study, we enrolled a total of 14 candidate functional single nucleotide polymorphisms (SNPs) at 6q26-q27 (318 kb), and then genotyped them by TaqMan method in a Chinese population including 1,147 colorectal cancer cases and 1,203 controls. Among that, 5 SNPs were identified statistical association with colorectal cancer risk by logistic regression analysis. Of which, SNP rs420038 G > A in SLC22A3 was related to decreased risk of colorectal cancer (adjusted odds ratio (OR) = 0.79, 95% confidence interval (CI) = 0.67-0.94, p = 0.007), and also associated with lower expression of SLC22A3 (p = 0.040) using expression quantitative trait loci (eQTL) analysis. Moreover, by the luciferase assays, we found that compared to the G allele of rs420038, the A allele could suppress the activity of the promoter in SLC22A3. Furthermore, the expression of SLC22A3 was significantly higher in colorectal cancer tissues than that in paired normal tissues (p < 0.001). Meanwhile, the phenotypes of proliferation, migration, invasion, cell cycle and apoptosis of colorectal cancer cell were significantly affected by SLC22A3 in vitro. Our results revealed a novel susceptible locus, rs420038 in SLC22A3, which may be involved in colorectal cancer development and progression.

Predictors of Colorectal Cancer Screening Prior to Implementation of a Large Pragmatic Trial in Federally Qualified Health Centers

Colorectal cancer screening can prevent cancer deaths. Federally qualified health centers serve a unique patient population that often is not screened. Knowing who in this environment is getting screened via fecal testing and via colonoscopy can assist in tailoring intervention to raise rates of colorectal cancer screening. We examined patient-level and neighborhood-level characteristics associated with being up to date with colorectal cancer screening guidelines. We also examined associations between these factors and being screened with a fecal test. We observed an increase in colorectal cancer screening rates from 2010 to 2015. Adjusted analyses revealed that the following factors were significantly associated with colorectal cancer screening: aged 65 or older, having any type of insurance, previous outpatient visits, and current or other preventive screenings. Among adults aged 50-75 who were up to date with colorectal cancer screening, factors associated with use of fecal testing, as opposed to colonoscopy, were: being younger, speaking a non-English language, being uninsured, having prior office visits, and having had a flu shot in past year. Our findings may inform clinic-based effort to raise rates of colorectal cancer screening, especially in the community clinic setting.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT01742065.

A blueprint for cancer screening and early detection: Advancing screening's contribution to cancer control

From the mid-20th century, accumulating evidence has supported the introduction of screening for cancers of the cervix, breast, colon and rectum, prostate (via shared decisions), and lung. The opportunity to detect and treat precursor lesions and invasive disease at a more favorable stage has contributed substantially to reduced incidence, morbidity, and mortality. However, as new discoveries portend advancements in technology and risk-based screening, we fail to fulfill the greatest potential of the existing technology, in terms of both full access among the target population and the delivery of state-of-the art care at each crucial step in the cascade of events that characterize successful cancer screening. There also is insufficient commitment to invest in the development of new technologies, incentivize the development of new ideas, and rapidly evaluate promising new technology. In this report, the authors summarize the status of cancer screening and propose a blueprint for the nation to further advance the contribution of screening to cancer control.

Analyzing Factors Associated With Decisional Stage of Adoption for Colorectal Cancer Screening Among Older Korean Americans Using Precaution Adoption Process Model

Introduction: For Korean Americans (KAs), colorectal cancer (CRC) screening rates remain lower than the national target. This study aimed to examine factors predicting decisional stage of CRC screening adoption among older KAs using the precaution adoption process model. Method: Convenience sampling was employed to recruit KAs aged 50 to 75 years from the Atlanta metropolitan area in the United States. A total of 433 KAs completed a cross-sectional survey that collects information on sociodemographics, CRC screening history, a physician's recommendation, knowledge, self-efficacy, and decisional balance pertaining CRC screening, and precaution adoption process model stage. Results: Higher scores of decisional balance (odds ratio [OR] = 1.34), having a physician's recommendation (OR = 8.61), and having regular annual medical checkups (OR = 4.44) were significantly associated with higher decisional stage compared with lower stage, controlling for other variables. Discussion: Intervention research should incorporate consideration of individuals' decisional stage to move KAs forward from not engaging the screening to maintaining regular participation in CRC screening.

Colorectal Cancer Screening: An Educational Intervention for Nurse Practitioners to Increase Screening Awareness and Participation

Colorectal cancer screening aims to detect colorectal cancer at an early stage, when treatment is more likely to be curative. Lack of participation in such screening is a major issue in primary care practices, where nurse practitioners (NPs) often provide care. This study aimed to determine whether an educational intervention for NPs would increase their awareness of, and increase patients' participation in, colorectal cancer screening. 
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Patient navigation for lung cancer screening among current smokers in community health centers a randomized controlled trial

Annual chest computed tomography (CT) can decrease lung cancer mortality in high-risk individuals. Patient navigation improves cancer screening rates in underserved populations. Randomized controlled trial was conducted from February 2016 to January 2017 to evaluate the impact of a patient navigation program on lung cancer screening (LCS) among current smokers in five community health centers (CHCs) affiliated with an academic primary care network. We randomized 1200 smokers aged 55-77 years to intervention (n = 400) or usual care (n = 800). Navigators contacted patients to determine LCS eligibility, introduce shared decision making about screening, schedule appointments with primary care physicians (PCPs), and help overcome barriers to obtaining screening and follow-up. Control patients received usual care. The main outcome was the proportion of patients who had any chest CT. Secondary outcomes were the proportion of patients contacted, proportion receiving LCS CTs, screening results and number of lung cancers diagnosed. Of the 400 intervention patients, 335 were contacted and 76 refused participation. Of the 259 participants, 124 (48%) were ineligible for screening; 119 had smoked <30 pack-years, and five had competing comorbidities. Among the 135 eligible participants in the intervention group, 124 (92%) had any chest CT performed. In intention-to-treat analyses, 124 intervention patients (31%) had any chest CT versus 138 control patients (17.3%, P < 0.001). LCS CTs were performed in 94 intervention patients (23.5%) versus 69 controls (8.6%, P < 0.001). A total of 20% of screened patients required follow-up. Lung cancer was diagnosed in eight intervention (2%) and four control (0.5%) patients. A patient navigation program implemented in CHCs significantly increased LCS among high-risk current smokers.

Final Results of a 3-Year Literacy-Informed Intervention to Promote Annual Fecal Occult Blood Test Screening

This three arm study was designed to make CRC screening with FOBTs more accessible, understandable and actionable for patients cared for in predominantly rural Federally Qualified Health Centers. Patients in an enhanced version of usual care received an annual CRC recommendation and FOBT kit; those in the education arm additionally received brief literacy and culturally appropriate education and those in the nurse arm received the education by a nurse manager who followed up by telephone. Baseline FOBT rates in this population were 3 %. We evaluated if FOBT rates could be sustained over 3 years. A three-arm, quasi-experimental evaluation was conducted among eight clinics in Louisiana. Screening efforts included: (1) enhanced usual care, (2) literacy-informed education of patients, and (3) education plus nurse support. Overall, 961 average-risk patients, ages 50-85, eligible for routine CRC screenings were recruited. The primary outcome was completing three annual FOBT tests. Of 961 patients enrolled, 381 (39.6 %) participants did not complete a single FOBT, 60.4 % completed at least one FOBT of which 318 (33.1 %) completed only one, 162 (16.9 %) completed two and 100 (10.4 %) completed three FOBTs over the 3-year period (the primary study outcome). The primary outcome, return of three FOBT kits over the 3-year period, was achieved by 4.7 % in enhanced care, 11.4 % in education and 13.6 % in the nurse arm (p = 0.005). Overall 3-year FOBT screening rates were not sustained with any of the three interventions, despite reports of promising interim results at years 1 and 2. New strategies for sustaining FOBT screening over several years must be developed.

Barriers to Colorectal Cancer Screening in a Primary Care Setting in Turkey

Colorectal cancer (CRC) is the third most common form of cancer in men worldwide and the second most common in women. The purpose of this study was to determine both barriers established by primary health care providers (PHCPs) and barriers perceived by them and to produce solutions for achieving the desired results. A four-part questionnaire was administered to family physicians (FPs) and family health personnels (FHPs) in Samsun, Turkey on 01-15 May, 2016. Sixty-six percent of PHCPs were contacted. Data were evaluated as numbers and percentages, and statistical significance was analyzed using the Chi square and t tests. 478 PHCPs participated; 49.4 % were FPs and 50.6 % FHPs. Of the participants, 86.6 % stated that they performed CRC screening on patients. The level of participants knowing that screening should start at age 50 and conclude at age 70 was 49.7 %. The level of subjects requesting the fecal occult blood test (FOBT) at the correct intervals was 29.7 %, but only 6.9 % recommended colonoscopy at the correct intervals. Additionally, 18.2 % of subjects knew that the test used is immunochemical FOBT, and 60.5 % reported not using reminders. PHCPs' low levels of knowledge, awareness and advice compatible with guidelines concerning CRC screening may represent an obstacle to such screening. Barriers perceived by PHCPs include patients' inability to access definite medical information, deficiencies in the reminder system and patients' lack of interest in CRC screening. Additions to the screening program will be useful in overcoming barriers.

Barriers and Facilitators to Colorectal Cancer Screening Among Rural Women in Community Clinics by Heath Literacy

BACKGROUND

Rural women lag rural men and urban women in colon cancer (CRC) screening completion.

OBJECTIVE

To identify rural female patients' knowledge, beliefs barriers, self-efficacy, prior recommendation and completion of CRC screening using an FOBT and to compare these factors by health literacy (HL) level.

METHODS

This descriptive study was conducted between 2015 and 2016 in 4 rural community clinics in south Louisiana. Patients overdue for screening were given a structured interview by a research assistant.

RESULTS

339 women were enrolled, mean age 58.5, 32% had limited HL, 66% were African American. Most (91.7%) had heard of CRC, yet only 71% knew of any CRC screening tests. Women with adequate HL had greater knowledge of specific tests than those with limited HL (78.4% vs 56.6%, p<0.001). Only 25.7% had been given information on CRC testing; those with adequate HL were more likely to have received information (30.1% vs 16.8%; p=0.017). Most women (93.2%) indicated they would want to know if they had CRC, while 72.2% reported a provider had recommended CRC screening. Only 24.9% said a healthcare provider had ever given them an FOBT or that they had ever completed an FOBT (22.7%). There were no differences in women's report of recommendation or completion by HL level.Self-efficacy for completing an FOBT was high; over 90% indicated they could get an FOBT, complete it and mail results to the lab. Level of confidence did not vary by literacy. Three of the four barrier items varied by HL with women with low HL being more likely to fear doing an FOBT because they thought FOBT instructions would be confusing (p=0.002), doing the test would be embarrassing (p=0.025) or messy (p=0.057).

CONCLUSIONS

Rural women are receptive to CRC screening and view FOBTs as effective. Rural community clinics need to provide low cost FOBTs with literacy, gender and culturally appropriate information.

Colorectal cancer screening at US community health centers: Examination of sociodemographic disparities and association with patient-provider communication

BACKGROUND

Colorectal cancer (CRC) screening rates are low among underserved populations. High-quality patient-physician communication potentially influences patients' willingness to undergo CRC screening. Community health centers (HCs) provide comprehensive primary health care to underserved populations. This study's objectives were to ascertain national CRC screening rates and to explore the relations between sociodemographic characteristics and patient-provider communication on the receipt of CRC screening among HC patients.

METHODS

Using 2014 Health Center Patient Survey data, bivariate and multivariate analyses examined the association of sociodemographic variables (sex, race/ethnicity, age, geography, preferred language, household income, insurance, and employment status) and patient-provider communication with the receipt of CRC screening.

RESULTS

Patients between the ages of 65 and 75 years (adjusted odds ratio [aOR], 2.49; 95% confidence interval [CI], 1.33-4.64) and patients not in the labor force (aOR, 2.32; 95% CI, 1.37-3.94) had higher odds of receiving CRC screening, whereas patients who were uninsured (aOR, 0.33; 95% CI, 0.18-0.61) and patients who were non-English-speaking (aOR, 0.42; 95% CI, 0.18-0.99) had lower odds. Patient-provider communication was not associated with the receipt of CRC screening.

CONCLUSIONS

The CRC screening rate for HC patients was 57.9%, whereas the rate was 65.1% according to the 2012 Behavioral Risk Factor Surveillance System and 58.2% according to the 2013 National Health Interview Survey. The high ratings of patient-provider communication, regardless of the screening status, suggest strides toward a patient-centered medical home practice transformation that will assist in a positive patient experience. Addressing the lack of insurance, making culturally and linguistically appropriate patient education materials available, and training clinicians and care teams in cultural competency are critical for increasing future CRC screening rates. Cancer 2017;123:4185-4192. © 2017 American Cancer Society.

Changes in Colorectal Cancer Screening Knowledge, Behavior, Beliefs, Self-Efficacy, and Barriers among Community Health Clinic Patients after a Health Literacy Intervention

OBJECTIVE

The objective in this pre- and post-survey assessment was to compare the effectiveness of a health literacy-directed intervention designed to increase knowledge, beliefs, barriers, self-efficacy and behavior associated with CRC screening with FOBT among patients cared for in predominantly rural community clinics and the change in these characteristics over the first 15 months after enrolling in a study designed to assess screening strategies.

METHODS

Between 2008 and 2011, a quasi-experimental intervention was conducted in 8 predominantly rural Federally Qualified Health Centers. Patients were orally administered a 15-minute survey at enrollment by a clinic research assistant (RA) and at 15 months by phone by a central RA. Participants included 428 community clinic patients aged 50-85 (mean 58.5); the majority (79%) were female, 69% were African American, and 54% had limited health literacy.

RESULTS

There was significant improvement across all groups with the number of patients reporting they had been given information /education on CRC testing (p<.0001), been given an FOBT kit (p<.0001), and completed an FOBT (p<.0001) with significant improvement in having a doctor recommendation in all groups except usual care. Confidence in an FOBT's potential to decrease chances of dying from CRC improved across all groups as well (p<0.002). In addition, patients 'belief that they would get CRC in their lifetime' decreased across all groups post-intervention (p<0.03) as did their worry that they may find out they have CRC (p<0.04).

CONCLUSION

Overall these low income FQHC patients who were not up-to-date with screening had heard of CRC screening, had positive attitudes toward screening and wanted to know if they had cancer. Results demonstrate the value of giving patients a recommendation and a kit; patients in all groups reported significant increases at 15 months in completing CRC screening (>83%) as confirmed by study records.

Characteristics of Effective Colorectal Cancer Screening Navigation Programs in Federally Qualified Health Centers: A Systematic Review

In the U.S., colorectal cancer (CRC) incidence and mortality have declined due to screening and improvements in early detection; however, racial/ethnic disparities in screening and mortality persist. Patient navigation has been shown to be effective in increasing CRC screening prevalence. This systematic review answered three questions about navigation in federally qualified community health centers (FQHCs): 1) Which navigation activities increased CRC screening prevalence? 2) What were the challenges to implementing these programs in FQHCs? 3) Which clinic protocols supported screening completion? Findings suggest that navigation services must be tailored to the specific screening test provided. Federally qualified community health centers report difficulty maintaining a current electronic medical records system and sustaining funding; they should establish excellent patient tracking systems (for follow-up and annual rescreening) and establish multiple protocols to facilitate screening completion. With the movement toward patient-centered care models, patient navigation will be integral to FQHCs and their clients.

The validation of electronic health records in accurately identifying patients eligible for colorectal cancer screening in safety net clinics

BACKGROUND

While electronic health records (EHRs) play a key role in increasing colorectal cancer (CRC) screening by identifying individuals who are overdue, important shortfalls remain.

OBJECTIVES

As part of the Strategies and Opportunities to STOP Colon Cancer (STOP CRC) study, we assessed the accuracy of EHR codes in identifying patients eligible for CRC screening.

METHODS

We selected a stratified random sample of 800 study participants from 26 participating clinics, in the Pacific Northwest region of the USA. We compared data obtained through codes in the EHR to conduct a manual chart audit. A trained chart abstractor completed the abstraction of eligible and ineligible patients.

RESULTS

Of 520 individuals in need of CRC screening, identified via the EHR, 459 were confirmed through chart review (positive predictive value = 88%). Of 280 individuals flagged as up-to-date in their screening per EHR data, 269 were confirmed through chart review (negative predictive value = 96%). Among the 61 patients incorrectly classified as eligible, 83.6% of disagreements were due to evidence of a prior colonoscopy or referral that was not captured in recognizable fields in the EHR.

CONCLUSIONS

Our findings highlight importance of better capture of past screening events in the EHR. While the need for better population-based data is not unique to CRC screening, it provides an important example of the use of population-based data not only for tracking care, but also for delivering interventions.

Diagnostic colonoscopy following a positive fecal occult blood test in community health center patients

PURPOSE

Fecal occult blood testing (FOBT) is a pragmatic screening option for many community health centers (CHCs), but FOBT screening programs will not reduce mortality if patients with positive results do not undergo diagnostic colonoscopy (DC). This study was conducted to investigate DC completion among CHC patients.

METHODS

This retrospective cohort study used data from three CHCs in the Midwest and Southwest. The primary study outcome was DC completion within 6 months of positive FOBT among adults age 50-75. Patient data was collected using automated electronic queries. Manual chart reviews were conducted if queries produced no evidence of DC. Poisson regression models described adjusted relative risks (RRs) of DC completion.

RESULTS

The study included 308 patients; 63.3 % were female, 48.7 % were Spanish speakers and 35.7 % were uninsured. Based on combined query and chart review findings, 51.5 % completed DC. Spanish speakers were more likely than English speakers to complete DC [RR 1.19; 95 % confidence interval (CI) 1.04-1.36; P = 0.009], and DC completion was lower among patients with 0 visits than those with 1-2 visits (RR 2.81; 95% CI 1.83-4.33; P < 0.001) or ≥3 visits (RR 3.06; 95% CI 1.57-5.95; P = 0.001).

CONCLUSIONS

DC completion was low overall, which raises concerns about whether FOBT can reduce CRC mortality in practice. Further research is needed to understand whether CHC navigator programs can achieve very high DC rates. If organizations use FOBT as their primary CRC screening approach and a substantial number of patients receive positive results, both screening rates and DC rates should be measured.

Third Annual Fecal Occult Blood Testing in Community Health Clinics

OBJECTIVES

Our objective was to determine the effectiveness of 3 approaches to encourage completion of fecal occult blood testing (FOBT) in the third year of the intervention.

METHODS

Between 2008 and 2011, a quasi-experimental intervention was conducted in 8 predominantly rural Federally Qualified Health Centers. Clinics were randomly assigned to enhanced care (screening recommendation and FOBT kit mailed annually), education (patients additionally received a health literacy appropriate pamphlet and simplified FOBT instructions), or nurse support (same as education but with nurse follow-up). Participants included 206 patients with negative FOBTs in years 1 and 2; ages 50-85, 80% female, 70% African American, and 52% had limited health literacy. The main outcome measure was completion of a third annual FOBT.

RESULTS

Third-year FOBT rates were 48% overall, 34.2% enhanced care, 59.6% education, and 47.4% nurse support (p = .21), even after adjustment for sex, marital status, and health literacy.

CONCLUSION

All mailed interventions were similarly effective in sustaining rates of FOBT screening. Post hoc analyses of the results analyzed by health literacy skills found that patients with both limited and adequate health literacy skills were more likely to complete FOBTs when mailed simplified instructions.

Contrasts in Practices and Perceived Barriers to Colorectal Cancer Screening by Nurses and Physicians Working in Primary Care Settings in Oman

Colorectal cancer (CRC) is the fourth most common type of cancer worldwide and it is responsible for 610,000 deaths annually, despite availability of screening tests that ensure early detection. Predictions specific to the Middle East show that this region will experience a significant increase in cancer mortality over the next 15 years. This study explored the practices and perceived barriers to CRC screening from the perspective of health care providers (HCPs) working in primary care settings in Muscat, Oman. A cross-sectional design and self-administered questionnaires were used to collect data from 142 HCPs. The HCPs were nurses (57.7 %) and physicians (42.3 %) with average age and clinical experience of 32.5 and 9.5 years, respectively. The majority of the HCPs (64.8 %) rarely ordered, referred, health educated, or recommended CRC screening to eligible patients. The only major patient-related barrier to CRC screening reported by HCPs was lack of awareness about CRC tests (63.7 %). There were significant differences between nurses' and physicians' rating of patient-related barriers such as fear of cancer diagnosis (p = 0.037), belief that screening is not effective (p = 0.036), embarrassment or anxiety about screening tests (p = 0.022), and culture (p = 0.001). The major system barriers to CRC screening were lack of hospital policy or protocols, lack of trained HCPs, lack of CRC screening services, and timely appointments to get CRC screening. The findings indicate a need for interventions to enhance patient awareness, HCPs CRC screening practices, and strategies to ameliorate patient and system barriers to CRC screening.

Quality Improvement Measures for Increasing the Colorectal Cancer Screening Rates at a Community Health Center

INTRODUCTION

Direct recommendation from health care professionals has been shown to generally increase colorectal cancer screening rates in the United States. However, data for rural, underserved communities are limited.

OBJECTIVE

To increase colorectal cancer screening rates at a rural community health center (CHC) by increasing health care professionals' awareness of patients' screening eligibility.

METHODS

Participants were health care professionals at a CHC treating patients eligible for colorectal cancer screening (defined as patients aged 50-74 years who visited the CHC between February 24, 2014, and March 15, 2014, and whose electronic medical records [EMRs] had no recording of colorectal cancer screening). For a 3-week period, these participants added electronic reminders to eligible patients' EMRs. Data reports for the screening rates of each participant, in addition to the overall CHC, were generated 4 weeks after the study period and compared with screening rates in 2013.

RESULTS

Five health care professionals volunteered to participate. No statistically significant difference was found in screening rates of participants compared with overall clinic rates between the 2013 (P=.639) and 2014 (P=.583) sample dates. No statistically significant difference was found in the overall CHC screening rates (P=.052), which were 47.69% and 40.84% in 2013 and 2014, respectively. During the study period, 99 eligible patients were seen. An incidental finding revealed a substantial EMR flaw in uniform data system reporting measures: self-reported colorectal cancer screenings by patients, without official documentation provided, were documented in an EMR section that is not retrieved during uniform data system reporting.

CONCLUSION

No associated change in colorectal cancer screening rates was found at the CHC after increasing participants' awareness of patients' screening eligibility using electronic flagging. However, colorectal cancer screening results cannot be reported with certainty given that incidental documentation and data collection discrepancies were found.

Colorectal cancer screening at community health centers: A survey of clinicians' attitudes, practices, and perceived barriers

Objective

Colorectal cancer (CRC) screening rates remain lower among some racial/ethnic groups and individuals with low income or educational attainment who are often cared for within community health centers (CHCs). We surveyed clinicians in a network of CHCs to understand their attitudes, practice patterns, and perceived barriers to CRC screening.

Methods

A clinician survey was conducted in 2013 within the Community Health Applied Research Network (CHARN).

Results

180 clinicians completed the survey (47.9% response rate). Participants had an average of 11.5 (SD: 9.8) years in practice, 62% were female, and 57% were physicians. The majority of respondents somewhat agreed (30.2%) or strongly agreed (57.5%) that colonoscopy was the best screening test. However, only 15.8% of respondents strongly agreed and 32.2% somewhat agreed that colonoscopy was readily available for their patients. Fecal immunochemical testing (FIT), a type of fecal occult blood test (FOBT), was viewed less favorably; 24.6% rated FIT as very effective.

Conclusions

Although there are no data showing that screening colonoscopy is superior to FIT, CHC clinicians believe colonoscopy is the best CRC screening test for their patients, despite the high prevalence of financial barriers to colonoscopy. These attitudes could be due to lack of knowledge about the evidence supporting long-term benefits of fecal occult blood testing (FOBT), lack of awareness about the improved test characteristics of FIT compared to older guaiac-based FOBT, or the absence of systems to ensure adherence to regular FOBT screening. Interventions to improve CRC screening at CHCs must address clinicians' negative attitudes towards FIT.

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We surveyed primary care clinicians in a nationwide network of Community Health Centers.

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The vast majority believed that colonoscopy was the best screening test for colorectal cancer.

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However, less than half agreed that colonoscopy was readily available for their patients.

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Fecal occult blood testing was viewed far less favorably than colonoscopy.

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These attitudes and barriers must be overcome to improve screening and reduce disparities.

Increasing Colorectal Cancer Screening at Community-Based Primary Care Clinics in San Francisco

CONTEXT

Adult colorectal cancer screening (CRCS) can lower disease incidence and mortality. However, widespread implementation is inconsistent, especially in the public sector. While specific interventions to increase CRCS have been identified, firsthand accounts of CRCS improvement efforts using multiple techniques in public sector settings are lacking.

OBJECTIVE

A program evaluation was conducted to assess the effect of implementing a culture of continuous quality improvement (QI) on CRCS practices and prevalence. A multipronged incremental effort over more than a decade to increase CRCS at the San Francisco Department of Public Health is described.

SETTING

Community-based primary care clinics.

PARTICIPANTS

Departmental activities and 5 clinics providing full-scope primary care to CRCS-eligible adults who participated in departmental activities and outreach interventions were assessed.

MAIN OUTCOME MEASURES

Departmental and clinic-specific CRCS activities and prevalence.

RESULTS

Efforts included departmental prioritization; data-driven QI incorporating routine data sharing (monthly reports and data walls); departmental and clinic-specific QI committees; panel management (a team approach to generation of eligibility lists prior to scheduled visits, routinely offering screening during appointments or mailing test kits for patients without appointments); and departmental mail and phone outreach events. Screening ranged from 36.6% to 54.4% in 2010; in 2013, it ranged from 43.6% to 70.2%. Increases occurred consistently over that time in 3 of the 5 clinics and ranged from 1.1% to 14.5%; decreases occurred during 2 intervals in 2 clinics and ranged from 2.3% to 4.3%.

CONCLUSION

CRCS prevalence can be markedly improved in the public sector with a data-driven panel management approach supported by departmental and clinic-specific QI committees and group outreach events. Continued prioritization of and focus on CRCS is required to ensure long-term success. Even small increases will result in avoidable morbidity and mortality associated with this highly preventable disease.

Colon cancer screening for Colorado's underserved: a community clinic/academic partnership

BACKGROUND

Colorectal cancer (CRC) is largely preventable by finding and removing adenomas, but many people have not been screened, especially the uninsured with low income.

PURPOSE

To establish a statewide infrastructure to ensure that low-income Coloradans receive colonoscopy for CRC screening and diagnostic evaluation.

DESIGN

In 2006, a statewide program to provide free colonoscopy to uninsured Coloradans was developed as a partnership between the University of Colorado Cancer Center and Colorado safety-net clinics. Funded by excise tax revenues, the Colorado Colorectal Screening Program (CCSP) successfully embedded screening into primary care, providing patient navigation support and reimbursement that allowed primary care providers to refer patients for colonoscopy.

SETTING/PARTICIPANTS

More than 50 safety-net clinics joined the CCSP to provide colonoscopies to uninsured Coloradans with low income, aged ≥50 years or <50 years at elevated risk, lawfully present and needing CRC screening by American Cancer Society consensus guidelines.

MAIN OUTCOME MEASURES

Process and clinical outcomes included people screened, show rates, patient satisfaction, and quality measures, such as adenoma detection rate, bowel cleansing quality, and timeliness of care. Program costs and benefits were estimated. The 2013 analysis was completed using 2006-2012 data on 13,252 of 13,774 people receiving colonoscopy.

RESULTS

In 2006-2012, the CCSP screened 13,774 people, with 38% minorities and 39% men. Patient navigators ensured >90% of those referred attended their colonoscopy. Adenomas were removed from 27% of patients and 1% had cancers diagnosed. Total direct medical services cost was $998/person receiving colonoscopy. About 325 fewer future incident CRCs were predicted due to adenoma removal, projecting substantial future cost savings.

CONCLUSIONS

The CCSP, a successful community clinic/academic partnership provides cost-effective CRC screening and prevention services to low-income uninsured Coloradans and establishes the infrastructure to support screening low-income Coloradans as Affordable Care Act reforms provide payer coverage for them.

Label-free quantitative mass spectrometry reveals a panel of differentially expressed proteins in colorectal cancer

To identify potential biomarkers involved in CRC, a shotgun proteomic method was applied to identify soluble proteins in three CRCs and matched normal mucosal tissues using high-performance liquid chromatography and mass spectrometry. Label-free protein profiling of three CRCs and matched normal mucosal tissues were then conducted to quantify and compare proteins. Results showed that 67 of the 784 identified proteins were linked to CRC (28 upregulated and 39 downregulated). Gene Ontology and DAVID databases were searched to identify the location and function of differential proteins that were related to the biological processes of binding, cell structure, signal transduction, cell adhesion, and so on. Among the differentially expressed proteins, tropomyosin-3 (TPM3), endoplasmic reticulum resident protein 29 (ERp29), 18 kDa cationic antimicrobial protein (CAMP), and heat shock 70 kDa protein 8 (HSPA8) were verified to be upregulated in CRC tissue and seven cell lines through western blot analysis. Furthermore, the upregulation of TPM3, ERp29, CAMP, and HSPA8 was validated in 69 CRCs byimmunohistochemistry (IHC) analysis. Combination of TPM3, ERp29, CAMP, and HSPA8 can identify CRC from matched normal mucosal achieving an accuracy of 73.2% using IHC score. These results suggest that TPM3, ERp29, CAMP, and HSPA8 are great potential IHC diagnostic biomarkers for CRC.

Reducing inequities in colorectal cancer screening in North America

Colorectal cancer (CRC) is an important cause of mortality and morbidity in North America. Screening using a fecal occult blood test, flexible sigmoidoscopy, or colonoscopy reduces CRC mortality through the detection and treatment of precancerous polyps and early stage CRC. Although CRC screening participation has increased in recent years, large inequities still exist. Minorities, new immigrants, and those with lower levels of education or income are much less likely to be screened. This review provides an overview of the commonly used tests for CRC screening, disparities in CRC screening, and promising methods at the individual, provider, and system levels to reduce these disparities. Overall, to achieve high CRC participation rates and reduce the burden of CRC in the population, a multi-faceted approach that uses strategies at all levels to reduce CRC screening disparities is urgently required.

Promotion and provision of colorectal cancer screening: a comparison of colorectal cancer control program grantees and nongrantees, 2011-2012

INTRODUCTION

Since 2009, the Centers for Disease Control and Prevention (CDC) has awarded nearly $95 million to 29 states and tribes through the Colorectal Cancer Control Program (CRCCP) to fund 2 program components: 1) providing colorectal cancer (CRC) screening to uninsured and underinsured low-income adults and 2) promoting population-wide CRC screening through evidence-based interventions identified in the Guide to Community Preventive Services (Community Guide). CRCCP is a new model for disseminating and promoting use of evidence-based interventions. If the program proves successful, CDC may adopt the model for future cancer control programs. The objective of our study was to compare the colorectal cancer screening practices of recipients of CRCCP funding (grantees) with those of nonrecipients (nongrantees).

METHODS

We conducted parallel Web-based surveys in 2012 with CRCCP grantees (N = 29) and nongrantees (N = 24) to assess promotion and provision of CRC screening, including the use of evidence-based interventions.

RESULTS

CRCCP grantees were significantly more likely than nongrantees to use Community Guide-recommended evidence-based interventions (mean, 3.14 interventions vs 1.25 interventions, P < .001) and to use patient navigation services (eg, transportion or language translation services) (72% vs 17%, P < .001) for promoting CRC screening. Both groups were equally likely to use other strategies. CRCCP grantees were significantly more likely to provide CRC screening than were nongrantees (100% versus 50%, P < .001).

CONCLUSION

Results suggest that CRCCP funding and support increases use of evidence-based interventions to promote CRC screening, indicating the program's potential to increase population-wide CRC screening rates.

Knockdown of β3GnT8 reverses 5-fluorouracil resistance in human colorectal cancer cells via inhibition the biosynthesis of polylactosamine-type N-glycans

Aberrant glycosylation is known to be associated with cancer chemoresistance. β-1,3-N-acetyl-glucosaminyltransferase (β3GnT)8, which synthesizes polylactosamine on β1-6 branched N-glycans, is dramatically upregulated in colorectal cancer (CRC). 5-Fluorouracil (5-FU) resistance remains a major obstacle to the chemotherapy of CRC. However, little is known with regard to the correlation between 5‑FU resistance and the expression of β3GnT8 in CRC. In this study, a 5-FU‑resistant cell line (SW620/5-FU) was generated, and 50% inhibition concentration (IC50) of 5-FU was determined by MTT assay. Flow cytometry and lectin blot analysis were performed to detect the alteration of polylactosamine structures. Quantitative RT-‑PCR and western blot analysis were used to identify and evaluate candidate genes involved in the synthesis of polylactosamine in SW620/5-FU cells. We found polylactosamine chains were significantly increased in SW620/5-FU cells. Inhibition of the biosynthesis of polylactosamine by 3'-azidothymidine (AZT) was able to reduce 5-FU tolerance. Further studies showed that β3GnT8 expression was also upregulated in 5-FU‑resistant cancer cells, and knockdown of β3GnT8 by RNA interference reversed 5-FU resistance through, at least partly, by suppressing the formation of polylactosamine. In conclusion, the alteration of β3GnT8 in CRC cells correlates with tumor sensitivity to the chemotherapeutic drug and has significant implication for the development of new treatment strategies.

Strategies to improve repeat fecal occult blood testing cancer screening

BACKGROUND

A comparative effectiveness intervention by this team improved initial fecal occult blood testing (FOBT) rates from 3% to 53% among community clinic patients. The purpose of this study was to evaluate the effectiveness and costs associated with a literacy-informed intervention on repeat FOBT testing.

METHODS

Between 2008 and 2011, a three-arm quasi-experiential comparative effectiveness evaluation was conducted in eight community clinics in Louisiana. Clinics were randomly assigned to receive: enhanced care, a screening recommendation, and FOBT kit annually; a brief educational intervention where patients additionally received a literacy appropriate pamphlet and simplified FOBT instructions; or nurse support where a nurse manager provided the education and followed up with phone support. In year 2, all materials were mailed. The study consisted of 461 patients, ages 50 to 85 years, with a negative initial FOBT.

RESULTS

Repeat FOBT rates were 38% enhanced care, 33% education, and 59% with nurse support (P = 0.017). After adjusting for age, race, gender, and literacy, patients receiving nurse support were 1.46 times more likely to complete repeat FOBT screening than those receiving education [95% confidence interval (CI), 1.14-1.06; P = 0.002] and 1.45 times more likely than those in enhanced care but this was not significant (95% CI, 0.93-2.26; P = 0.10). The incremental cost per additional person screened was $2,450 for nurse over enhanced care.

CONCLUSION

A mailed pamphlet and FOBT with simplified instructions did not improve annual screening.

IMPACT

Telephone outreach by a nurse manager was effective in improving rates of repeat FOBT, yet this may be too costly for community clinics.

Improving colon cancer screening in community clinics

BACKGROUND

The authors evaluated the effectiveness and cost effectiveness of 2 interventions designed to promote colorectal cancer (CRC) screening in safety-net settings.

METHODS

A 3-arm, quasi-experimental evaluation was conducted among 8 clinics in Louisiana. Screening efforts included: 1) enhanced usual care, 2) literacy-informed education of patients, and 3) education plus nurse support. Overall, 961 average-risk patients ages 50 to 85 years were eligible for routine CRC screening and were recruited. Outcomes included CRC screening completion and incremental cost effectiveness using literacy-informed education of patients and education plus nurse support versus enhanced usual care.

RESULTS

The baseline screening rate was <3%. After the interventions, the screening rate was 38.6% with enhanced usual care, 57.1% with education, and 60.6% with education that included additional nurse support. After adjusting for age, race, sex, and literacy, patients who received education alone were not more likely to complete screening than those who received enhanced usual care; and those who received additional nurse support were 1.60-fold more likely to complete screening than those who received enhanced usual care (95% confidence interval, 1.06-2.42; P = .024). The incremental cost per additional individual screened was $1337 for education plus nurse support over enhanced usual care.

CONCLUSIONS

Fecal occult blood test rates were increased beyond enhanced usual care by providing brief education and nurse support but not by providing education alone. More cost-effective alternatives to nurse support need to be investigated.