Barriers to Colorectal Cancer Screening Among Minorities

NEW YORK—When John Huggins, EdD, of Louisville, Kentucky, developed rectal bleeding shortly before his 50^th birthday, he promptly called his primary care physician. After a digital rectal exam, the physician told him he had an anal abrasion that was nothing to worry about. "But I did worry because the signs did not go away," the assistant director of student services for Jefferson County Public Schools said at a Cancer Research Foundation of America press briefing on colorectal cancer.

Eventually, his primary care physician referred him to another physician for a sigmoidoscopy. That examination revealed no problems, and Dr. Huggins waited for a time before again calling the doctor. This time his description of his problems prompted the doctor to order a colonoscopy, and this time he got a diagnosis: colorectal cancer. Persistence paid off for Dr. Huggins who is alive and well 7 years after a colectomy.

Dr. Huggins, who is black, is currently a patient of Wayne B. Tuckson, MD, associate professor of surgery, University of Louisville. Two other black patients who came to Dr. Tuckson’s attention more recently did not fare so well. One was a 50-year-old woman who had felt weak and tired for 2 years. Her physician told her not to worry, that her symptoms were due to her diabetes. "She died of metastatic colon cancer," he said.

Another woman, age 62, who had two family members with colorectal cancer, had never been screened for the disease when she "showed up with metastatic colon cancer," he said. She died within 4 months of the diagnosis. "There’s a problem out there," said Dr. Tuckson of the barriers to screening and care faced by minority and low-income populations.

Studies that Dr. Tuckson and his colleagues conducted in Jefferson County, in which 16% of the 685,000 residents are black, highlighted an apparent effect of income and race on colorectal cancer outcomes. Using data on patients diagnosed in 1991-1995, they compared outcomes by the patients’ income levels, with $22,500 and below being the lowest and $36,000 and above the highest.

In situ and stage I disease, "which should have about a 90% to 95% overall survival rate," Dr. Tuckson noted, was diagnosed in 38% of the high-income group but in only 28% of the low-income segment. Stage IV disease, on the other hand, was diagnosed in 22% of the low-income patients but only 12% of the wealthiest. "Income does seem to make a difference," Dr. Tuckson said. In the low-income group, 70.2% were black.

An analysis by race showed that stage of disease at diagnosis did not differ between blacks and whites, Dr. Tuckson noted, but survival did. Five-year survival with no evidence of disease was 49% for whites and 41% for blacks. In all, 26% of the white patients and 36% of the blacks died of the disease.

Barriers to cancer screening and care, Dr. Tuckson acknowledged, "may reflect the high percentage of African-Americans in poverty and all the problems associated with poverty." Blacks, he noted, tend to be treated in clinics rather than by primary care physicians who come to know them and their problems. They are less likely to see specialists or experienced physicians who know how to manage cancer cases effectively, he added.

They are also more likely to have comorbid conditions that affect their ability to "tolerate the onslaught of chemotherapeutic agents," he noted.

Lack of awareness of risk factors may be a barrier to preventive measures such as a healthy diet, as documented by Dr. Tuckson and his colleagues in a telephone survey, and to cancer screening. "If a physician doesn’t recommend screening," Dr. Tuckson declared, "it isn’t going to happen. In this population, we’re finding out that people aren’t being screened."

The Physician’s Role

Robert A. Smith, PhD, director of Cancer Screening, American Cancer Society, noted that in surveys conducted by his organization, the leading reason adults gave for getting colorectal tests is that their doctors recommended them. Conversely, the major reason for not getting them was not that they were distasteful or embarrassing but "because their doctors haven’t brought it up," he said.

"What prevents providers from playing their important role?" Dr. Smith asked. Among the reasons, he suggested, is that "cancer screening is not well integrated into primary care for any of our cancer screening tests. Doctors have role ambiguity. Should they initiate this test or should patients request it? They may not be aware of screening guidelines. In the busy practice, they have less and less time for preventive care, and their office system may not be geared to trigger screening reminders."

Finally, he said, in some cases, reimbursement policies are unrealistic. "If a primary care provider can earn more for the practice by seeing several patients than by doing one flexible sigmoidoscopy, the likelihood is that the screening test is not going to get done," he said. However, although the public perceives that there are insurance barriers, "I suspect right now there really are not," he said, adding that screening colonoscopy will become a Medicare benefit in July.

Currently, only 42% of Americans are in compliance with American Cancer Society recommendations for colorectal screening with flexible sigmoidoscopy, Dr. Smith said, compared with 85% for mammography. "Yet this disease is every bit as important," he said. Colorectal cancer, he noted, is the second leading cause of death among cancers that affect both men and women. Lung cancer is the leading cause.

In an effort to encourage more people to be screened for colorectal cancer, the ACS recently modified its recommendations for average-risk individuals age 50 or above to include either fecal occult blood testing (FOBT) annually or flexible sigmoidoscopy every 5 years, whereas previously it had recommended that individuals undergo both.

"We need systems changes to increase screening," Dr. Smith said. "We need physician and health insurer outreach and public awareness to increase the demand side of colorectal cancer screening, which will stimulate the supply side."

Elmer E. Huerta, MD, MPH, director, Cancer Risk Assessment and Screening Center, Washington Hospital Center, is trying to do just that in the Latino community. From his office in the nation’s capital, he distributes 2-minute programs on health in Spanish to 84 radio stations across the United States, Canada, and some Latin American countries. He also has a Spanish television program in which viewers are encouraged to call in their questions, and a website in Spanish (www.prevencion.org).

"We have media programs on health every single day of the week, exactly the same way that there are sports and weather every single day on the news," he said.

Dr. Huerta also runs a cancer prevention clinic at the Washington Hospital Center, which he publicizes on the radio and television shows. In 6 years, the clinic has seen more than 8,000 individuals.

Why is a doctor doing this? he asked. Because studies show that patients find physicians highly credible for talking about cancer (92%), rivaled only by cancer survivors (93%), he said. Dr. Huerta cautioned, however, that the physician must separate educational from business activities. "You don’t sell yourself," he said. "You reject commercial sponsorship because you want to give pure health messages to the community. That’s how you create trust in the community."

Dr. Tuckson is also involved with outreach programs on the Kentucky educational television network. The programs promote healthier diets by having people in the community demonstrate how to make dishes that "maintain ethnic and cultural variety," he said.

There are numerous barriers to getting the message of the need for preventive measures and screening to the Latino community—a diverse group with origins in many different countries. These include linguistic isolation, lack of information, inadequate health insurance, and poverty, Dr. Huerta said.

Poverty, he noted, causes people to focus on day-to-day survival. "Who’s going to care about screening for colorectal cancer," he asked, "if they don’t know if they are going to have food on the table the next day?"

To reach Latinos, Dr. Huerta stressed, physicians’ messages must be ethnically sensitive and culturally competent. When a woman he diagnosed with pancreatic cancer showed up for an appointment with 12 members of her family, staff members at his hospital were aghast. "They don’t understand that for Latinos, health is a family issue," he said, "and the whole family needs to be there to listen to the doctor."

Fatalism about cancer outcome may be a barrier to screening for whites, blacks, and Latinos, he said. An NIH survey showed that a majority of both women and men in all three groups did not know that early cancers could be cured.

The message that nearly 95% of persons treated for early colorectal cancer will be alive 5 years later has not reached the general public, he emphasized. "If they don’t know this," he said, "they may not see the point of getting a screen."