Colorectal Cancer Screening

The American Cancer Society (ACS) estimates that in 2009, there will be over 100,000 new cases of colon cancer, nearly 41,000 cases of rectal cancer and nearly 50,000 deaths from colorectal cancer. "Not counting skin cancers, colorectal cancer are the third most common cancer found in men and women in this country."

There are two recognized methods to decrease the risk of developing colorectal cancer, risk reduction and screening. Risk reduction includes weight reduction, diet modification to decrease red meat, and increasing consumption of fruits and vegetables. However, one of the most effective ways to reduce mortality due to colorectal cancer is by screening with annual Fecal Occult Blood Testing (FOBT) and imaging (colonoscopy, virtual colonoscopy and sigmoidoscopy). According to the Center for Disease Control, 60% of colorectal cancer deaths would be averted by the use of regular screening for Americans over 50 years old. The National Cancer Institute reports that only about 18% of age 50+ Massachusetts residents had a home Fecal Occult Blood Test (FOBT) in 2006. The target of the Federal Department of Health and Human Services program Healthy People 2010 is 50%.

The annual FOBT is an inexpensive home test, performed by the individual as opposed to sigmoidoscopy or colonoscopy which is performed in a hospital or clinic by a physician. The simplicity and low cost of the annual FOBT makes it an attractive recommendation to improve public health.

Unfortunately, most Americans do not understand their risk of colorectal cancer. In 2005, a behavioral risk factor survey demonstrated that adults with a family history of colorectal cancer have a heightened sense of awareness of the disease compared to adults with no family history of the disease; of those with a family history, over a third felt highly susceptible to colorectal cancer versus less than a tenth of those with no family history.

A study of patients of Boston area health centers who avoided colorectal cancer screening addresses perceived barriers to colorectal screening in health centers in Boston. There were four major concerns cited by the low income subjects of the study. First, there is a lack of trust of physicians among many of those not participating in colorectal screening. Many of the subjects reject screening due to a lack of symptoms. Subjects were influenced by their doctor's recommendation or lack thereof. Finally, many cited fatalistic views of cancer diagnosis as a reason to avoid screening. For example, diagnosis will lead to uncomfortable treatment followed by death. The results of this survey demonstrate that these patients do not believe that participating in screening will reduce the severity of the disease. One final barrier is the cost of the FOBT; even though the cost is low compared to the cost of other procedures, there are many Americans who cannot afford to buy a test for about $20.00.

Risk education creates demand for screening. Lasser's study of Boston clinics demonstrates the need for health care providers to make firm recommendations to their patients in favor of home FOBT's. Self efficacy is an important factor in this intervention. Promote advantages of home FOB testing, cost, reliability, and privacy.

The Center for Disease Control's Screen for Life program offers many print and broadcast media information spots in English and Spanish featuring celebrities including Jimmy Smits, Katie Couric and Diane Keaton. State and Federal public health departments should press for use of this resource.

Primary care providers (PCP's) should discuss the concept of annual home testing with their patients and demonstrate the use of the home FOBT. Hopefully, PCP's will ask their patients each year for the results of their home FOBT.

Sources:

American Cancer Society, "How Many People Get Colorectal Cancer?" 5/07/2009. http://www.cancer.org/docroot/CRI/content/CRI_2_2_1X_How_Many_People_Get_Colorectal_Cancer.asp?rnav=cri

American Cancer Society, "Can Colorectal Cancer be Prevented?" 5/07/2009. http://www.cancer.org/docroot/CRI/content/CRI_2_2_2X_Can_colorectal_cancer_be_prevented.asp?rnav=cri

Centers for Disease Control and Prevention, "Colorectal Caner Screening Rates," June 29, 2009. http://www.cdc.gov/cancer/colorectal/statistics/screening_rates.htm

National Cancer Institute, "State Cancer Profiles". A dynamic chart based on information from the Behavioral Risk Factor Surveillance System BRFSS Survey Data. http://statecancerprofiles.cancer.gov/cgi-bin/risk/risk.pl?08&0&2&0&1

Department of Health and Human Services, Healthy People 2010 Objectives, 3-12. http://www.healthypeople.gov/document/html/objectives/03-12.htm

A. Emeott, A. Rafferty, D. Duquette, C. Fussman, S. Lyon-Callo, J. Back, and P. Hager, "Family History, Risk Perception and Resk Reduction Behaviors of Colorectal Cancer - Mchigan Behavioral Resk Factor Survey, 2005", Center for Disease Control, Atlanta, Ga. http://www.cdc.gov/genomics/events/file/print/10year/52_famhx_coca_ab.pdf

K. Lasser, J. Ayanian, R. Fletcher, and M. DelVecchio Good, "Barriers to Colorectal Cancer Screening in Community Health Centers: A Qualitative Study", BMC Family Practice 2008, 9:15.

Cooper CP, Williams KN, Carey KA, Fowler CS, Frank M, Gelb CA. Advertising campaign on a major Internet search engine to promote colorectal cancer screening. British Medical Journal 2004;328(7449):1179-1180.

Jorgensen C, Gelb CA, Richards TB, Cooper CP. Centers for Disease Control and Prevention. Donated television airplay of colorectal cancer education public service announcements-United States, 1999-2002.MMWR 2003;52(10):196-199.

Jorgensen C, Gelb C, Merritt T, Seeff L. CDC's Screen for Life: A national colorectal cancer action campaign. Journal of Women's Health and Gender-Based Medicine 2001;10(5):417-422.

Cooper CP, Gelb CA, Jameson H, Macario E, Jorgensen CM, Seeff L. Developing English and Spanish television public service announcements to promote colorectal cancer screening. Health Promotion Practice 2005;6(4):385-393.