Practical steps can move needle on health disparities in colon cancer screening
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LAS VEGAS – Prioritizing equity efforts and taking three key steps toward improving accessibility and representation could move the needle on health disparities in colon cancer screening, according to an ACG Postgraduate Course presentation.
“We have had over 3 decades of evidence that suggest that colorectal cancer screening saves lives. We are doing screening as a means to prevent, interrupt or delay development of advanced disease because we know if we detect it early, the survival rate is quite high,” Darrell M. Gray II, MD, MPH, FACG, chief health equity officer for Anthem Inc., said during his postgraduate course presentation prior to ACG 2021. “Unfortunately, colorectal cancer and the burden of disease are not evenly distributed.”
Multifactorial barriers
Gray shared 2020 data that showed non-Hispanic Blacks had a 20% higher incidence rate of CRC and a 40% higher mortality rate from the disease compared with whites. He also mentioned diagnoses among Black populations occur at a younger age and later stage of disease.
Additionally, Gray showed 2020 screening rates in federally qualified health centers were just 40.1% among people aged 50 to 75 years, exemplifying how socioeconomic factors also play into health disparities.
“There are many barriers. Certainly, there are structural barriers. There are social barriers. We need to take into consideration the multifactorial and multilevel barriers,” Gray said, breaking these barriers down into levels for patients, providers, health systems and national policy.
At the patient level, CRC screening hurdles include fear, “warranted distrust,” cultural beliefs, education, health literacy, cost, comorbidities and other priorities.
“We have to recognize even as gastroenterologists who are gung ho about colorectal cancer screening, our patients may have priorities of getting their kids to school, putting food on the table or the lights on, that might compete with their ability to come into the office,” he said.
At the provider level, lack of recommendations, lack of knowledge of guidelines, personal beliefs, support and resources, as well as bias and discrimination all impact patient care.
“Lack of knowledge around guidelines can be an obstacle around someone successfully completing screening,” Gray said. “Beliefs at the provider level can lead to bias and discrimination that impact care or recommendations of care.”
At the health system level, Gray named access, capacity, quality of care, coordination and outreach as well as reminder systems among the barriers to CRC screening equity. While at the national policy level, guidelines, insurance access and coverage, cost shares and co-pays, along with structural racism, put a strain on health equities.
Priorities
Gray outlined three key priorities to increase screening in underserved populations: promoting all screening options; developing strategies to identify unscreened and uninsured individuals; and developing and implementing organized strategies for screening uptake.
Gray reminded the attendees that gastroenterologists and primary care physicians must recognize the mantra “the best test is the one that gets done” and apply that appropriately.
“We have talked a lot about colonoscopy and rightfully so, but certainly the evidence suggests outside of colonoscopy we are underutilizing the other recommended colorectal cancer screening tests. We also see that by race and ethnicity, compared to colonoscopy, we are not recommending as much stool-based testing to our diverse populations. This is going back to promoting options, but also improving accessibility and in accordance with affordability as well,” he said.
In recent studies, researchers showed that uninsured individuals were more likely to complete a no-cost fecal immunochemistry test vs. scheduling a colonoscopy when reached via mailing. Gray said these efforts must be recognized and utilized more often.
Additionally, physicians should implement higher levels of patient navigation to reach patients before disease progresses, he said. Increasing knowledge among patients and providers will help the population reach a higher level of health.
Practical steps
Gray left the audience with three practical steps to move the needle in health equity for CRC screening: enhance partnerships with primary care, explore opportunities to improve your practice and recruit top talent.
“We have to be equity focused. You can appreciate the difference between giving every population or every individual the same tool or tailoring the tools to what the population needs to achieve their optimal level of health possible,” he said.
Gray suggested increasing access to gastroenterology practices for the primary care physicians nearby. Educate other providers and patients “in a humble way,” he said, while increasing outreach to other practices.
Within one’s own practice, Gray said gastroenterologists need to improve history taking, both to look for family history of note and to understand the social drivers of patients’ health. Then GIs must recommend the best test for the individual patient in a “culturally sensitive way,” he said.
GIs must also think about how to tailor their services to the uninsured and under insured, Gray added, with many practices offering low- to no-cost colonoscopies as a community service.
Lastly, the gastroenterology specialty needs to recruit top talent to reflect the diverse populations served by their institutions and practices.
“There is a lack of diversity in our workforce, and this impacts patient care and impacts people in the community wanting to come in to receive colorectal cancer screening,” Gray said.
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Gray DM. Presentation: Disparities in Colon Cancer Screening: How do we move the needle? Presented at: ACG Annual Scientific Meeting; Oct. 22-27, 2021; Las Vegas (hybrid meeting).
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