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CDC Report: Why Do Certain Populations Never Screen for Colorectal Cancer?

Cancer screening remains a powerful tool. Even limited screening has long-term benefits compared to no screening  and can lower the risk of cancer and related deaths. A recent study by researchers at the CDC compared data on adults who reported they had not received a colorectal cancer (CRC) screening test between 2012 and 2020 using information from the Behavioral Risk Factor Surveillance System (BRFSS). The study identified various trends, most notably that 22 states did not meet the CDC’s Healthy People 2020 goal of 70.5% adults screened for CRC.

The sample was limited to adults aged 50 to 75 years, with up to date screenings defined as one of the following:

  • Home stool-blood test within the past year
  • Sigmoidoscopy within five years with fecal occult blood test or within one year with fecal immunochemical test
  • Colonoscopy within ten years

The ‘never screened’ numbers were a composite of those who answered no to being screened or those who were not up to date. Those who declined to answer or reported uncertainty were excluded. Overall, the study identified:

  • A 5.8% decrease in unscreened adults between 2012 and 2020 
  • States with the largest improvements were also those with the largest unscreened population in 2012 

 

Despite these improvements, CRC screening goals have yet to be met and may be difficult to meet with the new Healthy People 2030 standards. The target of 74.4% screened may have been a challenge to meet, possibly further exacerbated by the COVID-19 pandemic.

Researchers noted that including just two more questions on the BRFSS in 2020, the percentage of up to date screenings increased to 71.6%. These two questions enquired about:

  • Stool DNA testing
  • Computerized tomographic colonography

It is important to note that the National Colorectal Cancer Roundtable—a membership organization established by the CDC and the American Cancer Society—has set its goal to 80% screening rates across the country.

Study authors recognized recall bias and an inability to distinguish between screening versus diagnostic tests as major study limitations. Additionally, social desirability bias and a low response rate may have also affected the results. However, financial factors and health disparities may also describe the differences between states.

Following implementation of the Affordable Care Act, researchers at the American Cancer Society found that CRC screening among low-income adults across the U.S. increased by up to 8%, with the greatest increases observed in early Medicaid expansion states. They also noted that a majority of those who were never screened also lived in a state without expansion (South Dakota). 

Nonfinancial factors such as health disparities were studied in a mixed-methods analysis conducted at the Virginia Commonwealth University’s School of Medicine. Here, researchers noted that participants of gender-specific and race-specific focus groups brought forth nuanced concerns regarding screening. This included lack of awareness of both the disease and the screening, lack of physician recommendation that is clear and rational, and fear of being diagnosed and complications associated with testing. These concerns, if unaddressed, may limit others from seeking out CRC screening.

To read more about the Healthy People 2030 CRC screening standards and the current progress, visit Healthy People 2030.

 

Kaylinn Escobar is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation. 

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Medicaid Expansion May Have Improved Diagnosis of Early-Stage CRC

Health insurance coverage is an important determinant of access to health care. Most people in the U.S. receive health insurance through their employers and many others qualify for government insurance programs like Medicare (generally for those >65 years) or Medicaid (for low-income families/individuals). The 2010 Affordable Care Act mandated preventive screening coverage for those who are enrolled in Medicaid and provided support to participating states. A cross-sectional cohort study has now revealed that after Medicaid expansion in 2014, the proportion of patients diagnosed and treated at Commission on Cancer–accredited facilities increased within expansion states and decreased in non-expansion states. 

This study evaluated whether the proportion of patients diagnosed with early-stage colorectal cancer (CRC) changed over time within states that expanded Medicaid, compared with non-expansion states. The authors queried the multicenter registry data from the National Cancer Database (2006-2016) and identified a total of 10,289 patients in expansion states and 15,173 patients in non-expansion states. They found:

  • A 0.9% annual increase in the number of individuals diagnosed with early-stage CRC in expansion states after 2014 
  • A 0.8% annual reduction in the number of individuals diagnosed with with early-stage CRC in non-expansion states after 2014 
  • By 2016, the absolute difference in the propensity-adjusted proportion of early-stage CRC was 8.8% 

Similarly, a study published in the Journal of American Surgeons also found that Medicaid expansion has had a notable impact on the diagnoses of early-stage CRC compared to non-expansion states. 

Improved insurance coverage following Medicaid expansion may have facilitated access to screenings and earlier diagnoses. 

For more information on insurance coverage for CRC screening, please visit: Insurance Coverage for Colorectal Cancer Screening. 

 

Kitty Chiu is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

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