The Urban-Rural Divide in Colorectal Cancer Screening

Image source: anarosadebastiani (Pixaby) 

Colorectal cancer and breast cancer screening programs, when implemented properly, have led to significant reduction in death. However, screening uptake varies greatly across the U.S. Rural communities, specifically in Appalachia, the Mississippi delta, frontier lands, and prairie lands face issues with access that are accentuated by poor health behaviors.

A 2021 cross-sectional study by Shete et al, which was recently published in JAMA found that urban women were significantly more likely to be adherent to colorectal cancer screening as compared to women residing in rural areas (82% vs 78%, respectively; P=.01). When they conducted a multi-variable mixed effects analysis, they found that rural women had 19% lower odds of being adherent to colorectal cancer screening guidelines. 

Along with a difference in screening adherence, there was a significant difference in beliefs and understanding of cancer, health, and screening. When comparing the thoughts of women dwelling in rural vs. urban areas regarding cancer and cancer screening:

• 62% vs 52% believed “It seems like everything causes cancer”
• 24% vs 17% believed “There’s not much you can do to lower your chances of getting cancer”
• 76% vs 67% believed “There are so many different recommendations about preventing cancer, it’s hard to know which ones to follow”

Despite the differences in beliefs and perception of cancer screening overall, rural and urban women were similarly adherent (81% vs 81%) to breast cancer screening. Here the authors hypothesize that the difference in colorectal cancer screening is likely due to the difference in screening diffusion in the rural areas.

Newer colorectal screening technologies like fecal immunochemical tests (FIT) may work better in a rural setting because rural women are 69% more likely to skip going to a doctor due to cost. Taking away the face to face component can reduce cost for insurance companies and by effect patients, which could increase screening uptake. 

FIT tests can also be useful for working women. Among women over the age of 65, the adherence rate to colorectal cancer screening recommendations was significantly higher than among women ages 50-64 years. This difference in uptake due to age is likely because older/retired women do not have to take time off of work for screening tests such as a colonoscopy or a sigmoidoscopy.  

Furthermore, patients with insurance were 2 to 3 times more likely to get screened, so changes in insurance care coverage—particularly, the removal of a copayment for a preventive service—through the Affordable Care Act would increase screening uptake. In order to increase rural colorectal cancer screening uptake, programs that identify and act on access issues are needed as are policies that can improve access at the local level.