CRC paper

Running head: COLORECTAL CANCER SCREENING AND INCIDENCE 1
Colorectal Cancer:
Barriers to Screening and Relationship Between Screening and Incidence Rates
Jessica M. Mitchell
Clemson University

Abstract
Colorectal cancer is the second leading cause of cancer death in the United States. The U.S.
Preventative Services Task Force currently recommends that all adults aged 50 to 75 be screened
for colorectal cancer, however, less than half of this population is being screened. The biggest
contributing factor for individuals not being screened are multiple perceived barriers such as
being afraid of the procedure or the results, low literacy levels, or being too busy to have the
procedure done. With colonoscopy being the most commonly known form of screening, other
methods are also explored. The study population includes males and females of various
ethnicities; the overweight, obese, and persons of normal weight; and those who are 40 years of
age and older. Screening, incidence, and mortality trends are researched in multiple areas of the
United States, Canada, and many European countries including Belgium, Luxemburg, and the
United Kingdom. The most effective form of screening is the colonoscopy. However, this is
also the most expensive. Other effective, less expensive, options are fecal occult blood test,
sigmoidoscopy, fecal immunochemical test, and low-sensitivity guaiac fecal occult blood test.
Advanced practiced nurses can be more proactive in recommending screenings for patients when
they are aware of the multiple options available and knowing that most insurance companies are
required to cover screening for colorectal cancer.

Introduction
Colorectal cancer (CRC) is one of the leading causes of cancer deaths in the United
States (U.S). The incidence rate for colorectal cancer in the United States is 39.9 cases per
100,000 people, and for South Carolina, it is 37.1 cases per 100,000 (Centers for Disease Control
and Prevention (CDC), 2012; Surveillance, Epidemiology, and End Results Program (SEER),
2015). CRC is the second leading cause of cancer death, causing 8.4% of cancer deaths in the
U.S. It is the second most common cancer occurring among women after breast cancer (13.4%
of new cancer cases versus 35.3%, respectively) and the third most common among men (13.8%)
after prostate (27.0%) and lung cancer (16.6%) (Hal, Hoeck, & Roosbroeck, 2011). The
mortality rate is 14.7 per 100,000 people with 49,700 CRC deaths predicted for the year 2015.
(CDC, 2012; SEER, 2015).
In the past 30 years, there has been a significant increase in the number of adults in the
U.S., age 50 and greater, which are screened for CRC, with an increase of 13% from 2002 to
2010 (Yang, Gross, Soulos, & Yu, 2014; CDC, 2011). The U.S. Preventative Services Task
Force (USPSTF) currently recommends that all adults aged 50 to75 be screened for CRC
(USPSTF, 2008), but yet, discourages screening for adults between the ages of 76-85 (Weissfeld
et al., 2011). However, according to the source, 1 in 3 people who should be getting screened, or
half of adults over the age of 50, in the U.S. are not (CDC, 2011; Cohen, Murff, Signorello, &
Blot, 2012). For the purpose of this paper, CRC screening includes the methods of fecal occult
blood test (FOBT), endoscopy (to include colonoscopy and sigmoidoscopy), fecal
immunochemical test (FIT), and low-sensitivity guaiac fecal occult blood test.
Even with the increase in screening for CRC, factors need to be investigated as to why
there continues to be such a high morbidity and mortality rate. One contributing factor is that

barriers, such as social and economic, may prevent a person from having screenings (Guessous,
et al., 2010). In identifying these barriers, as well as other factors that keep the incidence rate of
CRC high, methods for further decreasing the incidence rate can be explored.
The purpose of this paper is to explore reasons why those in the population who should
be screened for CRC are not getting screened, identify effective interventions to increase
screening and discuss and compare the effectiveness of multiple screenings currently available.
The population researched for this paper includes males and females of various ethnicities; the
overweight, obese, and persons of normal weight; and those who are 40 years of age and older.
Screening, incidence, and mortality trends were researched in multiple areas of the United States,
Canada, and many European countries including Belgium, Luxemburg, and the United Kingdom.
This paper will also compare the incidence rates for each sub-population (categorized by sex and
age), investigate the differences among location of CRC, recommend any changes that may need
to take place to further decrease the morbidity and mortality rates of CRC, as well as discuss
implications for nursing education, practice and research.
Synthesis and Literature Review
Methodology
The search strategy involved searching electronically for English language articles
published from 2010-2015 in the Clemson library database. During the search, the key words
colorectal cancer screening, incidence/morbidity and mortality rates, and barriers to colorectal
screening were used in various combinations. The inclusion criteria for these studies were adults
aged 40 years and older. The exclusion criteria were: prior CRC or history of inflammatory
bowel disease, currently undergoing treatment for any type of cancer, family history of CRC,
people who had already had screening in the recent past, and under the age of 40. The search

yielded 11,680 journal articles of which 18 research articles were selected in the order they were
presented in the search. The articles were then obtained and reviewed. Additional articles were
also included for a total of 22 articles.
Barriers to screening
The reason there is still such a high rate of CRC is that there continues to be multiple
barriers to people getting screened. The top five reasons given for people in a specific region of
the southeastern U.S. were: they were afraid of either the procedure or the results; the pre-
procedure bowel prep was unpleasant; they were not aware of their need to be screened; they did
not want to experience any pain associated with the procedure; and the inability to afford the
procedure (Jones, Devers, Kuzel, & Woolf, 2010). The most common reasons for not affording
the procedure were lack of insurance or lower income families having to choose between basic
needs such as food and housing as opposed to medical care (Cohen et al., 2012). A person’s
socioeconomic status (SES) was a strong predictor of whether or not they got a colonoscopy
(Singh et al., 2010).
Other factors identified as barriers to screening were literacy and self-consciousness due
to being overweight, particularly among white women in the southeastern U.S (Arnold et al.,
2012; Cohen et al., 2012). Individuals with low literacy (defined as below a 9th grade reading
level) were more likely to agree or strongly agree that screening by FOBT was confusing,
embarrassing, and a lot of trouble (17.3%, 25.1%, and 16%, respectively) (Arnold et al., 2012).
Additional factors for people not getting screened include: too busy to have the procedure
done, too modest or embarrassed, feeling healthy with no symptoms or concerns, and finally, the
discomfort of the procedure (Jones et al., 2010; Hal et al., 2011).
Comparison of screening methods

Multiple methods of screening for CRC were compared in the studies. These methods
included: colonoscopy, flexible sigmoidoscopy, FOBT, and two types of fecal tests. Endoscopy,
namely colonoscopy, was found to be the most effective in detecting adenomas and CRC, with a
40% prevention rate (Nishihara, Wu, Lochhead, Morikawa, & Liao, 2013). It was, however, the
most expensive of all the screening types. (Weissfeld, et al., 2012). Current recommendations
for screening by colonoscopy are to have the procedure every 10 years (USPSTF, 2008).
Following behind a colonoscopy were flexible sigmoidoscopy and FOBT (Holme, et al.,
2014). These were both less costly than a colonoscopy and about equal in effectiveness.
Flexible sigmoidoscopy reduced CRC incidence by 20% and mortality by 21%. Multiple
screenings by flexible sigmoidoscopy were more effective than just one screening of the same
method. Screening by FOBT was more commonly used in people of lower income and/or
education and those without health insurance (Cohen, et al., 2012). Next, in both cost and
effectiveness, was an annual FIT followed by an annual low-sensitivity guaiac fecal occult blood
test (Quintero, Castells, Bujanda, Cubiella, & Salas, 2012; Telford, Levy, Sambrook, Zou, &
Enns, 2010). FIT was not able to detect adenomas in either the proximal or distal colon as
effective as a colonoscopy. However, both detected more stage I tumors than stage II or III
tumors (Qunitero et al., 2012). The decrease of morbidity for CRC for a low-sensitivity guaiac
fecal occult blood test annually versus a colonoscopy every 10 years was 44% and 81%,
respectively. The decrease in mortality for the same tests was 55% and 83%, respectively. No
screening at all was the least expensive and the least effective method.
Another factor that was commonly researched was the effectiveness of the endoscopy
methods for detecting proximal versus distal CRC. Colonoscopy was better able to detect
proximal colon cancers and there was less mortality for both distal and proximal colon cancers as

compared to flexible sigmoidoscopy or no screening at all. (Weissfeld, et al., 2012). There was
also a decrease in morbidity rate for both distal and proximal colon cancers up to 15 years after a
negative colonoscopy (Nishihara et al., 2013). It was also estimated that colonoscopy prevented
22% of proximal colon cancers and 61% of distal CRC. Flexible sigmoidoscopy only had a
decrease in morbidity and mortality for overall CRC of 21% and 26%, respectively (Schoen,
Pinsky, Weissfeld, Yokochi, & Church, 2012). This method was able to reduce morbidity and
mortality of distal CRC by 29% and 50% respectively, but only had a 14% reduction in
morbidity for proximal CRC as this portion of the colon is beyond the reach of flexible
sigmoidoscopy. Overall, there was a greater decrease in incidence and mortality for distal CRC
as opposed to proximal CRC.
CRC was more common in men with a rate of 56.4% (Schoen et al., 2012). Pre-
cancerous adenomas were also more common in men as well as older individuals (Strock et al.,
2011). Women, however, were more likely to have proximal CRC (Schoen et al., 2012).
Returning, or metachronous, CRC, defined as “appearing more than six months after the index
cancer and at least 5 cm distant from the primary cancer” (Pramateftakis et al., 2010, p. 63) was
also seen most often in men and was more common in the left colon with a rate of 75%. Another
difference between men and women was that there was a higher rate of missed or early CRC in
women after a negative colonoscopy as opposed to men (61% vs 47% respectively, p<0.001)
(Singh et al, 2010). There was also a higher incidence of proximal CRC after a negative
colonoscopy in women than in men (106 of 170, 62% vs 65 of 130, 50%, respectively; p=0.03).
CRC also increases with advance age and missed or early CRC was seen more in older people or
when the colonoscopy was performed by a non-gastroenterologist. The average age for first time
CRC diagnosis was 67, with 74 being the average age for metachronous CRC (Pramateftakis et

al., 2010). The highest cancer rates were seen in people aged 70-74 years (57.1 per 1000 people
screened) and between ages 65-69 years (57.0 per 1000 people screened) (Weissfeld et al.,
2011). The lower rates were in the people aged 60-64 (50.7 per 1000 people screened) and 55-
59 years of age (41.3 per 1000 people screened). This increase in diagnosis could be associated
with the fact that older people were more likely to be screened. Other factors associated with a
higher screening rate included people who had at least a college education or those who had a
history of CRC in their family. (Cohen, et al., 2011). Lower screening rates were observed in
individuals who did not have health insurance or who were or smokers. It is also important to
note that CRC was still a risk even after treatment (Pramateftakis et al., 2010). Therefore,
follow-up screenings are important. Overall, the research suggest that screening as
recommended does reduce the incidence and mortality rates of CRC.
Interventions to increase screening
The National Colorectal Cancer Roundtable (2015) currently has a campaign to have an
80% screening rate by the year 2018. There are multiple interventions that primary care
practitioners can implement to increase current screening rates and get closer to achieving the
goal of 80% by 2018. The following paragraph is information from the National Colorectal
Roundtable (2015).
The first method for increasing screening rates is to recommend screening for all patients
age 50 and greater. When providers do not tell patients about being screened for CRC as well as
the importance of it, they remain unaware. A second intervention is to be aware of current
screening rates at one’s particular practice and work on improving it. The third intervention is to
have reminders set in place for the provider, so in turn, this reminder can be sent to the patient.
Fourthly, inform patients about the multiple methods of screening when educating about the

importance of it. Even though some individuals may not be able to afford a colonoscopy, there
are other effective options available to them. Finally, be aware that most insurance companies
are required to cover screening for CRC, which means no out-of-pocket expenses for the patients
(National Colorectal Cancer Roundtable, 2015; Moloo, 2013).
Literature Critique
The strengths were that several longitudinal studies were used as well as a varied study
population was part of the research. The limitations of this research were as follows: there were
many observational studies; in some of the studies, the statistics were approximate estimations;
most of the studies only examined the relationships between colonoscopy and sigmoidoscopy;
finally, there was one study which used only volunteers, as this would skew the results of the
study.
Implications for Nursing
Education
With much focus on breast, lung, and prostate cancers, there is clearly much more
education needed in the realm of CRC. Nurses need to be educated on the fact that CRC remains
in the top five cancers worldwide. It is also important that Advanced Practice Nurses (APNs)
learn about the most effective screening methods in order to be more proactive in recommending
appropriate screening for patients. With more education, the hope is that there would be a
continued increased in screening and prevention.
Practice
As nurses and nurse practitioners are educated on the importance of screening for CRC,
and the different options available, this will change the way they practice by encouraging more
people to get screened. APNs must identify and utilize interventions that increase screening. It

is important for them to assist the patient in order to make the best decision for type of screening
method. It is also important for APNs to continuously ensure their patients are being screened in
a timely fashion.
Research
More research is needed to determine if the recommended age range should be lowered
from 50 to 40 as a few studies suggest that there are incidence rates even in this age range.
Earlier detection can further decrease morbidity and mortality rates. More longitudinal studies
could also be done to determine if the cut off age should continue to remain at 75. If lowering
the age is found to be necessary, this could save costs in the long run. On the other hand, if it is
found that the age needs to be increased, this could potentially further decrease incidence rates.

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