Improving Colorectal Cancer Screening Rates Among African Americans

Kelly Brittain, PhD, RN

Assistant Professor, Michigan State University College of Nursing

Colorectal cancer (CRC) is the third leading cause of cancer death among African Americans.¹ The CRC mortality rate among African Americans is 29.8% compared with 19.5% among Caucasians.¹ Overall, the incidence of CRC is 20% higher in African-American men and women, and the mortality rate is 45% higher, compared with whites.²

CRC is preventable when detected early through colonoscopy done every 10 years or through fecal occult blood test (FOBT) done annually.² However, CRC screening rates are well below 75%, and the rate among African Americans is 56% compared with 62% among Caucasians.¹

Previous research indicates that CRC screening interventions are modestly effective in increasing CRC rates among African Americans.³ Interventions such as mailings explaining the FOBT with a FOBT card, CRC screening reminders, printed materials and videos in waiting rooms, and healthcare provider recommendations have been methods cited to increase CRC screening rates among African Americans.3 Yet, CRC screening rates among African Americans remain virtually unchanged in the last 3 years.

What can oncology nurses do in busy clinics to increase CRC screening among African Americans? Having CRC screening materials that are visible, easily accessible, and specifically for African- American men and women that address barriers to screening, such as fatalism, CRC screening knowledge, and how to make an appointment has been shown to increase CRC knowledge and increase CRC screening adherence.^3,4

Past research suggests that delivering the CRC screening message in varying formats is important to increasing CRC screening.3 Traditional methods of delivering this message include mailings, leaflets, handouts, and videos. Newer methods of delivering CRC screening information include e-mail or links to websites or videos embedded in an e-mail or text message. In the future, there will be mobile apps that assist patients in making an informed decision about the type of CRC screening that is right for them. Delivering the CRC screening message in varying formats and at multiple time points may give oncology nurses additional opportunities to understand patient CRC screening values and preferences.

Other important factors in CRC screening include assessing the patient’s CRC screening values and preferences.^5,6 Knowing if there is a family history of CRC, if a family member or friend had screening, and what the patient has heard about CRC screening can elucidate how the patient values CRC screening, and potential barriers or facilitators to screening.⁴

Table. Colorectal Cancer by the Numbers¹⁰

(per 100,000 men/women)

White

Black

Incidence (Male)

51.3

64.3

Incidence (Female)

38.4

49.2

Mortality (Male)

19.1

28.7

Mortality (Female)

13.4

19.0

Research has shown that people with a family history of CRC may be more likely to adhere to CRC screening guidelines.⁷ However, oncology nurses should note that patients with a history of cancer may require additional support, as studies indicate that their cancer screening rates are no different when compared to cancer screening rates of people who have never had cancer and no family history of CRC.⁸ Previous research has found that patients have definite preferences for CRC screening related to certain test features.⁹ These preferences are often not communicated to their physician, which can lead to the lack of or delay in CRC screening completion.⁹

Acknowledging patient preferences may also reveal potential screening barriers. For example, if colonoscopy is chosen, will the patient have problems with transportation, the test prep, or taking a work day off? Oncology nurses have a great opportunity to match their patients’ values and preferences for CRC screening so that patients select a CRC screening test they want to do and can complete rather than doing nothing.

Family support has been shown to be an important factor in making an informed decision about CRC screening among African Americans.4 Assessing family support includes asking: Is there an important person who the patient will talk to about CRC screening, and does the patient know if that person will be supportive of CRC screening? These questions will give the oncology nurse an opportunity to provide additional information to patients that supports their decision to have CRC screening and that may aid patients when discussing their CRC screening decision with family and/or friends.

Oncology nurses and providers should incorporate one or more of these strategies to increase CRC screening in their practice: using CRC information specifically for African-American men and women delivered in varying formats and at multiple time points; learning about their patients’ CRC screening values and preferences, and assessing their patients’ family support for CRC screening.

Using these tools will increase the patient’s knowledge about CRC screening, support the patient’s CRC screening preferences, reduce potential barriers to CRC screening completion, and thus help in the effort to reduce the CRC health disparity among African Americans.

References

1. American Cancer Society. Cancer Facts & Figures for African Americans 2013-2014. http://www.cancer.org/research/cancerfactsfigures/ cancerfactsfiguresforafricanamericans/cancer-facts-figures-africanamericans- 2013-2014. Accessed October 2, 2013.
2. American Cancer Society. Colorectal Cancer Facts and Figures 2011-2013. http://www.cancer.org/acs/groups/content/@ epidemiologysurveilance/documents/document/acspc-028323.pdf. Accessed October 2, 2013.
3. Powe BD, Faulkenberry R, Harmond L. A review of intervention studies that seek to increase colorectal cancer screening among African Americans. Am J Health Promot. 2010;25(2):92-99.
4. Brittain K, Loveland-Cherry C, Northouse L, et al. Sociocultural differences and colorectal cancer screening among African American men and women. Oncol Nurs Forum. 2012;39(1):100-107.
5. Briss P, Rimer B, Reilley B, et al. Promoting informed decisions about cancer screening in communities and healthcare systems. Am J Prev Med. 2004;26(1):67-80.
6. Rimer BK, Briss PA, Zeller PK, et al. Informed decision making: what is its role in cancer screening? Cancer. 2004;101(suppl 5):1214-1228.
7. Rawl SM, Champion VL, Scott LL, et al. A randomized trial of two print interventions to increase colon cancer screening among first-degree relatives. Patient Educ Couns. 2008;71(2):215-227.
8. Schumacher JR, Witt WP, Palta M, et al. Cancer screening of long-term cancer survivors. J Am Board Fam Med. 2012;25(4):460-469.
9. Hawley ST, Volk RJ, Krishnamurthy P, et al. Preferences for colorectal cancer screening among racially/ethnically diverse primary care patients. Med Care. 2008;46(9 suppl 1):S10-S16.
10. National Cancer Institute. Surveillance Epidemiology and End Results. SEER Stat Fact Sheets: Colon and Rectum. http://seer.cancer.gov/ statfacts/html/colorect.html. Accessed October 2, 2013.