Colorectal cancer, which includes cancers of both the colon and rectum, is the second-leading cause of cancer-related deaths in the United States. Only lung cancer claims more lives. An estimated 135,000 new cases and 56,000 deaths from colorectal cancer are expected in the coming year (MMWR. 2003;50:162-166).

Since the mid 1990s, the proportion of the U.S. population reporting having undergone colorectal cancer screenings has increased slightly, however, it  remains low. Various factors may contribute to the continued under utilization of these tests, including lack of knowledge by both public and health-care providers regarding the effectiveness of screening combined with low reimbursement rates for health-care providers who perform screening tests.

Colorectal cancer, however, is one of the most treatable forms of cancer when diagnosed early.  Research indicates that colon cancer screening can reduce cancer risk by as much as 90%. Advanced colorectal cancer is preventable through regular testing and through the removal of polyps (adenomas) in the colon, which may grow into cancerous tumors.  Regular preventive testing, such as a yearly Fecal Occult Blood Test (FOBT), a Sigmoidoscopy and Colonoscopy are widely recommended for adults ages 50 years and older and can significantly lower the chances of being diagnosed with advanced colorectal cancer.
 
In Southeastern Pennsylvania in 2000, approximately 1,300 adults died of colorectal cancer (Department of Public Health, 2000).  Many more have undiagnosed colorectal cancer as well as other colorectal problems. The following data from the PHMC 2002 Southeastern Pennsylvania Household Health Survey describe the colorectal screening utilization patterns among adults ages 50+ in the region. 

Blood Stool Test for Colorectal Screenings

There are several types of screenings or diagnostic tests used to screen for colorectal cancer.  Of these, the annual fecal occult blood stool test (FOBT), for persons age 50 years and older, is noteworthy for both its low cost and noninvasive characteristics.

• In Southeastern Pennsylvania, more than one half (52.1%) of adults ages 50 years or older have not had a FOBT in the past year; this percentage represents 570,200 adults who have not had this important screening.  Slightly more than one in five adults (22.4%) ages 50+ have never had a FOBT, representing 245,000 adults. 
• The percentage of adults in the region who have not have a FOBT in the past year is slightly higher than the Healthy People 2010 objective of at least 50% of adults aged 50+ who receive a FOBT within the preceding year. 
• The three main reasons given for not receiving a FOBT are: not needing the test (30.1%), the test was not recommended by a doctor (27%), and a lack of motivation to get the test (8.8%).
• Women 50 years of age and older are more likely than men of the same age group to have not received a FOBT in the past year (56.3% versus 47%) despite the fact that women tend to access the healthcare system on a more regular basis.     
• Almost six in ten (59.5%) adults ages 50-59 have not had a FOBT in the past year.  This is higher than for adults ages 60-74 (47.6%) and adults 75+ (46.1%). 
• Black adults ages 50 and older (44.3%) are less likely to have not had a FOBT in the past year than Latino (45.5%), Asian (52.2%), or white (54.2%) adults of comparable age.
• Uninsured adults are much more likely to have not received a FOBT in the past year compared to insured adults.  Almost nine in ten (86.3%) uninsured adults ages 50+ have not had a FOBT in the past year compared to one-half (51.4%) of insured adults.

Sigmoidoscopy and Colonoscopy

Sigmoidoscopy and Colonoscopy are two additional colorectal cancer screenings that allow for an examination of the colon, the lining of the rectum or a portion of the large bowel for abnormalities. These state-of-the-art technologies have profound lifesaving detection capabilities.  The following highlights the utilization patterns for these important screenings.

• In SEPA, slightly more than four in ten (42.7%) adults ages 50 years and older have never had a Sigmoidoscopy or colonoscopy.  This percentage represents 473,300 adults in the region, and falls short of the Healthy People 2010 objective of at least 50% of adults ages 50+ having ever received a Sigmoidoscopy or Colonoscopy. 
• The three main reasons given for not having these tests are: Don’t think the tests are needed (31.4%), doctor never recommended the tests (29.4%), and lack motivation (6.8%).
• Women 50 years of age and older (47.6%) are more likely than men (36.8%) to have never had a Sigmoidoscopy or Colonoscopy. 
• Younger adults ages 50-59 (52.1%) are more likely than older adults ages 60-74 (38.1%) and adults ages 75+ (33.1%) to have never had a Sigmoidoscopy or Colonoscopy. 
• Asian adults ages 50 years and older (55.5%) are more likely than Latino (48.3%), white (43.2%) or African American (39.6%) adults to have never had a Sigmoidoscopy or Colonoscopy.
• Uninsured adults ages 50 years and older are one and one half times as likely as insured adults to have never had a Sigmoidoscopy or Colonoscopy (72.1% versus 42.1%, respectively).  
• Adults ages 50+ who live below the federal poverty level (45.7%) are more likely than non-poor adults (42.3%) to have never had a Sigmoidoscopy or Colonoscopy.
• Slightly more than four in ten adults (42.1%) with a regular source of care have never had a Sigmoidoscopy or Colonoscopy.  Although this percentage is high, it is lower than compared to adults without a regular source of care (52.1%).   

Despite their efficacy in reducing incidence and mortality from colorectal cancer, these valuable screening tests are underutilized.  In addition, certain population groups are more likely to have not participated in these tests.  Women, the uninsured, and the poor are three such groups that suggest opportunities for further study.  Efforts to address barriers and to promote the use of colorectal cancer screening should be intensified. 
For more information about the above findings, contact Francine Axler at Francine@phmc.org

Visit the following websites:

Screen for Life: National Colorectal Cancer Campaign
http://www.cdc.gov/cancer/screenforlife

A Call to Action: Prevention and Early Detection of Colorectal Cancer
http://www.cdc.gov/cancer/colorctl/calltoaction/slide_index.htm.

Notes:

As is true with many cancer screenings, there is some controversy regarding how often one should have colorectal cancer screenings.  Currently, regular preventive colorectal cancer screening include a Fecal Occult Blood Test (FOBT), Sigmoidoscopy and/or Colonoscopy.  The FOBT is recommended for adults ages 50 years and older on an annual basis.  This test can be done using a home testing kit or in a doctor’s office.  The recommendations for Sigmoidoscopy or Colonoscopy vary depending on the health history of the individual.  A Sigmoidoscopy is generally recommended every five years or every two years for high-risk individuals.  High risk is defined as someone who has colorectal disease-related symptoms, a history of colon cancer, or inflammatory bowel disease.  A colonoscopy is recommended every 10 years for a person without known risk.