It chips away at quality of life. It shaves years off a
lifetime. It's the
second leading cause of death from cancers affecting
both men and women. And despite its unique status as a
preventable cancer, the
National Cancer Institute's 2013 report revealed the
nation's colorectal cancer (CRC) screening rate is only
60%, lagging way behind cervical and breast cancer with
screening rates of 73% and 80%, respectively.
The American Cancer Society's map of
states' CRC screening rates provides a quick visual
of rural screening disparities, the mostly-rural states
prominent in darker green. According to
Healthy People 2020 (HP2020), only 58% of
nonmetropolitan residents were screened in 2015, compared
to 63% of metropolitan residents. For people
never screened, a 2013
Centers for Disease Control and Prevention (CDC)
report shows a similar rural disparity. Rural
disparity is also demonstrated by a recent
Arizona study. According to Arizona's state cancer
registry, rural residents presented with more advanced
CRC disease, thought largely due to inadequate screening.
And a July 7 CDC
MMWR Rural Health Series report delivering focused
details on rural-urban cancer incidence and death rates
said that "disparities could be attributed to differences
in adherence to screening guidelines."
Dr. Van Breeding, Director of Clinical Services at
Mountain Comprehensive Health Corporation in rural
Whitesburg, Kentucky, said he thought that, as much as
their patients allowed, their clinic did a good job
providing preventive care, including CRC screening. But,
their 2012 baseline data for that quality measure came as
When I found out we were only 19%, I said, 'That's
horrible! We've got to do better than that!'
"When I found out we were only 19%, I said, 'That's
horrible! We've got to do better than that!'" Breeding
In Idaho, Heather Hodges, Director of Quality Improvement
at Clearwater Valley Hospital and Clinics in Orofino and
St. Mary's Hospital and Clinics in Cottonwood, said they
also found their CRC screening rates were hovering around
50%, less than the HP2020's goal of 70%.
"Once you've seen your baseline," Hodges said, "you're
motivated to get where you need to go."
Where CRC Screening Starts: Talk. Talk. Talk.
recent American Cancer Society survey showed that
"nearly all unscreened people knew they should be
screened." Many who hadn't completed screening assumed if
they had no family history, they were at no risk for the
disease. Others perceived the test was expensive,
complicated, painful, embarrassing, and only needed for
worrisome symptoms. With information like this, many
providers feel that talking about CRC screening seems not
only delicate, but time-intensive in order to dispel
myths about screening, especially when discussions around
other cancer screenings are often as simple as "It's time
for you to make an appointment for a pap smear/mammogram/
So, talking about colon cancer screening includes a
lot of talk. There's the talk about home testing of
feces versus a colonoscopy. If interest is in the latter,
there's more talk. Talk about seeing another provider who
does the test, followed by talk about getting the
prescription for the colon purge medication. And more
talk about why the colon lining needs to be "clean" so
the fiber-optic hose traversing the private area of the
body can see small abnormalities. If a patient is
interested in the home feces test instead, there's even
more talk about the how-to's on feces collection and the
need for yearly checks. So, for providers and patients
alike, CRC screening involves talk, talk, and more talk.
But Whiteburg's Breeding insists it doesn't take
that much time — and that "talk" was exactly the key to
launching their Appalachian community's CRC screening
success. He said their effort started with everyone in
their clinic talking about it: from check-in personnel to
lab team members to providers — everyone started
talking about colorectal cancer screening.
We got everyone who had contact with the patient to talk
about it, starting with a simple question: 'Have you ever
been screened for colon cancer?'
"We got everyone who had contact with the patient to talk
about it, starting with a simple question: 'Have you ever
been screened for colon cancer?'" Breeding said.
Clearwater Valley's Hodges said they used a similar
approach, talking with everyone eligible for screening.
Using an electronic record indicator, providers were
reminded to talk to unscreened patients during any
appointment scheduled for any reason. In addition to
talk, they mailed reminders to patients.
"We're renegades out here and we wanted to do things our
way," Hodges said. "I did some research on primary care
strategies and methods geared to increasing colon cancer
screening, and we decided one of the first places to
start was at 'point of care.' No matter why patients were
at the clinic, if we'd see those patients needing
screening, it was an opportunity, and we'd talk about
Why Screen? Simple Answers
According to the CDC, with current screening rates, there
over 135,000 new cases of colorectal cancer diagnosed
yearly, along with over 50,000 deaths. And if diagnosed
at a stage where it is metastatic, spreading outside the
lining of the colon and invading the liver, lungs, and
bones, 5-year mortality data shows that survival
rates are only 5 to 13%. Screening can improve all
In addition, data surrounding costs and disability help
make the case for screening campaigns. Aside from the
associated with the emotional and physical aspects of
having colorectal cancer, research also demonstrates that
for the elderly, it is one of the most
expensive cancers to treat, with projected costs of
$17.7 billion by 2020. And a study published in the
Journal of the National Cancer Institute
concluded that, compared to patients with breast and
prostate cancer, colorectal cancer patients had higher
"excess medical expenditures" and "excess employment
Despite the benefits of screening, Hodges and Breeding
said they still met some organizational challenges to
their screening programs. Both shared that their most
powerful tool in overcoming these challenges was a simple
statement: "But, colon cancer screening is the right
thing to do."
Rural CRC Screening: Who Are We Screening? When Are We
screening guidelines are provided by the U.S.
Preventive Services Task Force (USPSTF) and apply to
rural and urban populations alike. No one is considered
"low-risk," so recommendations start with those of
"average risk." For people without personal or family
history of colorectal cancer, screening should start at
age 50 and continue until age 75, the frequency depending
on the screening test chosen. For those aged 76-85, the
screening decision should embrace a patient's overall
health status, noting that there may be some benefit for
those never screened. If a family history of colon cancer
is present, screening
starts earlier, aligned with the age the family
member's cancer was diagnosed. Still other
recommendations exist for those with inflammatory bowel
disease, like Crohn's and ulcerative colitis.
What is your personal risk for developing colon cancer?
The National Cancer Institute provides a risk assessment
But, for Breeding in Appalachia, "risk" had a different
meaning. After first learning about his clinic's baseline
screening rates, he began to think about growing up in
Whitesburg, getting his entire education in Kentucky –
he'd even been a patient at the very clinic he now serves
in this Appalachian region. He suddenly realized that his
family, his friends, his community, all were living in an
area that colorectal cancer seemed to own, an area where
its incidence and death rates are the highest in the
country. Added to this was the discovery that, during his
own screening, a precancerous polyp was detected.
"With no risk factors other than living here, my own
results really made me an advocate to make it easier for
patients to get screening done," Breeding said. "And we
needed to make people realize how important it is to have
this done. You might not have any history but, by
waiting, you might end up having colon cancer."
CRC Screening Importance: Prevention and Early
CRC screening uses two strategies: a head start
approach, and the yearly hunt approach.
Most colorectal cancers start with a bud-like structure
in the lining of the large intestine called a "polyp."
Over a 10-year period of time, a polyp can turn into
cancer. A procedure called a colonoscopy uses a lighted
tube to not only see a small polyp, but remove it,
getting a 10-year head start on preventing colon
When colonoscopy is not an option, either by choice or
by circumstance, a yearly hunt for intestinal blood is
used for screening. Since a pre-cancerous polyp or
full-blown colorectal cancer has blood vessels that
become damaged and bleed as feces pass by, intestinal
blood sticks to the stool and can be detected by
special tests. But, because polyps and cancers don't
always bleed, this test must be done yearly in order to
stay on top of any previously non-bleeding polyp, or to
detect an existing cancer before it spreads outside of
"Screening rates are lower in rural areas, where
geography causes barriers like lack of access to
providers and lack of specialists or access to those
specialists," Joseph said. "In some states, there are
hundreds of miles between the patient and the nearest
endoscopist. But, regardless of location, I tell
everyone, rural and urban, you can improve rates by
knowing your population. Know the number of endoscopists
in your area, know the population you are trying to
reach, know the income limits, and know insurance
She emphasized that knowledge about available resources
helps providers and patients decide on the best CRC
screening test. Joseph also pointed out that
evidence-based interventions such as reminders work well
in rural areas and can help small communities improve
screening rates. For patients, who often are dealing with
acute health problems or multiple chronic problems,
reminders are useful tools. For providers with multiple
high-priority tasks during an office visit, chart
reminders may prompt a short conversation about screening
But, regardless of location, I tell everyone, rural and
urban, you can improve rates by knowing your population.
In the recently released CDC report, cancer screening
programs that focused on a population approach were
further emphasized: "The goal is to work with health care
systems, health care payers, health care purchasers, and
other partners to implement interventions that address
barriers such as providing transportation assistance,
having clinics with modified hours, and providing
assessment and feedback reports on clinical practice
performance. Communities with lower screening rates or
higher incidence of and mortality from cancer might
particularly benefit from these interventions."
Many resources are available for organizing CRC
screening efforts in advance of Colorectal Cancer
Screening Month, March 2018:
Idaho's Orofino and Cottonwood teams began their CRC
project as part of their holding organization's push for
quality improvement. After researching options and
methods, they decided on a three-pronged approach: get
baseline data, use mailed and electronic reminders, and
take advantage of "health touch" moments, whether talking
with a patient during an office visit or reaching
patients at public health-oriented events.
Hodges said the subject of CRC screening is a bit
distasteful, but this can't prevent healthcare
organizations from doing community outreach. For example,
she and a medical provider even presented at a lunchtime
Rotary meeting where, despite the topic, they were
Proving how rural organizations can align with Dr.
Joseph's recommendations, Hodges said her organization
understood that, even though their community had
colonoscopy providers available (family medicine
physicians and gastroenterologists), for many patients,
their payer coverage for this procedure was lacking. So
instead of a colonoscopy, screening efforts also included
FIT testing, or fecal-immunochemical test: the test that
tracks intestinal blood shed from pre-cancerous polyps
and existing colon cancer.
"At first, our providers doubted the FIT results because,
in one calendar year of 250 tests, 123 were positive,"
Hodges said, "but, when the follow-up colonoscopies
showed that around 30 were abnormal, but not cancer; and
another 49 had precancerous pathology and 1 had invasive
cancer, they realized that the test was saving lives."
Hodges shared that one key to improving rates was sheer
competition using data transparency. In their clinic
setting, a flat screen TV with rotating information
showed screening rates accomplished by individual
"I'd always heard this worked, this internal
competition," she said, "and it did."
Hodges learned that, in addition to patient education,
the staff also needs education around the basics of colon
"It's two different conversations," she noted. "Staff
education is different from educating patients. Staff
education needs to be around documentation, how to have
conversations about screening, how to screen, why to
screen, and using staff education guidelines are
According to Hodges, their clinic went from 52% to 69% to
now setting a goal of 75% for 2017, well on target for
meeting the National Colorectal Cancer Roundtable's goal
of 80% by 2018, despite having patients in the
denominator who will always choose not to be screened.
Hodges also emphasized that their clinics' screening
process was a heavy lift for everyone. But, when she
reminds staff that what they've done added the equivalent
of more than 18,000 sunsets to the lives of those in
their community, everyone realizes the effort is
High-Risk Rural Kentucky: CRC Screening Means
Breeding said it was one thing to be surprised by their
clinic's CRC screening rate of less than 20%, but
surprise became concern when their clinic's quality
director came to him with the news they'd been contacted
by an outside agency wanting to help improve rates.
I suddenly felt ashamed, ashamed to think someone from
the outside was going to have to come here, tell me how
to be a good physician, a good steward for my community.
"I suddenly felt ashamed," Breeding said, "ashamed to
think someone from the outside was going to have to come
here, tell me how to be a good physician, a good steward
for my community. I knew I had to do something
immediately. We couldn't wait."
Before the outside agency had a chance to gear up,
Breeding launched a grassroots effort, starting first by
engaging their clinic's quality committee members.
Breeding said the momentum for colon cancer screening
built fast. A focus team emerged, spreading the effort to
every clinic staff member and all providers. Soon,
everyone was talking about CRC screening.
"Patients started hearing about it, over and over again,"
he said, "and it just wasn't something they wanted to
worry about. But, after what happened with my screening,
it made it easier for patients to understand."
Again, as the CDC's Joseph suggested, success came from
knowing the population. Breeding said they talked to
their area insurance carriers about ensuring colonoscopy
coverage. They also discovered that patients without
insurance could get assistance from the health department
due to the area's high risk. Next, the local hospital
decided to improve the endoscopy area, and the area's
surgeons, who performed the colonoscopies, immediately
accommodated a structured approach to direct screening.
Mondays and Fridays became designated testing days to
accommodate prep and recovery times.
According to Breeding, many factors drove their screening
rates from 19% to 73% by May of 2017, but one of the most
powerful was a new dynamic that emerged in their
tight-knit community: when community members looked into
the face of a family member, a friend, a neighbor, and
realized that person was living in an area of high
colorectal cancer incidence and death rates, they
encouraged one another to get screened. With this effort,
Breeding shared that more than 30 lives have been saved.
Their new screening goal — their community's
goal? It's now 100%.
Among the many lessons learned in this effort was
patients' understanding that the clinic was not just a
place to come when sick, but a place to come to get, and
stay healthy. According to Breeding, the clinic is now
leveraging those methods that worked to improve CRC
screening to improve all cancer screening, immunization
rates, and hypertension and diabetes control.
We learned, while working to make colon cancer a core
topic, that we were able to do dramatic things,
"We learned, while working to make colon cancer a core
topic, that we were able to do dramatic things,
exceptional things," Breeding said. "We went way above
what anyone predicted we could do. This was an
exceptional accomplishment not by me, not by our staff,
not by our clinic, but by our whole community. And that's
what it takes to accomplish a feat like this. It takes
exceptional dedication, perseverance, and hard work by
the whole community."
With a perspective gained from many years as a physician practicing in rural and urban locations, Dr. Kay Miller Temple writes on a variety of rural health topics and programs for RHIhub's Rural Monitor and Models and Innovations. She has a master's degree in Journalism and Mass Communication. Full Biography