Tackling disparity in colorectal cancer screening

Colorectal cancer is becoming a disease of poverty.

U.S. colorectal cancer incidence rates have decreased significantly since 1998, with credit for the improvement largely going to endoscopic screening that detects and removes polyps that could become cancerous.

In 2005, more than 141,000 new cases were diagnosed, and 53,000 people died of colorectal cancer, which is the second-deadliest cancer behind lung cancer. Timely endoscopic screening and polyp removal could reduce as many as 90 percent of the colorectal cancer cases.

The national colorectal cancer screening rate for those 50 and over is 61 percent. Those who are screened are overwhelmingly white and have insurance. American Cancer Society researchers have found that, with screening, colorectal cancer incidence rates especially have decreased specifically for whites 65 and over covered by Medicare in the last decade. Not coincidentally, Medicare began reimbursing physicians for selected screening tools in 1998 and 2001.

In contrast, screening and incidence rates have not decreased for blacks and Hispanics, even for those on Medicare. Both groups overall have higher rates of uninsured and less access to health services.

A recent study published in Cancer Epidemiology, Biomarkers & Prevention starkly quantified these disparities in Tarrant County. A research team, led by assistant professor Samir Gupta of the University of Texas Southwestern Medical Center, used data from the JPS Health Network to determine the screening rates in the safety-net system for the uninsured, Medicaid patients and other vulnerable populations.

The team looked at 2006 records of more than 20,000 screening-eligible patients ages 54-75. The result: Only 22 percent had been screened. Those with insurance, Medicare or Medicaid were almost three times as likely to be screened, and those who saw the doctor regularly were almost four times more likely to be screened.

"Once you controlled for [insurance and regular doctor visits], the screening rate dropped to 4 percent," Gupta said.

About 15 percent of the patients lived below the poverty line, and the median household income was $35,419. Most were either black or Hispanic, and about 20 percent spoke a language other than English.

Gupta said JPS Hispanic screening rates actually exceeded those of whites, underscoring the fact that access to care trumps ethnicity as a determining factor. He also noted that patients of JPS Connection, the network’s primary care clinics for the uninsured, had screening rates similar to those under private insurance.

Gupta praised JPS’s subsequent outreach efforts. A team of doctors — headed by Jay Haynes, Elizabeth Carter and Mark Koch — developed a program that sends out fecal occult blood testing kits to those 50 and over and contacts the patients by phone to encourage return of the tests. Results are sent to patients and their physicians for follow-up.

The program has grown from 600 contacts annually to 6,000, with a 24 percent return rate. The screening rate for the uninsured has almost quadrupled to 15 percent.

While the program covers only a fraction of the screening-eligible population, it is a laudable effort to mitigate what can result in potentially fatal healthcare disparities.

For that, the doctors and management team at JPS deserve recognition and applause.

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