By Russell Stanley, DO, and Lauren Stanley, MSN
Dr. Stanley, Texas College of Osteopathic Medicine/University of North Texas Health Sciences Center, Fort Worth, Texas, and School of Medicine/Texas Tech University Health Sciences Center, Lubbock, Texas; Ms. Stanley, Texas College of Osteopathic Medicine/University of North Texas Health Sciences Center. Send correspondence to Russell Stanley, DO, 4701 81st Place, Lubbock, TX 79521 (Telephone: 325 829-8315); email: russell.stanley[at]ttuhsc[dot]edu.
The purpose of this study was to look at the differences in colorectal cancer screening awareness between two rural communities in Texas. In Clifton, patients have access to colonoscopies in their local hospital, while in Haskell, patients have to travel to a tertiary center. A 24-question survey pertaining to colon cancer from the Behavior Risk Factor Surveillance System (BRFSS) was given to patients at primary care clinics in Clifton and Haskell. To take the survey, participants had to have been patients for at least 1 year in either Clifton or Haskell clinic and be at least age 50 years or older.
A total of 168 surveys were collected, 92 at Clifton and 76 at Haskell. A higher odds ratio (OR=3.61; CI = [1.11, 11.69]) was seen in Clifton compared with Haskell for patient colon cancer screening awareness. Also, a higher odds ratio (OR=2.50; CI = [1.13, 5.54]) was found of knowing at what age a person should be screened for colon cancer in Clifton compared with Haskell. A higher odds ratio (OR=3.61; CI = [1.42, 9.20]) was seen in Clifton compared with Haskell for patients ever having a colonoscopy or sigmoidoscopy.
This study supports the idea that providing colorectal cancer screening and screening procedures locally in the rural community by family medicine physicians helps to contribute to an improved awareness of colorectal cancer screening guidelines as opposed to communities that do not offer screening locally.
In recent years, colorectal cancer has become a major cause of death in the United States. Having a colonoscopy has become the gold standard for screening and preventing colon cancer by primary care physicians and gastroenterologists.1 However, despite the technology available and the ability of trained professionals to use the technology, a high incidence of colon cancer and deaths from colon cancer in the United States still remains.1
In a rural setting, numerous barriers to colorectal cancer screening exist. Two barriers worthy of discussion in this paper are lack of patient education and understanding of colorectal cancer screening guidelines, and lack of patient compliance with colorectal cancer screening guidelines demonstrated by limited access to screening procedures in rural communities. The former problem focuses primarily on the physician-patient relationship, while the latter problem focuses on access based upon who is and who is not trained to perform the colonoscopy procedure at the local hospital.
This paper supports the contention that colonoscopy procedures performed by family practitioners in a rural environment can improve patient compliance with colorectal cancer screening guidelines. Secondly, this paper seeks to make an impact on rural medicine by showing that patient education regarding colorectal cancer should become a central part of rural practice. Finally, the paper emphasizes the need for rural family practitioners to receive competent training in colonoscopies during their residencies so they can offer colorectal cancer screening tools for their patients upon finishing their training. Thus, by offering colonoscopies as a screening tool in a rural community, the family physician can seek to improve patient education, patient outcomes, and patient compliance with colorectal cancer screening guidelines.
Background/Literature Review: Stein et al. explained several of the tenets of colorectal cancer screening guidelines based upon recommendations from the World Health Organization, the United States Preventive Services Task Force, and the American College of Physicians.1 First, average-risk adults should begin colorectal cancer screening at age 50 by choosing one of the several options for screening. One of these options is a colonoscopy, considered a gold standard that should be performed every 10 years. For additional average-risk screening, patients should receive an annual fecal occult blood test (FOBT) and receive periodic flexible sigmoidoscopy procedures with a follow-up colonoscopy.
Persons who have a family history of familial adenomatous polyposis (FAP) or Gardner syndrome are recommended to undergo genetic screening or a receive a colonoscopy every 12 months, starting at the age of 10-12 until they are 35-40 years old.1 Patients who have a first-degree relative diagnosed with colon cancer or adenomas when younger than 60 years, or those who have multiple first-degree relatives diagnosed with colon cancer, should have a screening colonoscopy every 3 to 5 years, beginning when they are 10 years younger than their youngest affected relative.1
Looking at demographic factors in relationship to colorectal cancer screening, Jerant et al. examined racial and ethnic barriers to colorectal cancer screening in their study.2 A 2001-2005 Medical Expenditure Panel Survey and a 2000-2004 National Health Interview Survey were used to evaluate 22,973 respondents on the basis of the variables of race and ethnicity.2 The major groups in the study were non-Hispanic whites, Asians, African Americans, and Hispanics. The major findings of the study indicated that socioeconomic status, access, and language barriers are some of the major barriers among African Americans and Hispanics for not participating in colorectal cancer screening. Lower colorectal cancer screening rates were found for women when compared with men across all ethnic/minority groups, screening modalities, and analytic models. The minority/non-Hispanic white disparities observed were more pronounced for endoscopy than for FOBT. This study clearly merits the idea that screening compliance is followed unequally between racial and ethnic groups.
Realizing the importance of colorectal screening and the lack of screening compliance, researchers have focused on understanding why patients are not complying in rural and urban areas. Davis et al. examined the barriers to colorectal cancer screening, comparing urban areas with rural areas.3 In their study, 972 patients who were not up to date with their colorectal cancer screening and were scattered between urban and rural areas of Louisiana were interviewed. Rural and urban participants alike had positive perceptions regarding FOBTs. However, rural patients were more likely to report positive attitudes regarding FOBTs, with low-income, rural patients less likely to be informed about FOBT protocol. This study points out the importance in educating rural patients to be aware of FOBTs and shows that income and educational level may become an issue to which rural physicians and rural hospitals have to respond as they develop a strategy to promote colorectal cancer screenings.
With a difference between rural and urban areas regarding patient colorectal screening, researchers narrowed their study aims towards focusing on rural health settings. When looking at the use of colon cancer testing in rural Colorado primary care practices, Overholser et al. found that many patients visiting primary care practices were not up to date with colorectal cancer screenings, and did not intend to be screened in the future, even when they would have access to procedures and screenings.4 When patients felt that they were in control of their own health, they were more likely to participate in recommended colorectal cancer screening practices. Patients were also more likely to be up to date with screening when they were in control of their health. Adhering to the screening guidelines does not solely apply to patients, however. The study found that when primary care providers were up to date with colorectal cancer screening guidelines and actively working to educate their patients about colorectal cancer screening, patients were more likely to participate in colorectal cancer screening procedures and tests. Therefore, it is noteworthy that patient education, patient compliance, patient autonomy, and physicians practicing evidence-based medicine are all intimately connected to each other for enhancing the physician-patient relationship.
Lastly, Jilcott Pitts et al. proposed several major findings regarding barriers to colon cancer screening in a rural setting.5 The purpose of their study was to examine the factors encouraging patients to pursue colorectal cancer screenings and to examine the numerous barriers to colorectal cancer screening in a low-income, rural population. The authors found that the high cost of the tests — in addition to the follow-up care, fear of the test (colonoscopy) itself, fear of cancer diagnosis, and fear of burdening family members — all served as barriers in colorectal cancer screening.5 Despite the numerous and possibly common barriers existing with colorectal cancer screening, a great issue remains with lack of patient access to trained physicians performing the colonoscopy procedures in a rural setting.5 Because of the costs and the burden on the family, this lack of access to care creates a burden for rural patients who want to comply with colorectal cancer screening guidelines.
To understand ways in which health care providers can increase compliance with the screening guidelines among the patient population, research has been conducted to determine the efficacy of different colorectal screening programs. Walker et al. conducted a study looking at an innovative training program to increase access to endoscopy in primary care.6 They sought to identify quality training elements for when primary care practitioners are providing successful colonoscopy screenings. The study was conducted in both rural and urban areas. The study not only identified the necessity of training primary care providers but also provided a format for proper endoscopy mentorship. The major findings of the study focused upon the large number of those who completed the structured colonoscopy training program and had a heightened awareness of the need to do a complete and thorough screening for colorectal cancer in their patient populations. In addition, a large number of program participants reported performing colonoscopies in their respective communities once they received the proper training on how to perform colonoscopies through the structured program. As a result, the study indicates that a connection exists between primary care physicians receiving proper training in colonoscopy and the physicians providing access to proper care in their local communities where they practice.
A study conducted by Newman et al. reports on the quality outcomes of family physicians performing colonoscopy in a rural setting.7 The study, working from the understanding that only 5% of family physicians offer colonoscopy services either in the office or in the hospital, examined data from 731 colonoscopies performed between 1996 and 2001 in a rural Virginia family practice. The researchers found that 29 cases in which the patients were referred to specialty care correlated directly with the pathological findings of the original examination performed by the primary care physician. In addition, the patients in the survey reported a high level of satisfaction with their primary care physician performing the procedure in a familiar setting. This adds credence to the assertion that more primary care physicians should be trained to perform colonoscopies in a rural health care setting to increase patient satisfaction, patient compliance, and accessibility to high-quality care.
Kolber et al. also conducted a study to evaluate the quality of colonoscopies performed in a rural area in Canada.8 The study involved 13 rural and suburban hospitals in Alberta. The study found that during a 2-month study period, 10 study physicians performed 577 colonoscopies. The overall conclusion of the study was that primary care physicians performing colonoscopies have the ability to achieve quality benchmarks in colonoscopy. Additional primary care physicians in endoscopy may improve patient access and decrease endoscopic wait times, especially in rural areas. This finding is significant given that access to care and concern about quality of care are important issues when colonoscopy is performed, especially in a rural setting.
This paper aims to show how the journey to overcoming barriers to colorectal cancer screening in rural areas starts with competently trained family physicians. The impetus of the paper focuses mostly on the physician-patient relationship with regard to physicians educating patients about colorectal cancer screening in the rural environment and providing colonoscopy within the context of the rural health care setting. Some family physicians are not trained to perform colonoscopies adequately in the rural setting; however, in other locations, rural family physicians are well trained and commonly perform colonoscopies. This paper will look at the evidence in favor of family physicians performing colonoscopy in the rural setting so as to improve patient compliance.
Description of the Communities: This study compared the Texas communities of Clifton and Haskell. In Clifton, primary care physicians at Goodall Witcher Hospital perform colonoscopies in the hospital to prevent their patients from having to drive to a tertiary center to get this examination; however, in Haskell, the physicians do not perform colonoscopies at Haskell Memorial Hospital. As a result, the patients in Haskell County must drive to a tertiary center 65 miles away to get a colonoscopy.
Study Sample: All men and women who were 50 years of age or older were eligible to participate in the survey. Age 50 years was chosen as a cutoff because standard colonoscopy screening guidelines state that this is the youngest age to begin colon cancer screening in a person with no prior history of colon cancer in his or her family. Informed consent was obtained before patients took the survey. Before participation was requested, approval was obtained through the University of North Texas Health Sciences Center (UNTHSC) Institutional Review Board (IRB).
Sampling methods: A 29-question survey pertaining to colon cancer from the Behavior Risk Factor Surveillance System (BRFSS) was given to patients at primary care clinics in Clifton and Haskell between July 2014 and February 2016. Clinic staff and the researchers collected surveys while patients were in the waiting room of the clinic prior to their doctor appointments. In addition, surveys were placed in the waiting room where patients could pick up a survey to fill out. All surveys were handed back to the researcher or placed in a locked box to be picked up by the researchers. To be eligible to take the survey, participants had to be patients of either the Clifton or Haskell clinic for at least 1 year and be at least 50 years old. Patients were given informed consent forms before they began the survey. Questions from the survey included information regarding demographics, family history of cancer, previous colorectal cancer screenings, and patient knowledge of colorectal screening guidelines.
Design: The design of the study was a cross-sectional design. The study protocol was developed in accordance with Health Insurance Portability and Accountability Act (HIPAA) guidelines, and patient confidentiality was protected throughout all phases of the study. In addition, the protocol was subjected to approval by the IRB at UNTHSC.
Statistical Analysis Plan: Logistic regression was used to look at an association between the two clinics and with three main outcomes: patient colon cancer screening awareness, knowledge of what age a person should be screened for colon cancer, and whether or not patients had ever had either a sigmoidoscopy or a colonoscopy. Colon cancer screening awareness is based on whether the survey participant knew correctly that there is a test to find colorectal cancer. Participants were asked at what age a person should be screened for colon cancer (18, 21, 30, 40, 50, 60, or 70) to determine patient knowledge of when a person should be screened. Since 50 years is the recommended age, this variable was collapsed to whether the participant correctly chose 50 or one of the other answers. For the last outcome, patients were given definitions of sigmoidoscopy and colonoscopy and were asked if they have ever had either of these procedures. Having one of them was chosen as the preferred outcome.
Potential covariates included patient race, age, gender, education level, employment status, income, and family history of colorectal cancer. The race variable was coded as the participant being either white or not white. Age was collapsed into ages 50 to 64 years and 64 years or older. Education level was coded as less than high school, high school graduate (including those who have a General Education Diploma), and 1 year or more of college. Employment was categorized as employed, self-employed, out of work, homemaker, student, or retired. The survey included an answer for those who were out of work for more than 1 year and those who were out of work for less than 1 year. These two variables were combined to make the single category of out of work. If survey participants marked an answer as not sure or did not know, then their answer was coded as missing and was not included in the analysis. Backwards selection was used for removal of covariates. All statistics were done by using SAS 9.3 with significance level of P ≤ .05.
A total of 168 surveys were collected, 92 at Clifton and 76 at Haskell. Of the collected patient surveys, 80% of patients were white, 62% of patients were female, and the mean age was 63 years. All descriptive statistics can be seen in Table 1.
Colon Cancer Screening Awareness
A higher odds ratio (OR=3.31; CI = [1.20, 9.17]; P=.02) for patient colon cancer screening awareness was seen in Clifton when compared with Haskell. Of the Clifton patients, 90% knew correctly that a test exists to find colorectal cancer, whereas only 77% of the Haskell patients correctly answered the question. Of those who correctly answered that there is a test for colorectal cancer from both Haskell and Clifton, 56% of the total respondents were patients at the Clifton clinic.
Patient Screening Age
A higher odds ratio (OR=2.38; CI = (1.11, 5.11); P=.01) of knowing at what age a person should be screened for colon cancer was found in Clifton compared with Haskell. The percentage of those who answered age 50 years was similar in both communities. However, Clifton had a slightly higher percentage (67%) than did Haskell (59%).
Ever having a colonoscopy or sigmoidoscopy
A higher odds ratio (OR=3.86; CI = (1.69, 8.82); P=.01) was seen in Clifton when compared with Haskell for patients ever having a colonoscopy or sigmoidoscopy after being adjusted for family history of colorectal cancer. In Clifton, 85% of the patients had ever had one of these examinations. For Haskell, 58% of the patients had undergone the examinations. Of those patients who had taken the examination, 65% lived in Clifton.
The higher odds ratio for colorectal cancer screening awareness in Clifton as compared with Haskell support the hypothesis that a higher level of knowledge for colorectal cancer screening is present in areas with primary care physicians who are interested in colorectal cancer patient awareness. The statistical analysis showing higher odds of knowing at what age a person should be screened for colorectal cancer in the Clifton clinic as compared with the Haskell clinic also supports this hypothesis. Both of these associations show that the patient population in Clifton is more likely to have a better foundational knowledge for when they should begin colorectal screening. Additionally, there is support for the notion that having primary care physicians within a rural community provide direct access to colorectal cancer screening tools, such as colonoscopies, helps to improve colorectal cancer screening awareness and to prevent colorectal cancer in the rural patient population.
Finding a higher odds ratio for patients ever having a colonoscopy or sigmoidoscopy in the Clifton clinic when compared with those in the Haskell clinic supports the hypothesis that Clifton has a higher compliance with screening guidelines. Therefore, patients among the population surveyed in Clifton are more likely to undergo screening for colorectal cancer in comparison with the patient population surveyed in Haskell. This association further supports the proposition that having direct access to colorectal cancer screening tools in a community helps to promote colorectal cancer prevention and knowledge among the patients.
Overall, this study supports the idea that having family medicine physicians perform colonoscopies within a rural community leads to higher odds of rural patients being aware of colorectal cancer screening and of following the colorectal cancer screening guidelines. Therefore, it is beneficial to have colonoscopies performed locally in a rural community in order to better prevent colorectal cancer.
The findings of this study imply that rural residency programs for family medicine should continue to offer colorectal cancer training to future rural family physicians. Training these future rural physicians provides opportunities to improve both patient knowledge and patient compliance with colorectal cancer screening guidelines. Previous research done by Newman et al. and Kolber et al. is consistent with the findings in this paper, suggesting that improving access to colonoscopies in rural settings and training more family physicians to provide colonoscopies in rural hospitals will improve colorectal cancer awareness in the rural healthcare setting.7,8
The study has several limitations. The first limitation is that this study compared only two rural communities within Texas. While the comparison led to important results for rural communities, the study can only be generalized to rural communities in the state of Texas. The second limitation was the number of surveys collected. While significant results were found for the sample size, only 92 surveys were collected in Clifton and 76 in Haskell. This small sample size, due to the small population size, resulted in wide confidence intervals and, therefore, results that are not precise. For future studies, researchers should consider including numerous rural clinics so as to analyze a larger sample and have more precise results. One other limitation is the design of the study. All data were collected through a survey at one point in time, making this study a cross-sectional study. Therefore, strong causality inferences cannot be made and only association can be inferred.
Other studies are needed to evaluate whether impediments such as lack of insurance, travel distances, gas prices, or other economic and medical access issues have any significant impact on patient awareness or compliance with guidelines for colorectal screening. A follow-up study is also needed to target patients’ preferences with regard to having a colonoscopy performed by a physician in their own rural community versus having to travel to an urban center. Targeting these patient preferences may lead to some valuable results that can further help in the prevention of colorectal cancer.
1. Stein DE, Geibel J. Colonoscopy. August 1, 2012. Available at: http://emedicine.medscape.com/article/1819350-overview?src=emailthis. Accessed August 24, 2013.
2. Jerant AF, Fenton JJ, Franks P. Determinants of racial/ethnic colorectal cancer screening disparities. Arch Intern Med. 2008; 165 (12):1317-1324.
3. Davis TC., Rademaker A, Baily SC, et al. Contrasts in rural and urban barriers to colorectal cancer screening. Am J Health Behav. 2013; 37 (3):289-298.
4. Overholser L, Zittleman L, Kempe A, et al. Use of colon cancer testing in rural Colorado primary care practices. J Gen Intern Med. 2009; 24 (10):1095-1100.
5. Jilcott Pitts SB, Lea CS, May CL, et al. “Fault-line of an Earthquake”: A qualitative examination of barriers and facilitators to colorectal cancer screening in rural, Eastern North Carolina. J Rural Health. 2013; 29 (1):78-87.
6. Walker T, Deutchman M, Ingram B, Walker E, Westfall JM. Endoscopy training in primary care: Innovative training program to increase access to endoscopy in primary care. Fam Med. 2012; 44 (3):171-177.
7. Newman RJ, Nichols DB, Cummings DM. Outpatient colonoscopy by rural family physicians. Ann FamMed. 2005; 2 (2):122-125.
8. Kolber M, Szafran O, Suwal J. Outcomes of 1949 endoscopic procedures performed by a Canadian rural family physician. Can Fam Physician. 2009; 55:170-175.