This study found that the predictors of CRC screening adherence were largely similar between FDR of people with CRC and the general public. Moreover, FDR were more likely to have had a discussion with a doctor regarding CRC screening and be adherent to screening recommendations than the general public. This suggests that many members in the group understand the increased risk. However, it is still likely that many do not.
Efforts to improve CRC screening among FDRs of people with CRC should focus on tailored communications specific to the population and their increased risk for the disease. Tailored communications have been shown to be about twice as likely to result in colonoscopy compared to more general communications . In addition, having the FDR with CRC advocating for screening to their relatives at increased risk is an effective way to reduce barriers related to fear of or apprehension to the procedure .
Promoting CRC screening may not benefit some of the population who would undergo the procedure but cannot due to cost issues. CRC screening is now provided largely without cost sharing for those insured ; however, one-third of participants in this study still reported paying some or all of the costs out-of-pocket. As this study found, being in poverty, uninsured, or covered by Medicaid were among the strongest associated variables with adherence. This is not limited to CRC screening, financial hardship has been associated with decreased likelihood of undergoing screening for breast and cervical cancer as well .
Among FDR of people with CRC, Medicare insurance was associated with reduced odds of colonoscopy compared to private insurance. This was not observed among the general population. The reason for these conflicting results are unclear. Medicare covers CRC screening at no-cost unless a polyp is detected, in that event, it is no longer considered screening and cost-sharing applies. About half of all participants in this study with a FDR with CRC reported polyps. It is possible that people are avoiding the procedure because of the anticipated out-of-pocket costs.
The concept of financial toxicity, the negative outcome that results from perceived ‘subjective financial distress’ and ‘objective financial burden’, has become widely accepted among people with cancer . It puts patients with cancer at greater risk for medical non-adherence, the delaying, rationing, or foregoing of needed care in attempt to reduce costs . I suggest that a similar phenomenon may be occurring here where people may be forgoing CRC screening because of the potential costs. Interestingly, the study did not observe an association between self-reported healthcare affordability issues and CRC screening. As the models also included health insurance coverage, Medicaid enrollment, and household income, all related to CRC screening and also likely to healthcare affordability, it is possible that these mediate the previously reported relationship .
Groups like the American Cancer Society advocate for eliminating cost-sharing associated with cancer screenings to improve adherence among those with more limited finances . Sweeden implemented universal free mammography for females age 40–74 in 2016; previously the charge was approximately $23 US dollars on average. This resulted in statistically significant increases in adherence among females with the lowest incomes and in areas with higher cost sharing .
Another finding of the current study is that while Black Americans were more likely to be adherent to CRC than their white peers. This finding is inconsistent with earlier reports . Interestingly, in the current study, among people with a FDR with CRC there was a trend for reduced adherence among Black Americans compared to Caucasians, but it was not statistically significant. A prior study found that among Black Americans, a familial history of CRC did not increase adherence rates, but did for all other racial groups . In a post-hoc analysis, the current study found that Black Americans with a family history of CRC were more likely to be adherent to screening recommendations (70% compared to 61%; p = 0.040; data not shown).
Efforts to increase adherence in the Black and African American community in recent years seem to have been effective, possibly even more effective among those with a FDR with CRC. Additional efforts are needed among members of other racial groups and the Hispanic community who still have lower rates. In particular, patient navigators, a specifically trained person who helps a person obtain medical care, are beneficial for increasing screening rates but availability is still limited and some patients are hesitant to use the services .
The association of lower CRC screening adherence among males who are FDRs of a person with CRC is novel. A prior study using the 2005 California Health Interview Survey had very contrary findings. The researchers reported that females who had a familial history of CRC (first- or second-degree relatives) were 17% less likely to be adherent than their male counterparts . Among those without a family history of CRC, neither the current study nor the former found an association between gender and CRC screening adherence among the general population. Other studies regarding in the general population have reported mixed results . Additional research is needed to clarify the inconsistent results and determine the causes of any gender-based disparities.
The strength of the study is its large and nationally representative sample. However, it is not without its limitations. All measures were patient self-report and may not reflect actual screening behaviors or other measures. As with all observational studies, causality cannot be assumed for the associations found. Additionally, the data was collected in 2015 and may not be representative of current trends. While the NHIS is now collecting data for the CCS annually with each survey, the content is rotating and rather limited. It is unclear if/when the colorectal screening behavior and family history modules will be collected concurrently in future years. Lastly, the study was conducted in the United States, a country without universal healthcare coverage, and findings may not generalize to other countries.
Despite these limitations, this study adds to limited, although growing, body of literature regarding the screening behaviors of FDRs of people with CRC. The data suggests that although FDRs of people with CRC are more adherent to screening recommendations than their peers, about one-quarter still are not. Additional outreach is needed to members of the Hispanic community and those who identify as a race other than Caucasian or Black. If these measures are designed to target those with FDRs with CRC, tailored communications to members of that group will likely be more effective than more general communications regarding CRC screening. There is also a need to increase accessibility of CRC screening as living under the poverty level, being uninsured, or enrolled on Medicaid were among the strongest predictors of adherence.