Colon Cancer Screening Coverage Tripled in Poor Bronx Community when Hospital Made Simple Interventions, Finds Study in Academy???s Journal of Urban Health

NEW YORK CITY, April 20??? With fewer than half of older adults getting screened for colon cancer, an important new study has found that screening coverage immediately tripled in one of the nation???s poorest urban neighborhoods after a local Bronx hospital made simple interventions. The study is co-authored by Academy researchers and appears in the current issue of the Journal of Urban Health: Bulletin of The New York Academy of Medicine.

These pronounced improvements were observed in the community served by Lincoln Medical Center, a New York City public hospital, after the hospital streamlined the colonoscopy referral process and hired two ???patient navigators??? to help consumers overcome healthcare system hurdles. Researchers also found that the rate of screening colonoscopies performed in the hospital itself doubled after the changes were adopted, and the rate of broken colonoscopy appointments was reduced by 60 percent. The study is a collaboration of The New York Academy of Medicine, Columbia University, and Lincoln Medical Center.

Though screening tests for colon cancer are significantly underutilized, they are highly effective at detecting cancer early and preventing its development (by removing precancerous polyps). Colon cancer is the second leading cause of cancer death in the United States.

???Clearly, there are significant healthcare system barriers to receiving screening colonoscopy that can easily be removed and can lead, as in this case, to substantial improvements in colorectal cancer screening coverage in the community,??? said lead author Denis Nash, PhD, MPH, who was at the Academy when the research was conducted. Nash is currently an Associate Professor of Epidemiology in Columbia University???s Mailman School of Public Health. ???These changes will reduce morbidity and mortality due to colorectal cancer in the community served by Lincoln Medical Center. The approach used here could very well work elsewhere, including healthcare centers in non-urban settings.???

The Bronx hospital implemented a system in August 2003 that allowed primary care doctors to refer patients directly to scheduling for a colonoscopy appointment. This greatly reduced patients??? wait time between scheduling and receipt of the procedure since previously, patients had to show up for a separate medical clearance appointment at the clinic where the procedure would occur. The new ???Direct Endoscopic Referral System??? relieves patients of that extra step. The hospital also hired two ???patient navigators??? to help patients complete paperwork and schedule appointments, and to remind them of upcoming appointments in the days immediately prior to the test. Nash said many patients have trouble following up after being referred to a specialist for colon cancer screening, especially if that wait time for an appointment is long. This intervention helped them to do so.

Three times as many 50-and-older residents of this Bronx community are now getting screened for colorectal cancer, as is recommended for this age group (15.6 percent are being screened, compared to 5.2 percent). Other hospitals may be able to mirror Lincoln???s improvements by making some relatively simple changes, said David Vlahov, PhD, Director of the Academy???s Center for Urban Epidemiologic Studies and one of the co-authors. "Put simply, this study shows that community sensitive and culturally competent case management to navigate care for colon cancer screening is good public health,??? Vlahov said.

The second colon-cancer-related study in the Journal shows that screening rates for colorectal cancer are low in large part, because the public sees colonoscopies and sigmoidoscopies as unpleasant and inconvenient. Screening rates would increase significantly if the public were informed that the procedure is not as unpleasant as they fear and if patients??? preparation for the test could be simplified, the study found. ???The perceived inconvenience and unpleasant aspects of these procedures are substantial barriers to screening,??? said lead author Richard K. Zimmerman, MD, MPH, of the University of Pittsburgh School of Medicine.

Zimmerman and colleagues surveyed 319 patients age 50 and over from three inner city health centers in Pittsburgh to understand their reluctance to being screened. Only 46 percent of those patients had had a sigmoidoscopy or colonoscopy within the recommended time frame of every 10 years for a colonoscopy (which screens the entire colon), and every five years for a sigmoidoscopy (which screens the lower third). African Americans, smokers, and those who view the procedure as inconvenient and unpleasant were least likely to be screened. Although most patients don???t feel anything when getting a colonoscopy, because they are under anesthesia, many have anxiety about the exam, because it requires inserting a flexible scoping tube into the rectum. Patients must also follow a special diet the day before the exam and take a strong laxative in the hours before, and may need an enema to thoroughly cleanse the colon.

???Advances in colon preparation procedures and better educational campaigns might lessen this perceived barrier and may be particularly important in disadvantaged and African American communities,??? Zimmerman said. Colorectal cancer deaths are substantially higher in African Americans (27.6 per 100,000) than in whites (19.5 per 100,000). Screening exams are critical, since colorectal cancer often spreads unnoticed.

The Journal of Urban Health is published bimonthly for The New York Academy of Medicine, the country???s premier urban health policy and intervention center. The Academy focuses on enhancing the health of people living in cities through research, education, advocacy, and prevention. Visit us online at www.nyam.org.

Posted on April 20, 2006

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