Women who live in rural areas are less likely than urban-dwelling women to undergo regular screenings for colorectal cancer (CRC), including colonoscopies, sigmoidoscopies, or stool tests, according to research published online October 4 in JAMA Network Open. In contrast, women in rural areas are just as likely as their urban counterparts to undergo mammograms to detect potential breast cancer.
“Our hypothesis was that there would be fewer people up to date for both breast and colon in rural areas compared to urban areas, and we found that it was only colorectal cancer,” said author Electra Paskett, PhD, Marion N. Rowley Professor of Cancer Research at the Ohio State University and director of the Division of Cancer Prevention and Control in the College of Medicine, Columbus, Ohio. Paskett explained that race, ethnicity, and age are known to affect access to medical advances such as cancer screening, but to her knowledge, this is the first study to show the impact of geography.
The team collected data for the study prior to the COVID-19 pandemic. Their analysis was conducted after data emerged indicating that the pandemic has led to delays in cancer screenings and consequently an increase in diagnoses of disease at later stages, when cancers are harder to treat.
“We’ve got to get people screened,” stressed Paskett. She argues that stool-based tests, which people take at home and mail for processing, are a convenient screening alternative to colonoscopies and may be advantageous for people in rural areas who typically need to travel farther to undergo a colonoscopy.
Paskett and colleagues assessed the results of 11 surveys conducted throughout the United States from 2017 to 2020. The surveys asked women aged 50 and older to report how recently they had undergone screening for breast cancer or CRC. The researchers then determined what proportion of these screenings met national guidelines for preventive cancer care. Of a total of 2897 women surveyed, 1090 lived in rural areas, and the rest lived in urban settings. The total sample included more than 80% White women.
Undergoing mammography within 2 years of the survey date was within guidelines; so too was undergoing a stool test within 1 year, a sigmoidoscopy within 5 years, or a colonoscopy within 10 years. Data on which CRC screening tool people received were not provided because Paskett and colleagues chose to collapse all forms of screening into a single variable.
Urban-dwelling women were significantly more likely to be in compliance with CRC screening guidelines than those in rural areas (82% vs 78%, P = .01). But geography made no difference in adherence to breast cancer screening guidelines, which stood at 81% for both groups.
The team identified several factors that were associated with higher CRC screening adherence, including age 65 and older, income above $50,000 (vs below $20,000), and having Medicare, Medicaid, or private insurance (vs having no insurance).
“One of the biggest barriers is awareness and perception of colorectal cancer risk,” said Folasade P. May, MD, PhD, director of the Melvin and Bren Simon Gastroenterology Quality Improvement Program and assistant professor of medicine at the University of California, Los Angeles, who studies barriers to CRC screening. “Women are very familiar with breast cancer risk, whether you’ve seen it on TV or heard of a famous person getting it. It’s something that’s talked about, even the NFL [National Football League] wears pink.”
In contrast, May noted that cancers of the rectum or colon remain a taboo topic of discussion, so she is not surprised by the greater rates of adherence to breast cancer screening.
May agreed that a barrier to CRC screening in rural areas is likely logistics. Some people may need to drive 100 miles or more each way to reach a center where they can undergo a colonoscopy. In addition, they need to bring along a relative or friend to take them home afterward, and that person must be able to take off work for the duration of the journey and procedure. For these reasons, she also strongly recommends wider adoption of mail-in stool tests.
“We have to embrace multimodality colorectal cancer screening,” May said. This would involve greater use of mail-in stool tests, but May pointed out that colonoscopies will still be necessary for the 8% to 10% of people whose stool test is positive. So for rural women, there is still a need to increase access to colonoscopies, May said.
The research was supported by the National Cancer Institute of the National Institutes of Health. Paskett has received grants from the Merck Foundation, Pfizer, and the Breast Cancer Research Foundation outside the submitted work. The other authors have disclosed no relevant financial relationships.
JAMA Netw Open. Published online October 4, 2021. Full text
Marcus Banks reports on new health research, with a particular focus on cancer. His writing has appeared in Spectrum, Cancer Today, Nature Medicine, The Scientist, and Gastroenterology and Endoscopy News.
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