Skip to main content

Advertisement

Log in

Barriers Driving Racial Disparities in Colorectal Cancer Screening in African Americans

  • Large Intestine (R Chokshi, Section Editor)
  • Published:
Current Gastroenterology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Colorectal cancer screening has been shown to decrease mortality from colorectal cancer. Screening disparities continue to exist among ethnic minorities, particularly for African Americans. We herein review the barriers of colorectal cancer screening in this population.

Recent Findings

At its foundation are patient barriers, which are further compounded by physician-related barriers and the idiosyncrasies of the healthcare system. Interventions to address the barriers include patient outreach, provider education, and healthcare legislation addressing financial barriers. Recent research has focused on factors predicting intentions to undergo colorectal cancer screening. Underlying all of the barriers is the systemic racism that affects and influences the healthcare system as much as all other institutions and contributes to inequities in the delivery of effective cancer prevention efforts.

Summary

Perpetual disparities in CRC screening within the African American community are due to multifactorial barriers from the individual patient to provider and healthcare system and societal influences. An awareness of the behavioral and systemic factors that affect African Americans must underpin efforts to reach full equity in delivering CRC screening to this often medically underserved segment of our society.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin. 2019;69(1):7–34. https://doi.org/10.3322/caac.21551.

    Article  PubMed  Google Scholar 

  2. Shahidi N, Cheung WY. Colorectal cancer screening: opportunities to improve uptake, outcomes, and disparities. World J Gastrointest Endosc. 2016;8(20):733–40. https://doi.org/10.4253/wjge.v8.i20.733.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Montminy EM, Karlitz JJ, Landreneau SW. Progress of colorectal cancer screening in United States: past achievements and future challenges. Prev Med. 2019;120:78–84. https://doi.org/10.1016/j.ypmed.2018.12.004.

    Article  PubMed  Google Scholar 

  4. • Jackson CS, Oman M, Patel AM, Vega KJ. Health disparities in colorectal cancer among racial and ethnic minorities in the United States. J Gastrointest Oncol. 2016;7(Suppl. 1):S32–43. https://doi.org/10.3978/j.issn.2078-6891.2015.039Important review that discusses disparities by race.

    Article  PubMed  PubMed Central  Google Scholar 

  5. AA ACS facts and figures American Cancer Society. Cancer facts & figures for African Americans 2019-2021. Atlanta: American Cancer Society; 2019.

    Google Scholar 

  6. Ward SH, Lin K, Meyer B, Bass SB, Parameswaran L, Gordon TF, et al. Increasing colorectal cancer screening among African Americans, linking risk perception to interventions targeting patients, communities, and clinicians. J Natl Med Assoc. 2008;100(6):748–58. https://doi.org/10.1016/s0027-9684(15)31356-0.

    Article  PubMed  Google Scholar 

  7. Carethers JM. Screening for colorectal cancer in African Americans: determinants and rationale for an earlier age to commence screening. Dig Dis Sci. 2015;60(3):711–21. https://doi.org/10.1007/s10620-014-3443-5.

    Article  PubMed  Google Scholar 

  8. Williams R, White P, Nieto J, Vieira D, Francois F, Hamilton F. Colorectal cancer in African Americans: an update. Clin Transl Gastroenterol. 2016;7(7):e185. https://doi.org/10.1038/ctg.2016.36.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Waghray A, Jain A, Waghray N. Colorectal cancer screening in African Americans: practice patterns in the United States. Are we doing enough? Gastroenterol Rep (Oxf). 2016;4(2):136–40. https://doi.org/10.1093/gastro/gow005.

    Article  Google Scholar 

  10. Tsai MH, Xirasagar S, de Groen PC. Persisting racial disparities in colonoscopy screening of persons with a family history of colorectal cancer. J Racial Ethn Health Disparities. 2018;5(4):737–46. https://doi.org/10.1007/s40615-017-0418-1.

    Article  PubMed  Google Scholar 

  11. Sly JR, Edwards T, Shelton RC, Jandorf L. Identifying barriers to colonoscopy screening for nonadherent African American participants in a patient navigation intervention. Health Educ Behav. 2013;40(4):449–57. https://doi.org/10.1177/1090198112459514.

    Article  PubMed  Google Scholar 

  12. Hodges NL, Shoben AB, Paskett ED, Katz ML. Impact of a literacy-sensitive intervention on CRC screening knowledge, attitudes, and intention to screen. J Community Support Oncol. 2016;14(10):420–6. https://doi.org/10.12788/jcso.0209.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Green PM, Kelly BA. Colorectal cancer knowledge, perceptions, and behaviors in African Americans. Cancer Nurs. 2004;27(3):206–15; quiz 216-7. https://doi.org/10.1097/00002820-200405000-00004.

    Article  PubMed  Google Scholar 

  14. Adams LB, Richmond J, Corbie-Smith G, Powell W. Medical mistrust and colorectal cancer screening in African Americans. J Community Health. 2017;42(5):1044–61. https://doi.org/10.1007/s10900-017-0339-2.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Washington HA. Medical apartheid: the dark history of medical experimentation on black americans from colonial times to the present. New York: Doubleday; 2006.

    Google Scholar 

  16. Chen LA, Santos S, Jandorf L, Christie J, Castillo A, Winkel G, et al. A program to enhance completion of screening colonoscopy among urban minorities. Clin Gastroenterol Hepatol. 2008;6(4):443–50. https://doi.org/10.1016/j.cgh.2007.12.009.

    Article  PubMed  Google Scholar 

  17. •• Carethers JM, Doubeni CA. Causes of socioeconomic disparities in colorectal cancer and intervention framework and strategies. Gastroenterology. 2020;158:354–67. https://doi.org/10.1053/j.gastro.2019.10.029Details socioeconomic disparities and its relation to disparities in colon cancer outcome.

    Article  PubMed  Google Scholar 

  18. Muthukrishnan M, Arnold LD, James AS. Patient’s self-reported barriers to colon cancer screening in federally qualified health center settings. Prev Med Rep. 2019;15:100896. https://doi.org/10.1016/j.pmedr.2019.100896.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Horne HN, Phelan-Emrick DF, Pollack CE, Markakis D, Wenzel J, Ahmed S, et al. Effect of patient navigation on colorectal cancer screening in a community-based randomized controlled trial of urban African American adults. Cancer Causes Control. 2015;26(2):239–46. https://doi.org/10.1007/s10552-014-0505-0.

    Article  PubMed  Google Scholar 

  20. Sommers BD, Wilson L. Fifty-four million additional americans are receiving preventive services without cost-sharing under the affordable care act. Issue Brief, Office of the Assistant Secretary for Planning and Evaluation. 2012.

  21. Laiyemo AO, Adebogun AO, Doubeni CA, Ricks-Santi L, McDonald-Pinkett S, Young PE, et al. Influence of provider discussion and specific recommendation on colorectal cancer screening uptake among U.S. adults. Prev Med. 2014;67:1–5. https://doi.org/10.1016/j.ypmed.2014.06.022.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Palmer RC, Chhabra D, McKinney S. Colorectal cancer screening adherence in African American men and women 50 years of age and older living in Maryland. J Community Health. 2011;36(4):517–24. https://doi.org/10.1007/s10900-010-9336-4.

    Article  PubMed  Google Scholar 

  23. Coleman Wallace DA, Baltrus PT, Wallace TC, Blumenthal DS, Rust GS. Black white disparities in receiving a physician recommendation for colorectal cancer screening and reasons for not undergoing screening. J Health Care Poor Underserved. 2013;24(3):1115–24. https://doi.org/10.1353/hpu.2013.0132.

    Article  PubMed  PubMed Central  Google Scholar 

  24. May FP, Almario CV, Ponce N, Spiegel BM. Racial minorities are more likely than whites to report lack of provider recommendation for colon cancer screening. Am J Gastroenterol. 2015;110(10):1388–94. https://doi.org/10.1038/ajg.2015.138.

    Article  PubMed  Google Scholar 

  25. Coughlin SS, Thompson T. Physician recommendation for colorectal cancer screening by race, ethnicity, and health insurance status among men and women in the United States, 2000. Health Promot Pract. 2005;6(4):369–78. https://doi.org/10.1177/1524839905278742.

    Article  PubMed  Google Scholar 

  26. • Muliira JK, D'Souza MS, Ahmed SM, Al-Dhahli SN, Al-Jahwari FR. Barriers to colorectal cancer screening in primary care settings: attitudes and knowledge of nurses and physicians. Asia Pac J Oncol Nurs. 2016;3(1):98–107. https://doi.org/10.4103/2347-5625.177391Physician barriers to colorectal cancer screening.

    Article  PubMed  PubMed Central  Google Scholar 

  27. White PM, Sahu M, Poles MA, Francois F. Colorectal cancer screening of high-risk populations: a national survey of physicians. BMC Res Notes. 2012;5:64. https://doi.org/10.1186/1756-0500-5-64.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Gennarelli M, Jandorf L, Cromwell C, Valdimarsdottir H, Redd W, Itzkowitz S. Barriers to colorectal cancer screening: inadequate knowledge by physicians. Mt Sinai J Med. 2005;72(1):36–44.

    PubMed  Google Scholar 

  29. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, Epling JW Jr, et al. Screening for colorectal Cancer: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(23):2564–75. https://doi.org/10.1001/jama.2016.5989.

    Article  CAS  Google Scholar 

  30. National coverage determination (NCD) for colorectal cancer screening tests. (210.3). https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=281&ncdver=5&bc=AAAAQAAAAAAA&. Accessed May 6, 2020.

  31. Decision memo for screening for colorectal cancer – stool DNA testing (CAG-00440N). https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=277. Accessed May 6, 2020.

  32. Screening colonoscopies. https://www.medicare.gov/coverage/screening-colonoscopies. Accessed May 6, 2020.

  33. Uradomo LT, Mener A, Borum ML. Insurance coverage for screening colonoscopy at age 45 for African Americans: low adherence to guidelines in states with large African American populations. AGA Abstracts. 2011;140(5 Supplement 1):S–21. https://doi.org/10.1016/S0016-5085(11)60082-6.

    Article  Google Scholar 

  34. Bromley EG, May FP, Federer L, Spiegel BM, van Oijen MG. Explaining persistent under-use of colonoscopic cancer screening in African Americans: a systematic review. Prev Med. 2015;71:40–8. https://doi.org/10.1016/j.ypmed.2014.11.022.

    Article  PubMed  Google Scholar 

  35. May FP, Yang L, Corona E, Glenn BA, Bastani R. Disparities in colorectal cancer screening in the United States before and after implementation of the affordable care act. Clin Gastroenterol Hepatol. 2019. S1542–3565(19)30996–6. https://doi.org/10.1016/j.cgh.2019.09.008.

  36. DeGroff A, Sharma K, Satsangi A, Kenney K, Joseph D, Ross K, et al. Increasing colorectal cancer screening in health care systems using evidence-based interventions. Prev Chronic Dis. 2018;15:180029. https://doi.org/10.5888/pcd15.180029.

    Article  Google Scholar 

  37. Cooper GS, Kou TD, Schluchter MD, Dor A, Koroukian SM. Changes in receipt of cancer screening in Medicare beneficiaries following the Affordable Care Act. J Natl Cancer Inst 2015;108(5). https://doi.org/10.1093/jnci/djv374

  38. Cooper GS, Kou TD, Dor A, Koroukian SM, Schluchter MD. Cancer preventive services, socioeconomic status and the affordable care act. Cancer. 2017;123(9):1585–9. https://doi.org/10.1002/cncr.30476.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Haddad JD, You DM. Colorectal cancer screening and race in an equal access medical system. J Community Health. 2016;41(1):78–81. https://doi.org/10.1007/s10900-015-0068-3.

    Article  PubMed  Google Scholar 

  40. Burnett-Hartman AN, Mehta SJ, Zheng Y, Ghai NR, McLerran DF, Chubak J, et al. Racial/ethnic disparities in colorectal cancer screening across healthcare systems. Am J Prev Med. 2016;51(4):e107–15. https://doi.org/10.1016/j.amepre.2016.02.025.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Changoor NR, Pak LM, Nguyen LL, Bleday R, Trinh QD, Koehlmoos T, et al. Effect of an equal-access military health system on racial disparities in colorectal cancer screening. Cancer. 2018;124(18):3724–32. https://doi.org/10.1002/cncr.31637.

    Article  PubMed  Google Scholar 

  42. Itzkowitz SH, Winawer SJ, Krauskopf M, Carlesimo M, Schnoll-Sussman FH, Huang K, et al. New York citywide colon cancer control coalition: a public health effort to increase colon cancer screening and address health disparities. Cancer. 2016;122(2):269–77. https://doi.org/10.1002/cncr.29595.

    Article  PubMed  Google Scholar 

  43. Bailey ZD, Krieger N, Agenor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389:1453–63. https://doi.org/10.1016/S0140-6736(17)30569-X.

    Article  PubMed  Google Scholar 

  44. Colorectal cancer screening messaging guidebook: recommended messages to reach the unscreened. 2019. https://nccrt.org/resource/2019messagingguidebook/). Accessed on 2/10/20.

  45. • Klasko-Foster LB, Jandorf LM, Erwin DO, Kiviniemi MT. Predicting colonoscopy screening behavior and future screening intentions for African Americans older than 50 years. Behav Med. 2019;45(3):221–30. https://doi.org/10.1080/08964289.2018.1510365Investigates patient’s intentions to undergo colorectal cancer screening.

    Article  PubMed  Google Scholar 

  46. Rogers CR, Goodson P, Dietz LR, Okuyemi KS. Predictors of intention to obtain colorectal cancer screening among African American men in a state fair setting. Am J Mens Health. 2018;12(4):851–62. https://doi.org/10.1177/1557988316647942.

    Article  PubMed  Google Scholar 

  47. Cole H, Thompson HS, White M, Browne R, Trinh-Shevrin C, Braithwaite S, et al. Community-based, preclinical patient navigation for colorectal cancer screening among older black men recruited from barbershops: the MISTER B trial. Am J Public Health. 2017;107(9):1433–40. https://doi.org/10.2105/AJPH.2017.303885.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Ravenell J, Thompson H, Cole H, Plumhoff J, Cobb G, Afolabi L, et al. A novel community-based study to address disparities in hypertension and colorectal cancer: a study protocol for a randomized control trial. Trials. 2013;14:287. https://doi.org/10.1186/1745-6215-14-287.

    Article  PubMed  PubMed Central  Google Scholar 

  49. DeGroff A, Schroy PC 3rd, Morrissey KG, Slotman B, Rohan EA, Bethel J, et al. Patient navigation for colonoscopy completion: results of an RCT. Am J Prev Med. 2017;53(3):363–72. https://doi.org/10.1016/j.amepre.2017.05.010.

    Article  PubMed  Google Scholar 

  50. Gonzalez CM, Kim MY, Marantz PR. Implicit bias and its relation to health disparities: a teaching program and survey of medical students. Teach Learn Med. 2014;26(1):64–71. https://doi.org/10.1080/10401334.2013.857341.

    Article  PubMed  Google Scholar 

  51. Man LC, DiCarlo M, Lambert E, Sifri R, Romney M, Fleisher L, et al. A learning community approach to identifying interventions in health systems to reduce colorectal cancer screening disparities. Prev Med Rep. 2018;12:227–32. https://doi.org/10.1016/j.pmedr.2018.10.009.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Lucas T, Manning M, Hayman LW Jr, Blessman J. Targeting and tailoring message-framing: the moderating effect of racial identity on receptivity to colorectal cancer screening among African-Americans. J Behav Med. 2018;41(6):747–56. https://doi.org/10.1007/s10865-018-9933-8.

    Article  PubMed  Google Scholar 

  53. Kennedy MG, McClish D, Jones RM, Jin Y, Wilson DB, Bishop DL. Effects of an entertaining, culturally targeted narrative and an appealing expert interview on the colorectal screening intentions of African American women. J Community Psychol. 2018;46(7):925–40. https://doi.org/10.1002/jcop.21983.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Kwaan MR, Jones-Webb R. Colorectal cancer screening in black men: recommendations for best practices. Am J Prev Med. 2018;55(5 Suppl 1):S95–102. https://doi.org/10.1016/j.amepre.2018.05.008.

    Article  PubMed  Google Scholar 

  55. May FP, Whitman CB, Varlyguina K, Bromley EG, Spiegel BM. Addressing low colorectal cancer screening in African Americans: using focus groups to inform the development of effective interventions. J Cancer Educ. 2016;31(3):567–74. https://doi.org/10.1007/s13187-015-0842-z.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Daniel CL, Gilreath K, Keyes D. Colorectal cancer disparities beyond biology: screening, treatment, access. Front Biosci (Landmark Ed). 2017;22:465–78. https://doi.org/10.2741/4495.

    Article  Google Scholar 

  57. Green BB, Anderson ML, Cook AJ, Chubak J, Fuller S, Kimbel KJ, et al. Financial incentives to increase colorectal cancer screening uptake and decrease disparities: a randomized clinical trial. JAMA Netw Open. 2019;2(7):e196570. https://doi.org/10.1001/jamanetworkopen.2019.6570.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Steven H. Itzkowitz.

Ethics declarations

Conflict of Interest

Dr. Itzkowitz reports personal fees from Exact Sciences Corporation, during the conduct of the study. Dr. White has no potential conflicts to disclose.

Human and Animal Rights and Informed Consent

All reported studies/experiments with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Large Intestine

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

White, P.M., Itzkowitz, S.H. Barriers Driving Racial Disparities in Colorectal Cancer Screening in African Americans. Curr Gastroenterol Rep 22, 41 (2020). https://doi.org/10.1007/s11894-020-00776-0

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11894-020-00776-0

Keywords

Navigation