NEW YORKWhen John Huggins, EdD, of Louisville,
Kentucky, developed rectal bleeding shortly before his 50th birthday, he
promptly called his primary care physician. After a digital rectal exam, the
physician told him he had an anal abrasion that was nothing to worry about.
"But I did worry because the signs did not go away," the assistant
director of student services for Jefferson County Public Schools said at a
Cancer Research Foundation of America press briefing on colorectal cancer.
Eventually, his primary care physician referred him to another
physician for a sigmoidoscopy. That examination revealed no problems, and Dr.
Huggins waited for a time before again calling the doctor. This time his
description of his problems prompted the doctor to order a colonoscopy, and
this time he got a diagnosis: colorectal cancer. Persistence paid off for Dr.
Huggins who is alive and well 7 years after a colectomy.
Dr. Huggins, who is black, is currently a patient of Wayne B.
Tuckson, MD, associate professor of surgery, University of Louisville. Two
other black patients who came to Dr. Tuckson’s attention more recently did
not fare so well. One was a 50-year-old woman who had felt weak and tired for 2
years. Her physician told her not to worry, that her symptoms were due to her
diabetes. "She died of metastatic colon cancer," he said.
Another woman, age 62, who had two family members with
colorectal cancer, had never been screened for the disease when she
"showed up with metastatic colon cancer," he said. She died within 4
months of the diagnosis. "There’s a problem out there," said Dr.
Tuckson of the barriers to screening and care faced by minority and low-income
Studies that Dr. Tuckson and his colleagues conducted in
Jefferson County, in which 16% of the 685,000 residents are black, highlighted
an apparent effect of income and race on colorectal cancer outcomes. Using data
on patients diagnosed in 1991-1995, they compared outcomes by the patients’
income levels, with $22,500 and below being the lowest and $36,000 and above
In situ and stage I disease, "which should have about a
90% to 95% overall survival rate," Dr. Tuckson noted, was diagnosed in 38%
of the high-income group but in only 28% of the low-income segment. Stage IV disease, on the other hand, was diagnosed in 22% of
the low-income patients but only 12% of the wealthiest. "Income does seem
to make a difference," Dr. Tuckson said. In the low-income group, 70.2%
An analysis by race showed that stage of disease at diagnosis
did not differ between blacks and whites, Dr. Tuckson noted, but survival did.
Five-year survival with no evidence of disease was 49% for whites and 41% for
blacks. In all, 26% of the white patients and 36% of the blacks died of the
Barriers to cancer screening and care, Dr. Tuckson
acknowledged, "may reflect the high percentage of African-Americans in
poverty and all the problems associated with poverty." Blacks, he noted,
tend to be treated in clinics rather than by primary care physicians who come
to know them and their problems. They are less likely to see specialists or
experienced physicians who know how to manage cancer cases effectively, he
They are also more likely to have comorbid conditions that
affect their ability to "tolerate the onslaught of chemotherapeutic
agents," he noted.
Lack of awareness of risk factors may be a barrier to
preventive measures such as a healthy diet, as documented by Dr. Tuckson and
his colleagues in a telephone survey, and to cancer screening. "If a
physician doesn’t recommend screening," Dr. Tuckson declared, "it
isn’t going to happen. In this population, we’re finding out that people
aren’t being screened."
The Physician’s Role
Robert A. Smith, PhD, director of Cancer Screening, American
Cancer Society, noted that in surveys conducted by his organization, the
leading reason adults gave for getting colorectal tests is that their doctors
recommended them. Conversely, the major reason for not getting them was not
that they were distasteful or embarrassing but "because their doctors
haven’t brought it up," he said.
"What prevents providers from playing their important
role?" Dr. Smith asked. Among the reasons, he suggested, is that
"cancer screening is not well integrated into primary care for any of our
cancer screening tests. Doctors have role ambiguity. Should they initiate this
test or should patients request it? They may not be aware of screening
guidelines. In the busy practice, they have less and less time for preventive
care, and their office system may not be geared to trigger screening
Finally, he said, in some cases, reimbursement policies are
unrealistic. "If a primary care provider can earn more for the practice by
seeing several patients than by doing one flexible sigmoidoscopy, the
likelihood is that the screening test is not going to get done," he said.
However, although the public perceives that there are insurance barriers,
"I suspect right now there really are not," he said, adding that
screening colonoscopy will become a Medicare benefit in July.
Currently, only 42% of Americans are in compliance with
American Cancer Society recommendations for colorectal screening with flexible
sigmoidoscopy, Dr. Smith said, compared with 85% for mammography. "Yet
this disease is every bit as important," he said. Colorectal cancer, he
noted, is the second leading cause of death among cancers that affect both men
and women. Lung cancer is the leading cause.
In an effort to encourage more people to be screened for
colorectal cancer, the ACS recently modified its recommendations for
average-risk individuals age 50 or above to include either fecal occult blood
testing (FOBT) annually or flexible sigmoidoscopy every 5 years, whereas
previously it had recommended that individuals undergo both.
"We need systems changes to increase screening," Dr.
Smith said. "We need physician and health insurer outreach and public
awareness to increase the demand side of colorectal cancer screening, which
will stimulate the supply side."
Elmer E. Huerta, MD, MPH, director, Cancer Risk Assessment and
Screening Center, Washington Hospital Center, is trying to do just that in the
Latino community. From his office in the nation’s capital, he distributes
2-minute programs on health in Spanish to 84 radio stations across the United
States, Canada, and some Latin American countries. He also has a Spanish
television program in which viewers are encouraged to call in their questions,
and a website in Spanish (www.prevencion.org).
"We have media programs on health every single day of the
week, exactly the same way that there are sports and weather every single day
on the news," he said.
Dr. Huerta also runs a cancer prevention clinic at the
Washington Hospital Center, which he publicizes on the radio and television
shows. In 6 years, the clinic has seen more than 8,000 individuals.
Why is a doctor doing this? he asked. Because studies show that
patients find physicians highly credible for talking about cancer (92%),
rivaled only by cancer survivors (93%), he said. Dr. Huerta cautioned, however,
that the physician must separate educational from business activities.
"You don’t sell yourself," he said. "You reject commercial
sponsorship because you want to give pure health messages to the community.
That’s how you create trust in the community."
Dr. Tuckson is also involved with outreach programs on the
Kentucky educational television network. The programs promote healthier diets
by having people in the community demonstrate how to make dishes that
"maintain ethnic and cultural variety," he said.
There are numerous barriers to getting the message of the need
for preventive measures and screening to the Latino communitya diverse group
with origins in many different countries. These include linguistic isolation,
lack of information, inadequate health insurance, and poverty, Dr. Huerta said.
Poverty, he noted, causes people to focus on day-to-day
survival. "Who’s going to care about screening for colorectal
cancer," he asked, "if they don’t know if they are going to have
food on the table the next day?"
To reach Latinos, Dr. Huerta stressed, physicians’ messages
must be ethnically sensitive and culturally competent. When a woman he
diagnosed with pancreatic cancer showed up for an appointment with 12 members
of her family, staff members at his hospital were aghast. "They don’t
understand that for Latinos, health is a family issue," he said, "and
the whole family needs to be there to listen to the doctor."
Fatalism about cancer outcome may be a barrier to screening for
whites, blacks, and Latinos, he said. An NIH survey showed that a majority of
both women and men in all three groups did not know that early cancers could be
The message that nearly 95% of persons treated for early
colorectal cancer will be alive 5 years later has not reached the general
public, he emphasized. "If they don’t know this," he said,
"they may not see the point of getting a screen."