Improving Colorectal Cancer Screening For the Underserved

A study of an equal-access military health system shows universal health insurance for both the military and civilian populations could improve CRC screening rates.

When examining an equal-access military health system, black patients had higher rates of screening for colorectal cancer than previously reported, and higher rates of screening compared with white patients, a study showed.

Previous research has reported significantly lower rates of colorectal cancer screening among minorities compared with white patients. However, in this study, black patients were more likely to receive age-appropriate screening than white patients.

“Unfortunately, the overall rate of screening across all races remained suboptimal at 54%,” according to researchers led by Navin R. Changoor, MD, of Harvard Medical School and Harvard School of Public Health.

“The hypothesis that universal access increases colorectal cancer screening, especially among minorities, is strongly supported by our analysis,” Changoor and colleagues wrote in Cancer. “Even though we studied only a specific subset of the US population, aspects of this study highlight the need to consider factors beyond insurance coverage when screening programs are being developed.”

The study used data from TRICARE, the insurance for active, reserve, or retired members of the US armed services and their dependents, from 2007–2010. The data included adults aged 50 in the year 2007. These adults were followed for 4 years to find their first lower endoscopy and/or fecal occult blood test (FOBT).

The majority of enrollees were white (69.2%), and about one in five enrollees was black (20.3%). Overall, 54.0% of enrollees received a type of colorectal cancer screening; 45.2% received endoscopy, and 8.8% had FOBT.

Screening rates were 56.5% among black patients compared with 53.5% among white patients. Similarly, black patients had higher rates of endoscopy (47.3% vs 45.1%). Asian enrollees had the highest rate of FOBT screening (11.5%) followed by black enrollees (9.3%) and then white enrollees (8.4%).

Black enrollees had a 14% increased odds of undergoing screening compared with white enrollees (odds ratio [OR] = 1.14; 95% CI, 1.06–1.23).

Commenting on the study, Folasade P. May, MD, PhD, MPhil, director of Melvin and Bren Simon Gastroenterology Quality Improvement Program at UCLA, pointed out the historically, screening rates have been lowest in minorities and in the under or uninsured, and this paper confirms that insurance does play a big role in these disparities.

“They found that black/white disparities seen in typical healthcare settings do not exist when there is universal healthcare,” May told Cancer Network. “A universal healthcare system might be beneficial to increase utilization of preventive services like colorectal cancer screening and might help mitigate healthcare disparities that we currently see in screening. Individuals with insurance coverage in this country are not receiving the care that they need and might have better cancer outcomes if they had better health insurance and access to preventive services.”

Peter Liang, MD, MPH, of NYU Langone Health, also spoke with Cancer Network about the study, adding, "Previous studies pertaining to colorectal cancer outcomes in the VA have shown similar results for black vs white [patients]. However, it is notable that while there was no evidence of racial/ethnic disparities, there was evidence of socioeconomic disparity based on military rank."

Liang went on to question the generalizability of the results "because there are military educational requirements (as the author's state) and because those in service may be more amenable to following recommended health exams."