Screening and Followup: Engaging Systems, Teams, and Educating Patients (SAFE STEP)

Cancer incidence and mortality are often higher in rural compared to urban and suburban areas and evidence suggests this disparity is widening. Patients from rural areas are less likely to be screened for colorectal cancer, may have more limited access to and use of treatments for colorectal cancer, and have poorer colorectal cancer outcomes. Rural populations face additional barriers to colorectal cancer screening and diagnostic procedures because they may have greater travel distances and fewer accessible specialists (colorectal surgeons, gastroenterologists, oncologists).

While national and state-level cancer incidence is trending down, incidence rates in Southern Illinois are stable or increasing.

Colorectal cancer mortality in rural southern Illinois exceeds the state and national levels, and is decreasing at a slower rate than in urban Illinois.

Southern Illinois has been noted for its medically underserved status and challenging patient demographics. 2016 HRSA data showed 1.3 gastroenterologists and 0.3 colorectal surgeons per 100,000 residents in Southern Illinois, compared to 3.4 and 0.4 per 100,000 statewide. In our preliminary research, we found that colonoscopy is also performed by general surgeons and in some cases by primary care providers to fill the capacity.

Colorectal cancer screening is recommended for average-risk adults starting at age 50 and outcomes are worse for patients diagnosed later. Only about 60% of US age-eligible adults are “up-to-date” on colorectal cancer screening. Many primary care clinics in medically underserved areas use fecal immunochemical testing (FIT) for first-stage screening, however the full benefit of screening is only attained when positive screenings are followed by complete diagnostic evaluation. Nationally, only about half of all adults with a positive FIT go on to receive a colonoscopy during the recommended timeframe. Delays in diagnostic follow-up are associated with poorer outcomes.

Diagnostic follow-up is not merely a patient behavior. From screening to diagnosis, the process involves several steps and requires collaboration and action by patients, primary care, and specialty care. Due to this complexity, barriers at multiple levels influence completion rates of colonoscopy after positive FIT. Most attention has focused on patient and provider barriers to screening, with only recent shifts to focus on follow-up.

Interventions (such as printed materials, or a combination of printed and verbal instructions) to reduce patient-level barriers to follow-up after positive FIT are necessary but not sufficient for realizing the potential for screening to reduce population-level mortality. Interventions that ensure patients receive FIT results and referrals, and reduce structural barriers, can increase completion of diagnostic testing after a positive FIT.

At the provider and staff level, strategies that improve confidence and competencies (e.g. knowledge, attitudes, skills for using tracking systems), and provider level feedback on performance can improve screening and follow-up. At the clinic level, clinics that have support for systems (paper or electronic) for tracking or prompts can help clinical teams recognize and schedule needed follow-up. Clinic-level feedback on performance can be effective as well.

Our long-term goal is to reduce colorectal cancer mortality in the rural southern Illinois region via improvements in the screening process and screening follow-up.

This study is funded by an Institutional Grant from the Barnard Trust and the Foundation for Barnes‐Jewish Hospital Cancer Frontier Fund through Siteman Cancer Center, and U01 CA209861. The study received approval from the Washington University in St. Louis Institutional Review Board.