Colorectal cancer screening in North Carolina. Community clinicians' perspectives.

Politics often makes strange bedfellows, but is there an odder couple in the US Senate than Jesse Helms (R-NC), champion of the conservative Republican right, and Ted Kennedy (D-MA), darling of the Democratic liberal left? One issue facing the 107th Congress united these polar political opposites: colorectal cancer screening. Senators Helms and Kennedy introduced and co-sponsored legislation to increase access to colorectal cancer screening (S710, “Eliminate Colorectal Cancer Act”). Colon cancer and colorectal cancer screening deserve attention from the public, the medical community, and government, as well as from politicians. Long in the shadow of breast cancer and more recently eclipsed by debate over prostate cancer screening, colorectal cancer is the forgotten major cancer, receiving less media attention and less research funding than either of these two other prominent cancers.1,2 Yet in 2001 more than 56,000 men and women in the United States will die from the disease—more deaths than from either breast (40,200) or prostate cancer (31,500).3 This year, 4000 North Carolinians will be diagnosed with, and 1700 will die from, colorectal cancer.3 Expert groups from the American Cancer Society, the American Gastroenterological Association, and the US Preventive Services Task Force support periodic screening of asymptomatic, average-risk persons beginning at age 50.4-6 Routine screening for colorectal cancer is covered by Medicare.7 All groups support periodic screening with a fecal occult blood test (FOBT) or flexible sigmoidoscopy or both. In rigorous studies, both tests have reduced colorectal cancer mortality.8,9 Despite the prevalence of disease, strong evidence that screening is effective, and consensus support from experts, screening performance is low. Nationally, in 1999, 44% of persons 50 years and older reported having had an FOBT in the past year or colon endoscopy in the past five years.10 We do even less well in North Carolina. In 1999, 30% of persons 50 years and older had used a take-home FOBT kit in the past year, and only 53% had ever used one. In addition, 31% had had a colon endoscopy in the past five years, and only 39% had ever had one.10,11 Barriers to screening include a variety of procedural, patient, provider, and health care system factors.12 As with other cancer screening procedures, a doctor’s recommendation is the most powerful single factor promoting colorectal cancer screening. Improving clinicians’ adoption of the idea of colorectal cancer screening is a critical first step in improving screening performance.12 In 1997 and 1998, we surveyed primary care doctors in North Carolina to determine their training for, attitudes about, and current practices of screening for colorectal cancer with FOBT and flexible sigmoidoscopy. Data from this survey have been used by the North Carolina Advisory Committee on Cancer Coordination and Control and its Early Detection Subcommittee to develop strategies to help primary care doctors in North Carolina increase colorectal cancer screening. Colorectal Cancer Screening in North Carolina