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Even in a safety net health system,
colorectal cancer screening disparities
PHILADELPHIA – Colorectal cancer screening
rates are much lower among those in a safety
net health system compared to the national
average, and the number one predictor of
screening is a combination of regular visits
and insurance access.
Colorectal cancer is the second leading cause of cancer death in
the United States behind lung cancer. Nearly
50,000 Americans will die from colorectal
cancer this year.
Although scientists have differing opinions on the best method, the
benefits of early screening are beyond
debate — cancers caught early are easier to
manage and treat.
Still, the nationwide rate of colorectal cancer screening is 61
percent, with much of the lack of screening
concentrated among blacks, Hispanics and
those without insurance.
However, results of a study published in Cancer Epidemiology,
Biomarkers & Prevention, a journal of
the American Association for Cancer
Research, showed that the screening rate was
merely 22 percent among individuals served
by a safety net health system in Texas.
"Of our patients who did get screened, they either had insurance or
saw their doctor regularly. Once you
controlled for those variables, the
screening rate was essentially zero," said
Samir Gupta, M.D., assistant professor in
the Department of Internal Medicine at the
University of Texas Southwestern Medical
Gupta and colleagues conducted their study using data from the
Tarrant County Hospital District John Peter
Smith Hospital Health Network, a safety net
The system serves 155,000 individuals a year in Tarrant County,
Texas, a geographic area that includes Fort
Worth, and is committed to delivering health
care to the uninsured, Medicaid and other
Using their electronic administrative records, Gupta and colleagues
identified 20,416 patients who were between
54 and 75 years old and were eligible for
colorectal cancer screening.
The median age of these patients was 60 years, and about 60 percent
of them were women. Approximately 15 percent
of the population lived below the poverty
line and median household income was
$35,419. The majority of the patients were
either black or Hispanic; nearly 20 percent
reported a primary language other than
Although 40 percent were classified as having health insurance,
including those on Medicare and Medicaid,
another 40 percent only had medical coverage
through their connection to the safety net
system; 20 percent had no insurance at all.
Over the previous five years, 22 percent of these patients were
screened for colorectal cancer. Women were
slightly more likely than men, and Hispanics
were slightly more likely to be screened
than whites, but the largest increase came
when insurance and regular medical care were
Those with insurance were almost three times as likely to be
screened, and those who saw the doctor
regularly were nearly four times as likely
to be screened.
Karen Glanz, Ph.D., M.P.H., professor of medicine and nursing at
the University of Pennsylvania and an
editorial board member of Cancer
Epidemiology, Biomarkers & Prevention, said
this study documents an important issue in a
"The idea that colorectal cancer screening rates are too low is not
a new idea, but this is one of the first to
document it in a specific population," said
"Access to care clearly has consequences, and any talk of health
care reform needs to address proven
prevention measures like screening."
Gupta said a national model already exists for successful
screening. Low income, uninsured and
underserved women can get breast and
cervical cancer screening through the
Centers for Disease Control's National
Breast and Cervical Cancer Early Detection
Program, but Gupta said such an approach is
far too disease-specific.
"Theoretically, the same model could be applied to colorectal
cancer, but do we want to keep passing
legislation for programs that target
specific types of cancer, or could we
provide more broad access to health care so
we can make a serious and coordinated effort
at prevention?" said Gupta.
"That's the question that needs answering."