Behavior and economic barriers to colorectal cancer screening: Are current recommendations a barrier?

Colorectal cancer is a major cause of cancer mortalities, but can be effectively treated with early diagnosis. In one rural US state, 30% of colorectal cancer deaths could have been prevented with early diagnosis. While many studies have indicated that colorectal cancer (CRC) screening is cost-effective (CE), screening rates nationally remain poor. The colonoscopy is indicated as a CE screening modality, is considered the ‘gold standard' and is the most commonly recommended. A recent survey in the same state asked residents (n = 981) age 50+ about their experiences, attitudes and behaviors related to CRC screening. Of the reported barriers, respondents were more likely to rate barriers related to the colonoscopy as major to moderate factors in deciding whether to be screened. Expense (45.3%) and the preparation liquid (48.8%) were rated as the most important factors in decision-making. Over 40% cited the time required for screening as a factor while lack of health insurance coverage and the test being uncomfortable were concerns for over one-quarter of the respondents. When comparing respondents who reported having been previously screened against those never screened, the unscreened group was statistically more likely to cite the preparation liquid (p < .01), lack of insurance coverage (p < .001), expense (p < .001), transportation (p < .01), the test being embarrassing (p < .001), and the test being uncomfortable (p < .001) as major factors in their decision not to screen. As confirmed by these findings, the colonoscopy, while extremely effective, poses many behavioral and financial barriers. While the colonoscopy is CE, so too are many alternate screening modalities, especially when the incremental CE ratio is considered and not just the misleading average CE results reported in many CE studies. Furthermore, many of these studies fail to consider productivity losses associated with the colonoscopy, including leave requirements for preparation, procedure and recovery, need for a care-giver and the need to travel for treatment, especially in rural areas. Together, these findings suggest that poor rates of CRC screening may be improved if alternate CE screening modalities to the colonoscopy were offered. Additionally, considering the research using Social Cognitive Theory and ‘Foot-in-the-Door', persons may be more willing to address the behavior and economic barriers of the ‘gold standard' colonoscopy, once they have been screened using a less expensive and less invasive test. Therefore, a subsequent benefit of encouraging alternate screening modalities could be increased colonoscopy screening rates.