Colorectal Cancer Screening in Appalachian Kentucky: A Survey of Practices and Attitudes of Primary Health Care Providers

Background: Colorectal cancer (CRC) is the second leading cause of cancer death in Kentucky. Screening for colorectal cancer in Kentucky lags behind national rates, and is lowest in Appalachian counties. To address this problem, a five-year project funded by the National Cancer Institute was developed to increase screening recommendations among rural primary care providers in Appalachian Kentucky. Methods: Primary care practices in rural, Appalachian Kentucky were surveyed to determine practices and attitudes regarding CRC screening. The survey focused on five areas: 1) cancer screening beliefs and practices, 2) attitudes toward and training in CRC screening, 3) colorectal cancer screening modalities, 4) practice and other characteristics, and 5) attitudes about colorectal cancer screening. Surveys were delivered in person or faxed to the practices, completed by the lead provider and collected by study personnel. Results: Responses were obtained from 63 practices, of which 47(74.6%) were family practice or general practice and 16 (25.4%) general internal medicine. Of the 63, 90.5% most often recommend one or a combination (3.2%) of standard colorectal cancer screening tests for their asymptomatic average risk patients. Colonoscopy alone (80.7%) was most frequently recommended, followed by fecal occult blood test (FOBT) alone (7.0%). In rating CRC screening tests, 95.2% rated colonoscopy as very effective, with 15.9% rating FOBT and 16.1% rating double contrast barium enema (DCBE) at this level. The majority (65.1%) of physicians report that over the past three years, the volume of CRC screening procedures they order, perform, or supervise has increased, with 25.4% reporting an increase of more than 20% per year. These physicians indicate that national guidelines are somewhat or very influential on their recommendations for CRC screening, with the three most influential being the American Cancer Society (96.8%), the U.S. Preventive Services Task Force (96.4%), and the American Academy of Family Physicians (94.2%). Conclusions: Results from the study indicate that primary care physicians recommend colorectal screening to their patients in traditionally underserved communities in Appalachian Kentucky. Results further suggest that physicians prefer colonoscopy as a screening modality and that they identify cost and lack of insurance as major barriers to recommending screening to their patients.