Barriers to Colorectal Cancer Screening and Surveillance in Homeless Patients :  A Case Report and Policy Recommendations

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Abstract

Patients experiencing homelessness face a high burden of chronic disease, including colorectal cancer. Access to colonoscopy is limited by many structural barriers in this population. In an exemplar case, we describe the barriers encountered by a homeless patient with a history of colorectal cancer who was lost to follow up and presented 11 years later with a new primary colon cancer. We provide policy solutions to increase the use of primary and secondary screening, including essential private bathroom access for colonoscopy preparation in patients who had a positive screening or require surveillance after diagnosis and treatment. We believe that increasing early detection and treatment may be cost-effective and could reduce disparities in morbidity and mortality in homeless patients.

Abstract

Mini-abstract: Patients experiencing homelessness face significant barriers to screening and treatment for colorectal cancer, leading to worse outcomes. In this perspective, we use an exemplar patient case to highlight potential policy solutions for reducing this health care disparity by increasing access to early detection and treatment in this population.

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Most cited references 9

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Health interventions for people who are homeless.

Stephen Hwang, Tom Burns (2014)

Homelessness has serious implications for the health of individuals and populations. Primary health-care programmes specifically tailored to homeless individuals might be more effective than standard primary health care. Standard case management, assertive community treatment, and critical time intervention are effective models of mental health-care delivery. Housing First, with immediate provision of housing in independent units with support, improves outcomes for individuals with serious mental illnesses. Many different types of interventions, including case management, are effective in the reduction of substance misuse. Interventions that provide case management and supportive housing have the greatest effect when they target individuals who are the most intensive users of services. Medical respite programmes are an effective intervention for homeless patients leaving the hospital. Although the scientific literature provides guidance on interventions to improve the health of homeless individuals, health-care providers should also seek to address social policies and structural factors that result in homelessness.

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Mailed fecal immunochemical test outreach for colorectal cancer screening: Summary of a Centers for Disease Control and Prevention–sponsored Summit

Samir Gupta, Gloria Coronado, Keith Argenbright … (2020)

Uptake of colorectal cancer screening remains suboptimal. Mailed fecal immunochemical testing (FIT) offers promise for increasing screening rates, but optimal strategies for implementation have not been well synthesized. In June 2019, the Centers for Disease Control and Prevention convened a meeting of subject matter experts and stakeholders to answer key questions regarding mailed FIT implementation in the United States. Points of agreement included: 1) primers, such as texts, telephone calls, and printed mailings before mailed FIT, appear to contribute to effectiveness; 2) invitation letters should be brief and easy to read, and the signatory should be tailored based on setting; 3) instructions for FIT completion should be simple and address challenges that may lead to failed laboratory processing, such as notation of collection date; 4) reminders delivered to initial noncompleters should be used to increase the FIT return rate; 5) data infrastructure should identify eligible patients and track each step in the outreach process, from primer delivery through abnormal FIT follow-up; 6) protocols and procedures such as navigation should be in place to promote colonoscopy after abnormal FIT; 7) a high-quality, 1-sample FIT should be used; 8) sustainability requires a program champion and organizational support for the work, including sufficient funding and external policies (such as quality reporting requirements) to drive commitment to program investment; and 9) the cost effectiveness of mailed FIT has been established. Participants concluded that mailed FIT is an effective and efficient strategy with great potential for increasing colorectal cancer screening in diverse health care settings if more widely implemented.

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Patient and provider barriers to colorectal cancer screening in the primary care safety-net.

K Robin Yabroff, James A O’Malley, Dorcas E. Beaton … (2004)

This study examines patient and provider barriers to screening for colorectal cancer among low-income uninsured African-Americans aged 50 years or older in an urban safety-net primary care clinic, with the goal of informing a future intervention. Four focus groups were conducted among 40 patients from, or living in the immediate neighborhood of, a primary care clinic for uninsured residents of Washington, DC. An additional focus group was conducted among primary care providers from the same clinic. Using semistructured open-ended questions, moderators elicited perceptions of barriers and promoters of colorectal cancer screening and suggestions to improve adherence to screening guidelines. The focus groups were audio-taped and transcribed verbatim. The transcripts were independently coded by two reviewers using established qualitative methodology. Patient and provider comments from the five focus groups fell into one of eight content areas: primary care characteristics (36% of comments), procedural issues related to screening (16% of comments), knowledge (14% of comments), cost/insurance coverage (13%), ordering of priorities (12%), attitudes (5%), information sources (2%), and perceptions of discrimination (2%). Involving various members of the primary care team in colorectal cancer screening processes, and using reminders with feedback, were identified as promising avenues for future interventions in the safety-net setting. Patients and providers cited the lack of referral sources for colonoscopy for follow-up of abnormal fecal occult blood tests (FOBT), and lack of treatment sources as major barriers to the initiation of colorectal cancer screening in uninsured populations. Organizational level interventions, such as a team approach to colorectal cancer screening, are important areas identified for future colorectal cancer screening interventions in the safety-net primary care setting. Larger policy efforts to provide coverage for screening, diagnosis, and treatment among the uninsured are critical to implementing adequate colorectal cancer screening for this population. Copyright 2004 The Institute for Cancer Prevention and Elsevier Inc.

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Author and article information

Journal

Journal ID (nlm-ta): Ann Surg Open

Journal ID (iso-abbrev): Ann Surg Open

Journal ID (publisher-id): AS9

Title: Annals of Surgery Open

Publisher: Wolters Kluwer Health, Inc. (Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103 )

ISSN (Electronic): 2691-3593

Publication date Collection: September 2022

Publication date (Electronic): 2 August 2022

Volume: 3

Issue: 3

Page: e183

Affiliations

From the [* ] University of California, San Francisco School of Medicine, San Francisco, CA

[† ]Department of Surgery, University of California, San Francisco, San Francisco, CA

[‡ ]Department of Medicine, University of California San Francisco, San Francisco, CA.

Author notes

Reprints: Hope Schwartz, 513 Parnassus Ave, S-245, San Francisco, CA 94143. E-mail: hope.schwartz@ 123456ucsf.edu .

Article

Accession ID: 00014

DOI: 10.1097/AS9.0000000000000183

PMC ID: 9511985

PubMed ID: 36187331

SO-VID: 790121bd-29df-48ee-89e4-183d2c6b4e55

License:

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 2 March 2022

Date accepted : 14 June 2022

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Keywords: colonoscopy,colorectal cancer,homeless,policy,screening,surveillance

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Keywords: colonoscopy, colorectal cancer, homeless, policy, screening, surveillance

Barriers to Colorectal Cancer Screening and Surveillance in Homeless Patients : A Case Report and Policy Recommendations

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Most cited references 9

Health interventions for people who are homeless.

Mailed fecal immunochemical test outreach for colorectal cancer screening: Summary of a Centers for Disease Control and Prevention–sponsored Summit

Patient and provider barriers to colorectal cancer screening in the primary care safety-net.

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