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Colorectal cancer (CRC) is the third most commonly diagnosed cancer, excluding skin cancers, and the second leading cause of cancer death in the United States among men and women combined (1). Multiple clinical trials have shown that stool-based screening, such as the fecal immunochemical test (FIT), is effective at prevention or early detection of CRC, making it one of two screening modalities (as well as direct visualization) that the U.S. Preventive Services Task Force recommends for average-risk patients (2). A recent national survey suggested that stool-based tests are preferred by patients nationwide over colonoscopy and other direct visualization tests, likely because they reduce many individual-level barriers to screening such as bowel prep, time away from employment, transportation needs, and other related out-of-pocket costs (3). Further, the use of FIT as a screening modality has been shown to reduce or remove common misperceptions and barriers associated with other screening modalities, such as colonoscopy (4,5).
Screening rates in rural areas of the United States lag behind urban areas, a gap largest in states with overall lower CRC screening rates (6). Screening disparities, in part, contribute to rural areas being overburdened by more frequent late-stage CRC diagnosis and, subsequently, greater mortality (7,8). Mailed FIT represents a promising population health strategy for improving CRC screening rates in medically underserved rural areas where distance to travel to primary care clinics and specialists might inhibit screening adherence and follow-up, when necessary (9). Accordingly, rural primary care clinics that implement a mailed FIT program might have a tangible impact on increasing community CRC screening rates.
Nevertheless, rural primary care clinics have unique challenges to implementing broad strategies, such as a mailed FIT program. Davis and colleagues (10) examined electronic health record (EHR) data from 15 urban clinics within a large federally qualified health center (FQHC) system and conducted key informant interviews to determine clinic-specific factors that contributed to higher or lower FIT completion rates. They found that the nine higher-performing clinics (38.5%–56.3% completion) presented with 1 of 3 factors: (1) the addition of back-office and/or front-office staff in the past year; (2) medical assistants or care coordinators to navigate patient barriers; or (3) non-physician staff to hand out FIT kits and provide patient education. By contrast, the six clinics designated as lower-performing (29.7%–34.9% completion) lacked all three factors. These findings are particularly important because they identify modifiable factors that individual clinics or systems can address to increase FIT screening rates. Ultimately, the finding from this urban FQHC system boils down to the importance of clinics having a number of support staff who can fill different roles needed to support implementation of a multicomponent mailed FIT intervention. These additional staff, however, are often not available in rural primary care clinics, many of which are understaffed, underfunded, and overburdened (11).
With respect to COVID-19, Davis and colleagues also note that mailed FIT interventions represent a promising way to minimize care disruptions related to colonoscopy backlogs stemming from pandemic-related restrictions (10). In our research in rural Kentucky, we found that primary care clinics coping with COVID-19 were willing to shift from a colonoscopy-first model to one that prioritized stool-based screening for average risk patients due to extreme regional colonoscopy backlogs; however, our clinic partners vastly preferred FIT-DNA (i.e., Cologuard®) to FIT because it required fewer clinic resources (12). For mailed FIT interventions to be successful at increasing CRC screening rates, they need to include staff who can dedicate time to supporting distinct implementation strategies (e.g., patient navigation, small media education) that have been suggested to be particularly important for rural patients using FIT as a screening modality (13). Rural clinics often simply lack the number of people to fulfill these roles and do not usually have the available bandwidth to burden their current staff by taking on additional duties.
In light of these difficulties, perhaps the most salient theme from Davis and team’s key informant interviews was the identified importance of funding clinic staff who can take on these ancillary intervention roles, particularly given the relatively high levels of physician and staff turnover in community practices cited by the authors (10). We have anecdotally noticed a similarly high level of staff turnover in our partnerships with rural Kentucky clinics, with many staff citing burnout as a reason for leaving practice. Accordingly, it is critical that grant-funded CRC screening programs in rural clinics set aside funding to hire support staff. Even simply adding a dedicated patient navigator would likely go a long way to increasing buy-in (and adding bandwidth) for a mailed FIT intervention in a small rural primary care clinic. Should this approach not be feasible, then the burden must be on the research team to make sure they understand the community landscapes well enough to be able to identify and leverage existing community resources that might partly be able to fill these support roles (14).
References
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