Jenny Chiang, MD, FAAFP, Medical Director, MetroWest Healthcare Alliance, Wellforce

COVID-19 has disrupted healthcare practices and challenged Primary Care Providers (PCPs) to rapidly innovate to deliver care. It has also upended patients’ lives and forced many to skip preventive care checkups and screenings, as well as highlighted gaps in chronic diseases and disparities in outcomes. In the last two years, cancer screening rates have plummeted in nearly all age groups

despite a rising incidence of colorectal cancer (CRC) in younger adults.

 Colorectal cancer is the second leading cause of cancer deaths in the United States;

 however, when caught in early stages, it is treatable in ~90% of people.

Regular screening can help catch cancer early.

 So, as we consider patient care in light of the ongoing pandemic, how can we encourage eligible adults to get screened when they’re due? We have an opportunity to redesign our approach – action is needed across the healthcare spectrum to ensure health systems, community centers, and PCPs partner to prioritize health literacy and ensure patients have the necessary support and resources to make informed decisions.

Increasing health literacy is critical to combatting colorectal cancer. With the recommended colorectal cancer screening age starting at 45 for average-risk Americans

, there should be a sense of urgency in finding new ways to engage with patients around preventive care measures.

New data from The Harris Poll** highlighted a lack of awareness about the risk*** of colorectal cancer. Many of those surveyed perceived themselves to be at minimal risk. In fact, 73% of respondents aged 45-49 believed they are at low risk for colorectal cancer. This demonstrates a critical and concerning gap in health literacy. We have a responsibility to ensure screening-eligible Americans, particularly adults aged 45-49 and those in vulnerable communities, have the resources and information they need to understand why screening should be a priority.

So, what steps can we take to drive progress? While I would love to see sweeping public health changes on initiatives for self-management of preventive care, where colon cancer screenings could be as accessible and convenient as a home-delivered rapid COVID antigen test, taken after using a validated screening calculator to self-assess their risk level for colorectal cancer, I believe that there are a few simple actions that can make a large impact now. 

We could reframe how we engage in cancer screening conversations. It is easy to lead with, “Now you’re 45, it’s time for your colonoscopy.” But perhaps start with, “Do you ever think about getting cancer?” It might be a surprising question to hear, even alarming, but it could give you some insights on your patient’s fears or willingness to screen for the recommended cancers or only specific types and why. Primary care providers are a trusted resource and can start the conversation about personal risk and share the best screening options to meet patients where they are.

Another option is to offer a choice in colon cancer screening options to patients first, before waiting to hear if there is any hesitancy about colonoscopy. While a colonoscopy is considered the primary screening option for colorectal cancer, offering a choice in screening can encourage those who have hesitancy to get scoped.

 Many respondents to the Harris Poll noted that their discomfort – physical or stigma-related – with colorectal cancer screening has prevented them from staying up to date, indicating an opportunity for more screening options. In fact, among those who have ever skipped a colorectal cancer screening after a referral, 38% of those surveyed cite having done so due to discomfort with the idea of invasive procedure. Additionally, 74% of adults surveyed agreed that they would get screened for colorectal cancer if it were a non-invasive procedure, while 72% of respondents said that they would be more willing to get screened if they could use an at-home test instead of going to a doctor's office.

Despite these results, only 4 in 10 respondents (40%) were familiar with at-home DNA based stool tests. Each type of screening test has its strengths and shortcomings when comparing effectiveness, accessibility, and ease of use, but the best screening is the one that gets done. When considering health disparities in populations where paid sick time is not available, or patients are primary caregivers to children or elders and unable to take time away for the colonoscopy prep and procedure, providing resources that clearly delineate various screening options is critical.

At-home screening options such as Cologuard® can provide a non-invasive, effective, and convenient screening option for adults 45 and older, who are at average risk for colorectal cancer. In the effort to improve health literacy, it is important to discuss with patients what makes them eligible and ineligible for Cologuard. Small practices and solo PCPs with limited resources have found it helpful that Cologuard also has a built-in, 24/7 patient support team to follow-up on and encourage test completion in over 240 languages which can help make the process more convenient and contact free, particularly as screening rates have dropped amidst COVID-19.

As we navigate this complex healthcare landscape, action is needed to ensure health systems, community centers, and PCPs partner to prioritize health literacy and engage patients with the meaningful resources and necessary support to make informed decisions. To do so, we must reframe our approach as we face increasingly challenging areas of care. With colorectal cancer incidence rates on the rise in younger populations,

 screenings remain the most important tool to detect preventable fatalities. Meeting patients where they are with solutions that fit their specific needs is critical to catching up on missed screenings and encouraging future screenings.

Indication and Important Risk Information


Cologuard is intended to screen adults 45 years of age and older who are at average risk for colorectal cancer by detecting certain DNA markers and blood in the stool. Do not use if you have had adenomas, have inflammatory bowel disease and certain hereditary syndromes, or a personal or family history of colorectal cancer. Cologuard is not a replacement for colonoscopy in high-risk patients. Cologuard performance in adults ages 45-49 is estimated based on a large clinical study of patients 50 and older.

The Cologuard test result should be interpreted with caution. A positive test result does not confirm the presence of cancer. Patients with a positive test result should be referred for diagnostic colonoscopy. A negative test result does not confirm the absence of cancer. Patients with a negative test result should discuss with their doctor when they need to be tested again. False positives and false negative results can occur. In a clinical study, 13% of people without cancer received a positive result (false positive) and 8% of people with cancer received a negative result (false negative). Rx only.

** Data is according to a national survey of 5,021 U.S. adults aged 45-75 conducted by The Harris Poll on behalf of Exact Sciences between March 25 and April 15, 2021.

*** Average risk in this survey was defined as those who do not have a personal history of: colorectal cancer, Inflammatory Bowel Disease, adenomas, a positive result from a colorectal cancer screening within the last 6 months, a family history of: colorectal cancer, Familial adenomatous polyposis (FAP, Hereditary non-polyposis colorectal cancer syndrome (HNPCCC or Lynch Syndrome), Peutz-Jeghers Syndrome, MYH-Associated Polyposis (MAP), Gardner’s Syndrome, Turcot’s (or Crail’s) syndrome, Cowden’s syndrome, Juvenile Polyposis, Cronkhite-Canada syndrome, or Neurofibromatosis, and are not experiencing rectal bleeding.

Chen RC, Haynes K, Du S, Barron J, Katz AJ. Association of Cancer Screening Deficit in the United States With the COVID-19 Pandemic. JAMA Oncol. 2021;7(6):878–884. doi:10.1001/jamaoncol.2021.0884

Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average‐risk adults: 2018 guidelines update from the American Cancer Society. CA Cancer J Clin. 2018;68(4):250‐281. doi:10.3322/caac.21457.

Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2021. CA Cancer J Clin. 2021;71:7-33. doi:10.3322/caac/21654.

National Cancer Institute. Cancer stat facts: colorectal cancer. Accessed November 10, 2021. https://seer.cancer.gov/statfacts/html/colorect.html.

Davidson KW, Barry MJ, Mangione CM, et al. Screening for colorectal cancer - US Preventive Services Task Force recommendation statement. JAMA. 2021;325(19):1965-1977. doi:10.1001/jama.2021.6238

Jenny Chiang, MD, FAAFP, Medical Director, MetroWest Healthcare Alliance, Wellforce

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