Colon cancer

Illustration by Brian Evans

14 The Nurse Practitioner • Vol. 33, No. 12 www.tnpj.com


screening:
Recommendations and
barriers to patient participation
Darlene P. Peters, RN, MSN
olorectal cancer is the third most common cancer
C in men and women, and the second leading cause
of cancer-related deaths in the United States.1,2
Worldwide estimates reveal that there could be more than 1
million new colorectal cancer cases and approximately half
a million related deaths annually.3 Each year an additional
135,000 to 147,000 new cases are reported.1,4,5 Survival rates
for colorectal cancer are related to the stage at diagnosis.2
Five-year survival rates range from less than 10% for those
diagnosed with late stage colorectal cancer to greater than
90% for early diagnosis.1,6
Screening recommendations from national organiza-
tions vary and can be difficult to navigate. It is estimated that
less than half of adults older than 50 are screened for colon
cancer. Primary care provider (PCP) recommendations can
influence a patient’s decision to participate in screening. Ad-
ditional research is needed to establish an effective dialogue
between patients and PCPs, and to develop appropriate tools
to increase participation in colon cancer screening.Advanced
practice nurses and nurse researchers can play a vital role in
improving colon cancer screening among patients.
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■ Development and progression
With such a large number of adults affected by colorectal
cancer, it is important to understand the development and
progression of the disease. Development is associated with
both modifiable and nonmodifiable risk factors. Modifiable
risk factors include obesity, physical inactivity, smoking,
heavy alcohol consumption, a diet high in red or processed
meat, a high-fat diet, and an inadequate intake of fruits and
vegetables.5,7-9 Nonmodifiable factors include age, a personal
or familial history of colorectal cancer, and a personal his-
tory of inflammatory bowel disease.5
Most incidences of colorectal cancer are caused by ade-
nomatous polyps.5 It is estimated that colorectal adenomas
are present in up to 40% of individuals by age 60.8 The pro-
gression from adenoma to cancer is the most common patho-
logic pathway, which is caused by an accumulation of a series
of genetic mutations within the cells of the colon (see The
histogenesis of adenomatous polyps of the colon).5,10 This
process occurs during a period of 5 to 10 years and includes
a multistep transformation of the colon cells.5,10,11 Once the
initial lesion forms, the risk of additional lesions increases.11
The Nurse Practitioner • December 2008 15
 Colon cancer screening

The histogenesis of adenomatous polyps of the colon

The initial proliferative abnormality of the colonic mucosa and the extension of the mitotic zone in the crypts leads to
the accumulation of mucosal cells. The formation of adenomas may reflect epithelial-mesenchymal interactions.

Source: Rubin R, Strayer D. Rubin’s pathology: Clinicopathologic foundations of medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2008: 604.

There are also two syndromes that can cause hereditary
colorectal cancer: hereditary nonpolyposis colon cancer
(HNPCC) and familial adenomatous polyposis (FAP).5
These syndromes can be responsible for early onset and
increase a patient’s chance of experiencing colorectal cancer.
Benign hyperplastic polyps account for about half of small
colonic polyps discovered at colonoscopy. There is no cur-
rent method to determine which polyps will develop into
cancer; thus all polyps identified at colonoscopy should be
removed regardless of size or location.

■ Treatment options ■ Screening recommendations

The course of treatment is decided by the presentation of
disease progression at diagnosis.2,3 Local tumors can be
removed surgically, which may eliminate the cancer; how-
ever, as the disease progresses—as seen by the depth of the
cancer into the bowel wall and spread to surrounding
lymph nodes—adjunct therapies including chemotherapy
and radiation are indicated. Chemotherapy is not routinely
indicated for stage II cancer, as 5-year survival rates of
patients undergoing chemotherapy are similar to survival
rates of patients who did not receive chemotherapy.3 An
emerging treatment of metastatic cancers is anticancer
medication that uses monoclonal antibodies to target the
epidermal growth factor associated with colorectal cancer.
Not all colonic polyps are adenomas, however, and
approximately 90% of adenomas do not progress to cancer.8
Colorectal cancer screening offers both prevention of disease
as well as an opportunity for early detection and treatment.5
(see the “This Just In” column in the September 2008 issue
of The Nurse Practitioner.) Detection and removal of polyps
before they become cancerous and the removal of early stages
of cancerous lesions is associated with an increased 5-year
survival rate.1,2,12 Up to 90% of deaths can be prevented by
the removal of precancerous polyps.1
Screening for colorectal cancers in asymptomatic adults
should begin at age 50 for patients of average risk.13 Although
the term “average risk” is found frequently in the literature,
no definition was noted in a review of current research.
Patients considered at “increased risk” include those with a
family history of HNPCC or FAP, a family or personal
history of colon cancer, or a history of inflammatory bowel

16 The Nurse Practitioner • Vol. 33, No. 12 www.tnpj.com


disease.5,14 For patients at increased risk, screening is recom-
mended at age 40 or the age of a first-degree relative with
colorectal cancer at diagnosis minus 10 years.5 The
effectiveness of a screening program is dependent on the
accuracy of the tests used.
Guaiac-based fecal occult blood testing (gFOBT) is the
most noninvasive form of testing. It consists of testing two
separate samples from three consecutive bowel movements.15
Although this is an effective screening tool for blood in the
digestive system, it is nonspecific to its origination.16 It is
also noted that a single sample obtained during a digital rec-
tal exam is not an effective screening tool; this practice is
strongly discouraged.1,15 Additionally, aspirin, nonsteroidal
anti-inflammatory drugs,or red meat consumed several days
prior to testing may lead to false-positive results.16 Vitamin C
in excess of 250 mg per day may cause false-negative results.
The immunochemical fecal occult blood test (FIT) and
stool DNA are alternative screening tools that may be used
in place of gFOBT.1,17 One benefit of FIT includes less
dietary and medication restrictions which may increase
compliance.17 Another benefit of FIT is an increased sensi-
tivity, which leads to less false positive
results.1 In stool DNA (sDNA), the
entire specimen is examined for mark- Despite its cost, risk, and inconvenience,
ers which arise from pre-malignant
colonoscopy is a reliable procedure used
adenomas and tumors. However, after
recent data collection, the American
Cancer Society and U.S. Multi-Society
Task Force (USMSTF) on Colorectal
Cancer, along with the American College of Radiology,
concluded that there is significant data to include sDNA as
an acceptable option for colorectal cancer screening.1
Flexible sigmoidoscopy is an effective tool in reducing
16
mortality from colon cancer. While it is limited in visual-
ization of the distal colon, this is the most common area of
occurrence of adenomas. A sigmoidoscopy may be used to
determine if a colonoscopy is necessary.
Double contrast barium enema (DCBE) is a lower cost
alternative to a colonoscopy, but it poses a number of draw-
backs. The sensitivity is less for smaller lesions, so it requires
a more frequent interval of testing (5 years versus 10 years)
than with colonoscopy.16 It also does not allow for excision
of lesions or biopsy during the exam, which is a benefit of
colonoscopy. While information about the DCBE test still
occurs in the literature and in screening guidelines, the
actual use of this screening tool is not known.
Colonoscopy can lead to a decreased incidence of can-
cer and death due to the detection of precancerous lesions
and early stage cancer.18 Colonoscopy is the preferred
method for screening due to its ability for complete colonic
19
visualization and current polyp removal. It is estimated
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Colon cancer screening
that the relative mortality reduction is 25% for those screen-
ed via colonoscopy.20 This reduction in mortality is most
likely attributed to the discovery of early stage versus late
stage cancers. Despite its cost, risk, and inconvenience,
colonoscopy is a reliable procedure used for screening
beginning at age 50.
Complications of colonoscopy included colon perfora-
tion and bleeding either at the time of the procedure or in
the days to weeks that follow, although rates of complica-
tions were very low.20 The reported low risk lends further
support for colonoscopy as an effective means for colorectal
cancer screening.
Computed tomography colonography (CTC), also
referred to as virtual colonoscopy, is a minimally invasive
alternative to colonoscopy. The technology required to
visualize the entire large intestine has improved since its
inception in the mid 1990’s.1 The advanced technology
allows for the integrated use of both 2D and 3D views for
enhanced visualization and optimum detection of polyps.1
However, it does not allow for excision of lesions or biopsy
during the exam. The ability to visualize extracolonic struc-
for screening beginning at age 50.
tures provides an added bonus for the patient. Bowel prepa-
ration prior to the CTC is required; however, there is no
need for procedural sedation, thus decreasing recovery
time.1 Research is currently underway to support the use of
CTC as an effective means of detecting colorectal cancer.
Reimbursement for CTC is a major hurdle in its use at this
time, limiting the professional capacity to provide this test
to patients. Nonetheless, capacity is expected to increase
when third-party payers begin reimbursement for the
screening.1
■ Patient participation
The Healthy People 2010 initiative set goals for 50% of the
population to have FOBT in the last 2 years, with 50%
having had a sigmoidoscopy.13 The most recent results
from the 2001 Behavioral Risk Factor Surveillance System
show FOBT in the last 12 months at 23.5% and lower
endoscopy at 43% in the last 10 years.13 Screening recom-
mendations from national organizations vary (see Screening
recommendations).21-23
Even though it is widely known that the removal of
polyps can reduce mortality and prevent disease, there is not
The Nurse Practitioner • December 2008 17
 Colon cancer screening

Screening recommendations1,21-23

Listed below are acceptable options for colorectal cancer screening in average-risk adults starting at 50 years of age.

Organization Age Test Time frame

CDC 50+ gFOBT Annually

Flexible sigmoidoscopy Every 5 years

Colonoscopy Every 10 years

Double contrast barium enema Every 5 years

The U.S. Preventive 50 to 75* gFOBT Annually

Services Task Force
Flexible sigmoidoscopy and Every 5 years and
fecal occult blood test every 3 years
Colonoscopy Every 10 years

American Cancer Society/ 50+ Fecal tests:

U.S. Multi-Society • gFOBT • Annually
Task Force/American College • FIT • Annually
of Radiology • sDNA • Interval to be
determined

Flexible sigmoidoscopy Every 5 years

Colonoscopy Every 10 years

Double contrast barium enema Every 5 years

CTC Every 5 years

* The U.S. Preventive Services Task Force 2008 recommendations for colorectal cancer screening recommend screening for adults ages 50 to 75 years.
Routine screening is not recommended for adults ages 76 to 85 years, and adults over age 85 should not be routinely screened.

a major increase in screening rates.24 It is suggested that a
population-wide barrier to colon screening may change
over time as tests are more readily adopted by the public.
When screening tests are introduced into clinical practice,
there is an initial period of adjustment by both clinicians
and the community. As awareness increases, so too should
participation. For example, initially there were similar bar-
riers to both Pap tests and mammograms—two routine
screening tests that currently show high participation rates.
However, with guidelines being in place for more than 10
years, it is unlikely that this same trend will occur. There-
fore, it is important to determine why the level of testing
has remained low.
While colonoscopy is the most accurate screening
tool, there are several factors that limit its use. The main
reasons why patients do not participate in the recom-
mended screening tests include cost (insurance or out-
of-pocket expenses); accessibility; a patient’s fear or
psychological distress at either having the procedure,
facing the possible results of the test, or fear of pain or
loss of modesty; time, including scheduling conflicts
or time spent communicating with the insurance com-
pany; feeling the test was unnecessary; and knowledge
deficit.1,2,4,13,25-27
One study, which was used in conjunction with the Na-
tional Health Interview Survey in 2000, found that lower
screening rates were driven by a lack of PCP counseling about
screening or patient nonadherence to PCP recommenda-
tions.4 More than 32,000 surveys were issued, with a response
rate of 83%. These respondents were then subcategorized
with an emphasis placed on adults aged 50 to 75 years (n =
11,427). When looking at this subgroup, 7,863 participants
did not undergo a sigmoidoscopy or colonoscopy. Overall,
72% of this group was unaware that they needed screening,
and 21% reported that their PCP did not recommend the
procedure. Of participants to whom screening was not rec-
ommended, more than 90% were seen by their PCP during
the previous year.

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■ Implications
Review of screening patterns in patients shows that a large
percentage of adults are not participating in routine screen-
ing for colorectal cancer. It is estimated that fewer than
40% of adults over age 50 undergo screening for colorectal
cancer.13,25 Because survival is inversely related to stage at beginning at age 50, but counseling patients about screen-
time of diagnosis and the cost of screening is less than that
of treatment, barriers to screening—whether attributed
to patient or PCP—need to be eliminated.
While PCP recommendation is a significant predictor
of completing screening exams, one study sought to
determine the frequency of recommen-
dations. Primary care physicians who
completed a questionnaire regarding As NPs more frequently assume the PCP role,
routine recommendations for colon
it is vital that patient recommendations be
cancer screening and communication
styles were mailed additional surveys. based on best practice and current guidelines.
The response rate was 57.9% (n = 270),
and the survey was followed by a study
that randomly selected PCPs to videotape encounters be-
tween a physician and patient (n = 18). These studies
showed that while physicians rated colonoscopy as the
most important screening option to discuss, self-reports
of the frequency of this recommendation were much
higher than occurrence rates. While PCPs recognized the
importance of discussing colorectal cancer screening with
patients, the dialogue does not occur as often as re-
ported.28
One intervention sought to provide patients with indi-
vidualized screening guidelines.29 A cue card was given to
each patient older than 50 with information about what
cancer screening tests were appropriate for age, history, and
date of last screening exam. Short-term improvements were
noted in this group; however, the percentage of patients who
were screened fell back to baseline by the end of the study.
Another study for FOBT screening offered bilingual infor-
mational brochures and a motivational video with FOBT
30
cards and instructions. Patients were randomized into two
groups, and the intervention group was assigned to a health
educator. The interventional group showed a participation
rate of almost 70% compared with 27.6% in the control
group.
Another study showed the success of providing a re-
minder mailing to patients referred for colonoscopy screen-
ing. A one-page, double-sided brochure was customized to
include a welcome message and contact information from
the patients’ PCP.31 Large font, cartoon diagrams, and copy
written at an eighth-grade level were used. After randomly
assigning a population of 792 patients into two groups,
patients who received the mailer were 20% more likely to
have a colonoscopy.
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Colon cancer screening
■ Communication is crucial
In the early stages, colon cancer is almost 90% curable.
The CDC, The U.S. Preventive Services Task Force, and
the American Cancer Society recommend screening of
asymptomatic adults of average risk for colon cancer
ing must be increased. Interventions that address the
common reasons for nonadherence with screening tests,
such as lack of PCP recommendation, fear, cost, time and
accessibility, also need to be developed. NPs who pro-
vide primary care are in a great position to increase
awareness and assure understanding of the importance
of screening in their patients.
As NPs more frequently assume the PCP role, it is vital
that patient recommendations be based on best practice and
current guidelines. Each PCP needs to evaluate their indi-
vidual practice to determine the current level of participa-
tion within their patient population. Levels of participation
in screening can then be used as a measure of quality care.
Once the level of participation is established, it is important
to identify barriers that affect patient participation rates.
Options such as tools that provide cues, a health educator,
and reminder mailings are shown to be effective in increasing
referral for and completion of screening.1,29,31
Additional study is needed in this area, especially for ef-
fective communication between patients and PCPs, and the
development of appropriate tools to increase participation
in colon cancer screening. As prevention is a cornerstone of
the profession of nursing,advanced practice nurses and nurse
researchers can play a vital role in the future of colon cancer
screening among adults.
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6. O’Connell J, Maggard M, Ko C. Colon cancer survival rates with the new
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INSTRUCTIONS
Colon cancer screening: Recommendations and barriers to patient participation
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the faecal occult blood test, Hemoccult [Review]. Cochrane Database Syst
Rev. 2007;(1):CD001216.
21. Centers for Disease Control and Prevention. Cancer—colorectal screening
guidelines. Available at: http://www.cdc.gov/CANCER/colorectal/basic_info/
screening/guidelines.htm. Accessed October 20, 2008.
22. U.S. Preventive Services Task Force. Screening for Colorectal Cancer: Clini-
cal Summary of U.S. Preventive Services Task Force Recommendation.
Available at: http://www.ahrq.gov/clinic/uspstf08/ colocancer/colosum.htm.
Accessed October 20, 2008.
23. American Cancer Society. American Cancer Society Guidelines for the early
detection of cancer. Available at: http://www.cancer.org/docroot/PED/
content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp. Accessed
October 20, 2008.
24. Finney RL, Nelson D, Meissner H. Examination of population-wide trends
in barriers to cancer screening from a diffusion of innovation perspective
(1987-2000). Prev Med. 2005;38:258-268.
25. Denberg T, Melhado R, Coombes J, et al. Predictors of nonadherence to
screening colonoscopy. J Gen Intern Med 2005;20(11):989-995.
26. Lilijegren A, Lindgren G, Brandenberg U, et al. Individuals with an in-
creased risk of colorectal cancer: perceived benefits and psychological
aspects of surveillance by means of regular colonoscopies. J Clin Oncol.
2004;22(9):1736-1742.
27. Gurudu S, Fry L, Fleischer D, et al. Factors contributing to patient nonatten-
dance to open-access endoscopy. Dig Dis Sci. 2006;51:1942-1945.
28. Wolf M, Baker D, Makoul G. Physician-patient communication about
colorectal cancer screening. J Gen Intern Med. 2006;22(11):1493-1499.
29. Ruffin IV M, Gorenflo D. Interventions fail to increase screening rates in
community-based primary care practices. Prev Med. 2004;39:435-440.
30. Tu S, Taylor V, Yasui Y, et al. Promoting culturally appropriate colorectal
cancer screening through a health educator. Cancer. 2006;107(5):959-966.
31. Denberg T, Coombes J, Byers T. Effect of a mailed brochure on appointment-
keeping for screening colonoscopy. Ann Intern Med. 2006;145:895-900.
AUTHOR DISCLOSURE
The author has disclosed that she has no significant relationship or financial in-
terest in any commercial companies that pertain to this educational activity.
Darlene P. Peters is a family nurse practitioner at Greater Elgin Emergency
Services, Elgin, Ill.
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