The Pulse | Thursday, September 27, 2018

Building Healthier Communities Through Practice

Colorectal cancer prevention and awareness is important for a healthy community. That comes through education and screening. But barriers do indeed exist.

We sat down with Nancy Schlossberg, BA BSN RN CGRN — a GI nurse for 40 years — to discuss how nurses can play a role in breaking down the barriers and improving awareness among patients. 

SGNA: Why is colorectal cancer prevention and awareness important for a healthy community?

Schlossberg: Everyone deserves to live the healthiest life possible. A healthy community is a community in which all people have access to the services and conditions that contribute to physical, mental, educational, environmental and economic health.  All communities deserve the chance to reach their greatest health potential.

Colorectal cancer is the second leading cause of cancer death in United States when men and women are combined and causes considerable suffering among more than 135,000 adults diagnosed with colorectal cancer each year.  But this does not have to be! Mammograms, Pap smears and PSA screening tests may be effective for early detection but provides no ability to prevent cancer itself.  in terms of the quality of scientific evidence that early detection saves lives, there are no better cancer screening tests than those for colorectal cancer.

Screening is the process of looking for cancer or pre-cancer in people who have no symptoms of the disease. When all adults ages 50 to 75 and at average risk for colorectal cancer adults get screened for colorectal cancer, it can be detected early at a stage when treatment is most likely to be successful, and in some cases, it can be prevented through the detection and removal of precancerous polyps.

Regular colorectal cancer screening is one of the most powerful weapons in preventing colorectal cancer, but only if people actually get screened.  When colorectal cancer is found at an early stage before it has spread, the 5-year survival rate is about 90%. However, only about 4 out of 10 colorectal cancers are found at this early age. 60% of deaths could be prevented if all men and women aged 50 years or older in the U.S. were regularly screened.

SGNA: What are the biggest barriers to preventing people from getting screened for colorectal cancer?

Schlossberg: Screening can save lives, but only if people get tested. Groups less likely to take part in screening include those aged 50-64, men, Hispanics, American Indian or Alaskan natives, people living in rural areas, and individuals with lower education and income. (Morbidity and Mortality Weekly Report: Vital Signs: Colorectal Cancer Screening Test Use – United States 2012. Centers for Disease Control and Prevention. November 5, 2013, Vol 62). We know what we need to do to get more people screened for colorectal cancer, prevent more cancers and save lives. 

The decision to undergo colorectal cancer screening is influenced by factors including an individual’s cultural perceptions and beliefs, social, and physical environments, knowledge, access, educational status. 

For example, some patients think they need to get screened only if they have symptoms or have a family history of colorectal cancer. However, the majority of people who develop colorectal cancer have no family history.

Patients and providers do not always know about or consider all the available recommended screening tests. Some patients do not know about screening because their doctors fail to recommend it. Some patients are confused by having to choose between more than one colorectal screening test, each of which has pros and cons that are difficult to explain in a five-minute conversation. Also, many health care providers and systems are not set up to help more people get screened for colorectal cancer.

Screening also endures an unpleasant and inconvenient reputation, often termed the “ick” factor. The best test is the test that gets done. Now, at-home colon cancer screening tests remove some of the “ick” factor.

However, the expense may be the biggest barrier to screening. Without insurance, a colonoscopy with anesthesia can cost several thousand dollars. Screening colonoscopies are covered by most private insurance plans. But once a polyp is detected and removed, the screening becomes a diagnostic procedure and costs may rise and become an out of pocket expense. People also have to take a day off from work to prepare for a colonoscopy. While at-home tests to detect colorectal cancer may be more affordable up front. However, if the l test suggests there is a problem, you need a colonoscopy.

SGNA: Do you see these barriers getting more difficult to overcome or less difficult to overcome in the future?

Schlossberg: The barriers are coming down as the need and expectation for screening continues to generate momentum. The public is used to television ads discussing mammograms and PSAs. Since Katie Couric had her colonoscopy on prime-time network television, increasingly TV and media discuss the benefit of colon cancer screening, and large inflatable colons appear at health fairs. Such public information makes it easier for patients to have conversations with their primary care providers and their families.

More people now have access to colorectal cancer screening because of the implementation of the Affordable Care Act (ACA). The New England Journal of Medicine estimates that as of 2014, 10 million people have gained coverage for screening under the Affordable Care Act. (The New England Journal of Medicine: Health Reform and Changes in Health Insurance Coverage in 2014.)

The “80% by 2018 initiative,” in which more than 1,000 organizations have committed to substantially reducing colorectal cancer as a major public health problem for those 50 and older, is led by the American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC) and the National Colorectal Cancer Roundtable (an organization co-founded by ACS and CDC). Organizations that have signed the 80% by 2018 pledge are working toward the shared goal of 80% of adults aged 50 and older being regularly screened for colorectal cancer by 2018. The organizations “stand united in the belief that we can substantially reduce colorectal cancer as a major public health problem. We have screening technologies that work, the national capacity to apply these technologies, and effective local models for delivering the continuum of care in a more organized fashion. Equal access to care is everyone’s responsibility. We share a commitment to eliminating disparities in access to care.” (80% by 2018” Vision Statement.”  http://nccrt.org/wp-content/uploads/80-by-2018-TALKINGPOINTS-Final-2.16.17.pdf).

SGNA: How can nurses improve COLORECTAL CANCER awareness among patients?

Schlossberg: America’s 3.6 million registered nurses are keys to promoting health and creating communities in which everyone has access to high-quality care, especially with the increasing number of nurses with advanced degrees and nurses in leadership roles, and the expanding numbers of states with broader scopes of practice for nurses, and brining more nurses into leadership positions. 

Nurses help lead the effort to see that everyone lives the healthiest life possible. Education and communication are keys to nurses promoting colorectal cancer awareness among patients. First and foremost, nurses need to get educated and make sure they know the colorectal cancer risk factors based on family history and susceptibility, and risks and benefits of options, when to start and follow up colorectal cancer screening testing. Nurses, trusted educators, can help ensure that patients do not die from embarrassment related to the Ick factor.

Knowing one’s risk profile for disease facilitates health behavior.  Armed with this knowledge, nurses should act locally, communicating the facts to patients in their individual practice arenas. Nurses must also spread the word in their community, educating patients, family and friends at dinner parties, at church and at the hair dresser, for example!

Especially, GI and Endoscopy nurses are positioned to take the lead in these efforts, as they see and appreciate firsthand the regrettable consequences of patients who did not got screened too late, did not follow up on screening, or did not get screened at all because they were afraid, or just did not understand the importance of screening.

Patient navigation in cancer care is individualized support for patient families, and care givers to help them overcome health care system barriers and get the medical, social and psychological care they need. For colorectal cancer screening, patient navigation helps patients test the test they need by ensuring undersigning of and compliance with test instructions and preparation, providing appointment reminders and other activities to support he patient through the process.

Nurses in all settings should make sure patients and families have an up to date supply of literature on colon cancer screening available in their practice settings, including physician office, in and outpatient hospital waiting rooms. Organizations such as the American Cancer Society (ACS), the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the Centers for Disease Control and Prevention (CDC) offer free print colorectal cancer factsheets, brochures, and other materials to encourage men and women to get screened.

All nurses should participate in March is National Colorectal Cancer Awareness month activities. This is an annual campaign to raise awareness of the disease and fundraise for research into its cause, prevention, diagnosis, treatment, survivorship and cure as well as to support those affected by colorectal cancer. One such activity is the annual Dress in Blue day, the first Friday in March. Wear blue and unite for a future free of colon cancer awareness and raise the awareness of the general public about colorectal cancer.

Again, it’s all about communication and creating and promoting the expectation that our patients, friends and families will incorporate colorectal cancer screening into their healthy lifestyle.  Nurses are a critical lynchpin in building bridges among health care, the community, and the social supports needed to create a Culture of Health — so that everyone in America lives the healthiest life possible.