Colorectal cancer (CRC) screening is considered one of the most effective and successful tools to protect public health: Screening has been found to significantly reduce the incidence of CRC through the removal of precancerous polyps during colonoscopies and to decrease mortality through early identification and early treatment. Yet uptake of CRC screening remains low across the United States.
In a new study, Yale researchers evaluated the uptake of different tests and procedures used to screen for CRC among privately insured adults in the U.S. They found important differences in the use of various screening tests and procedures based on sex, socioeconomic status, and metropolitan versus nonmetropolitan residence.
“Elucidating these patterns is key to addressing health disparities and improving screening for all, as there is no ‘one size fits all’ approach to screening for CRC among diverse population subgroups,” said Sunny Siddique, postdoctoral fellow in the Department of Chronic Disease Epidemiology (CDE) at Yale School of Public Health (YSPH) and first author of the study.
The study appears in the journal JAMA Network Open.
CRC is the second leading cause of cancer death in the country. Over the past two decades, the incidence and mortality of CRC have decreased, largely due to the uptake of screening. Despite its benefits, however, screening participation remains below the national target of 80% among adults aged 45 years and older. In 2022, analysis of recent survey data has shown that, among adults aged 50 to 75 years, the CRC screening rate was approximately 61%.
There are several different tests and procedures that can be used to screen individuals for CRC. While colonoscopy is the most common, other screening tools and procedures include stool-based tests (such as fecal immunochemical tests (FIT) and stool DNA tests), radiologic tests (like computed tomographic (CT) colonography), and other visual endoscopic examinations. Yet the uptake of these different screening options has largely been unknown.
To close this critical knowledge gap, the researchers conducted a large national study of 24,973,624 privately insured adults to evaluate the uptake of different tests and procedures used to screen for CRC in the United States.
They compared the uptake of various CRC screening options from January 1, 2017, through December 31, 2024, using advanced time series methodology. They categorized those 96 months into 48 consecutive two-month periods to capture potential shifts in screening patterns and short-term epidemiologic phenomena (including each wave of the COVID-19 pandemic) that could have affected the uptake of CRC screening.
For each of those periods, they used deidentified claims data of individuals aged 50 to 75 years who are privately insured through Blue Cross and Blue Shield (BCBS), the largest provider of commercial insurance in the country. Those claims included different measures of demographic and socioeconomic characteristics, including age, sex, race, ethnicity, zip codes, and more.
Through their methodology, the researchers found that the use of colonoscopy and FIT declined during that time period, and that stool DNA test use has increased. They also found important disparities in the use of various screening tests and procedures based on sex, socioeconomic status (SES), and metropolitan area residential status. For example, men had higher use of colonoscopy while women had higher use of stool DNA test. And areas where a marker of SES was in the top 20% and metropolitan areas had more frequent use of both screening options.
“Our findings suggest important changes in the uptake of various CRC screening tests and procedures in the U.S.,” Siddique said. “It would be important to develop tailored interventions to improve screening uptake and reach the national target of screening 80% or more of the population in every community.”
The findings, researchers say, shed light on the rapidly evolving landscape of CRC screening in the U.S. Although all individuals included in the study had commercial insurance, the researchers still observed significant variations in the uptake of CRC screening, underscoring the need for more nuanced approaches to improve screening for all.
“In our future studies, we are interested in understanding geographic differences in the use of various CRC screening modalities to inform the development of targeted interventions,” said Xiaomei Ma, senior author of the study and professor of epidemiology and interim chair of the Department of Chronic Disease Epidemiology at YSPH. “Furthermore, we hope to examine the impact of different modalities on CRC incidence and mortality, as well as the cost-effectiveness of different modalities.”
Other Yale authors include Rong Wang, senior research scientist at the Department of CDE at YSPH and Cary Gross, professor of medicine (general medicine) and of epidemiology (chronic diseases) at Yale School of Medicine.
