Skip to main content
Log in

A Culturally Tailored Navigator Program for Colorectal Cancer Screening in a Community Health Center: A Randomized, Controlled Trial

  • Original Article
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Background

Minority racial/ethnic groups have low colorectal cancer (CRC) screening rates.

Objective

To evaluate a culturally tailored intervention to increase CRC screening, primarily using colonoscopy, among low income and non-English speaking patients.

Design

Randomized controlled trial conducted from January to October of 2007.

Setting

Single, urban community health center serving a low-income, ethnically diverse population.

Patients

A total of 1,223 patients 52-79 years of age overdue for CRC screening, randomized to intervention (n = 409) vs. usual care control (n = 814) groups.

Intervention

Intervention patients received an introductory letter with educational material followed by phone or in-person contact by a language-concordant “navigator.” Navigators (n = 5) were community health workers trained to identify and address patient-reported barriers to CRC screening. Individually tailored interventions included patient education, procedure scheduling, translation and explanation of bowel preparation, and help with transportation and insurance coverage. Rates of colorectal cancer screening were assessed for intervention and usual care control patients.

Results

Over a 9-month period, intervention patients were more likely to undergo CRC screening than control patients (27% vs. 12% for any CRC screening, p < 0.001; 21% vs. 10% for colonoscopy completion, p < 0.001). The higher screening rate resulted in the identification of 10.5 polyps per 100 patients in the intervention group vs. 6.8 in the control group (p = 0.04).

Limitations

Patients were from one health center. Some patients may have obtained CRC screening outside our system.

Conclusions

A culturally tailored, language-concordant navigator program designed to identify and overcome barriers to colorectal cancer screening can significantly improve colonoscopy rates for low income, ethnically and linguistically diverse patients.

ClinicalTrials.gov registration number: NCT00476970

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Figure 1
Figure 2
Figure 3
Figure 4

Similar content being viewed by others

References

  1. American Cancer Society, Cancer Facts and Figures 2006. 2006, American Cancer Society: Atlanta, GA.

  2. Paskett E, Rushing J, D’Agostino RJ, Tatum C, Velez R. Cancer screening behaviors of low-income women: the impact of race. Womens Health. 1997;3(3-4):203–26.

    CAS  PubMed  Google Scholar 

  3. Walsh J. Colorectal cancer screening. The time is now!. J Gen Intern Med. 2005;20(11):1068–70.

    Article  PubMed  Google Scholar 

  4. Klabunde CN, Lanier D, Breslau ES, et al. Improving colorectal cancer screening in primary care practice: innovative strategies and future directions. J Gen Intern Med. 2007;22(8):1195–205.

    Article  PubMed  Google Scholar 

  5. Thompson B, Coronado G, Neuhouser M, Chen L. Colorectal carcinoma screening among Hispanics and non-Hispanic whites in a rural setting. Cancer. 2005;103(12):2491–8.

    Article  PubMed  Google Scholar 

  6. Walsh J, Kaplan C, Nguyen B, Gildengorin G, McPhee S, Perez-Stable E. Barriers to colorectal cancer screening in Latino and Vietnamese Americans. Compared with non-Latino white Americans. J Gen Intern Med. 2004;19(2):156–66.

    Article  PubMed  Google Scholar 

  7. Cress RD, Morris C, Ellison GL, Goodman MT. Secular changes in colorectal cancer incidence by subsite, stage at diagnosis, and race/ethnicity, 1992-2001. Cancer. 2006;107(5 Suppl):1142–52.

    Article  PubMed  Google Scholar 

  8. Goel M, Wee C, McCarthy E, Davis R, Ngo-Metzger Q, Phillips R. Racial and ethnic disparities in cancer screening: the importance of foreign birth as a barrier to care. J Gen Intern Med. 2003;18(12):1028–35.

    Article  PubMed  Google Scholar 

  9. Hoffman-Goetz L, Breen N, Meissner H. The impact of social class on the use of cancer screening within three racial/ethnic groups in the United States. Ethn & Dis. 1998;8(1):43–51.

    CAS  Google Scholar 

  10. Polite B, Dignam J, Olopade O. Colorectal cancer model of health disparities: understanding mortality differences in minority populations. J Clin Oncol. 2006;24(14):2179–87.

    Article  PubMed  Google Scholar 

  11. Pollack LA, Blackman DK, Wilson KM, Seeff LC, Nadel MR. Colorectal cancer test use among Hispanic and non-Hispanic US populations. Prev Chronic Dis. 2006;3(2):A50.

    PubMed  Google Scholar 

  12. Ionescu MV, Carey F, Tait IS, Steele RJ. Socioeconomic status and stage at presentation of colorectal cancer. Lancet. 1998;352(9138):1439.

    Article  CAS  PubMed  Google Scholar 

  13. Bradley CJ, Given CW, Roberts C. Disparities in cancer diagnosis and survival. Cancer. 2001;91(1):178–88.

    Article  CAS  PubMed  Google Scholar 

  14. Haas JS, Earle CC, Orav JE, Brawarsky P, Neville BA, Williams DR. Racial segregation and disparities in cancer stage for seniors. J Gen Intern Med, 2008.

  15. Brouse C, Basch C, Wolf R, Shmukler C. Barriers to colorectal cancer screening: an educational diagnosis. J Cancer Educ. 2004;19(3):170–3.

    Article  PubMed  Google Scholar 

  16. Denberg T, Melhado T, Coombes J, et al. Predictors of nonadherence to screening colonoscopy. J Gen Intern Med. 2005;20(11):989–95.

    Article  PubMed  Google Scholar 

  17. Klabunde C, Vernon S, Nadel M, Breen N, Seeff L, Brown M. Barriers to colorectal cancer screening: a comparison of reports from primary care physicians and average-risk adults. Med Care. 2005;43(9):939–44.

    Article  PubMed  Google Scholar 

  18. Holmes-Rovner M, Williams GA, Hoppough S, Quillan L, Butler R, Given CW. Colorectal cancer screening barriers in persons with low income. Cancer Practice: A Multidisciplinary Journal of Cancer Care. 2002;10(5):240–7.

    Google Scholar 

  19. Greiner K, Born W, Nollen N, Ahluwalia J. Knowledge and perceptions of colorectal cancer screening among urban African Americans. J Gen Intern Med. 2005;20(11):977–83.

    Article  PubMed  Google Scholar 

  20. Oliffe J. Perceived barriers and benefits were factors in decision making about colorectal screening. E-B Nurs. 2006;9(1):31 (1 ref).

    Article  Google Scholar 

  21. Lasser KE, Ayanian JZ, Fletcher RH, Good MJ. Barriers to colorectal cancer screening in community health centers: a qualitative study. BMC Fam Pract. 2008;9:15.

    Article  PubMed  Google Scholar 

  22. Green AR, Peters-Lewis A, Percac-Lima S, et al. Barriers to screening colonoscopy for low-income latino and white patients in an urban community health center. J Gen Intern Med. 2008;In Press.

  23. Goodman M, Ogdie A, Kanamori M, Canar J, O’Malley A. Barriers and facilitators of colorectal cancer screening among Mid-Atlantic Latinos: focus group findings. Ethn Dis. 2006;16(1):255–61.

    PubMed  Google Scholar 

  24. Smedley BD, Stith AY, Nelson AR. Unequal treatment confronting racial and ethnic disarities in health care. 2003, Washington, DC: The National Academies Press.

    Google Scholar 

  25. Cheng EM, Chen A, Cunningham W. Primary language and receipt of recommended health care among Hispanics in the United States. J Gen Intern Med. 2007;22(Suppl 2):283–8.

    Article  PubMed  Google Scholar 

  26. Dohan D, Levintova M. Barriers beyond words: cancer, culture, and translation in a community of Russian speakers. J Gen Intern Med. 2007;22(Suppl 2):300–5.

    Article  PubMed  Google Scholar 

  27. Flores G. Language barriers to health care in the United States. New Engl J Med. 2006;355(3):229–31.

    Article  CAS  PubMed  Google Scholar 

  28. Jacobs EA, Lauderdale DS, Meltzer D, Shorey JM, Levinson W, Thisted RA. Impact of interpreter services on delivery of health care to limited-English-proficient patients. J Gen Intern Med. 2001;16(7):468–74.

    Article  CAS  PubMed  Google Scholar 

  29. Kandula N, Wen M, Jacobs E, Lauderdale D. Low rates of colorectal, cervical, and breast cancer screening in Asian Americans compared with non-Hispanic whites: Cultural influences or access to care? Cancer. 2006;107(1):184–92.

    Article  PubMed  Google Scholar 

  30. Sun W, Basch C, Wolf R, Li X. Factors associated with colorectal cancer screening among Chinese-Americans. Prev Med. 2004;39(2):323–9.

    Article  PubMed  Google Scholar 

  31. Wong S, Gildengorin G, Nguyen T, Mock J. Disparities in colorectal cancer screening rates among Asian Americans and non-Latino whites. Cancer. 2005;104(12 Suppl):2940–7.

    Article  PubMed  Google Scholar 

  32. Khankari K, Eder M, Osborn CY, et al. Improving colorectal cancer screening among the medically underserved: a pilot study within a federally qualified health center. J Gen Intern Med. 2007;22(10):1410–4.

    Article  PubMed  Google Scholar 

  33. Myers RE, Sifri R, Hyslop T, et al. A randomized controlled trial of the impact of targeted and tailored interventions on colorectal cancer screening. Cancer. 2007;110(9):2083–91.

    Article  PubMed  Google Scholar 

  34. Zapka JG, Lemon SC, Puleo E, Estabrook B, Luckmann R, Erban S. Patient education for colon cancer screening: a randomized trial of a video mailed before a physical examination. Ann Intern Med. 2004;141(9):683–92.

    PubMed  Google Scholar 

  35. Jandorf L, Gutierrez Y, Lopez J, Christie J, Itzkowitz S. Use of a patient navigator to increase colorectal cancer screening in an urban neighborhood health clinic. J Urban Health. 2005;82(2):216–24.

    PubMed  Google Scholar 

  36. Battaglia TA, Roloff K, Posner MA, Freund KM. Improving follow-up to abnormal breast cancer screening in an urban population. A patient navigation intervention. Cancer. 2007;109(2 Suppl):359–67.

    Article  PubMed  Google Scholar 

  37. Dietrich A, Tobin J, Cassells A, et al. Telephone care management to improve cancer screening among low-income women: a randomized, controlled trial. Ann Intern Med. 2006;144(8):563–71.

    PubMed  Google Scholar 

  38. Chen LA, Santos S, Jandorf L, et al. A program to enhance completion of screening colonoscopy among urban minorities. Clin Gastroenterol Hepatol, 2008.

  39. Nash D, Azeez S, Vlahov D, Schori M. Evaluation of an intervention to increase screening colonoscopy in an urban public hospital setting. J Urban Health. 2006;83(2):231–43.

    Article  PubMed  Google Scholar 

  40. Dohan D, Schrag D. Using navigators to improve care of underserved patients: current practices and approaches. Cancer. 2005;104(4):848–55.

    Article  PubMed  Google Scholar 

  41. Tu SP, Taylor V, Yasui Y, et al. Promoting culturally appropriate colorectal cancer screening through a health educator: a randomized controlled trial. Cancer. 2006;107(5):959–66.

    Article  PubMed  Google Scholar 

  42. Atlas SJ, Chang Y, Lasko TA, Chueh HC, Grant RW, Barry MJ. Is this "my" patient? Development and validation of a predictive model to link patients to primary care providers. J Gen Intern Med. 2006;21(9):973–8.

    Article  PubMed  Google Scholar 

  43. Lin O, Kozarek R, Schembre D, et al. Screening colonoscopy in very elderly patients: prevalence of neoplasia and estimated impact on life expectancy. JAMA. 2006;295(20):2357–65.

    Article  CAS  PubMed  Google Scholar 

  44. US Preventive Services Task Forces, The Guide to Clinical Preventive Services. 2006, Agency for Healthcare Research and Quality: Rockville, MD.

  45. Gross CP, McAvay GJ, Krumholz HM, Paltiel AD, Bhasin D, Tinetti ME. The effect of age and chronic illness on life expectancy after a diagnosis of colorectal cancer: implications for screening. Ann Intern Med. 2006;145(9):646–53.

    PubMed  Google Scholar 

  46. Walsh JM, Terdiman JP. Colorectal cancer screening: clinical applications. JAMA. 2003;289(10):1297–302.

    Article  PubMed  Google Scholar 

  47. Ell K, Vourlekis B, Muderspach L, et al. Abnormal cervical screen follow-up among low-income Latinas: Project SAFe. J Womens Health Gend Based Med. 2002;11(7):639–51.

    Article  PubMed  Google Scholar 

  48. Freeman HP, Muth BJ, Kerner JF. Expanding access to cancer screening and clinical follow-up among the medically underserved. Cancer Pract. 1995;3(1):19–30.

    CAS  PubMed  Google Scholar 

  49. Frelix GD, Rosenblatt R, Solomon M, Vikram B. Breast cancer screening in underserved women in the Bronx. J Natl Med Assoc. 1999;91(4):195–200.

    CAS  PubMed  Google Scholar 

  50. Basch CE, Wolf RL, Brouse CH, et al. Telephone outreach to increase colorectal cancer screening in an urban minority population. Am J Public Health. 2006;96(12):2246–53.

    Article  PubMed  Google Scholar 

  51. Walsh JM, Terdiman JP. Colorectal cancer screening: scientific review. JAMA. 2003;289(10):1288–96.

    Article  PubMed  Google Scholar 

  52. Fletcher RH. Successful colorectal cancer screening starts with primary care. Rev Gastroenterol Disord. 2002;2(Suppl 1):S27–34.

    PubMed  Google Scholar 

  53. Lieberman DA, Weiss DG. One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon. New Engl J Med. 2001;345(8):555–60.

    Article  CAS  PubMed  Google Scholar 

  54. Vijan S, Hwang E, Hofer T, Hayward R. Which colon cancer screening test? A comparison of costs, effectiveness, and compliance. Am J Med. 2001;111(8):593–601.

    Article  CAS  PubMed  Google Scholar 

  55. Gany FM, Shah SM, Changrani J. New York City’s immigrant minorities. Reducing cancer health disparities. Cancer. 2006;107(8 Suppl):2071–81.

    Article  PubMed  Google Scholar 

  56. Kanna B, Schori M, Azeez S, Kumar S, Soni A. Colorectal tumors within an urban minority population in New York City. J Gen Intern Med. 2007;22(6):835–40.

    Article  PubMed  Google Scholar 

  57. Polite B, Dignam J, Olopade O. Colorectal cancer and race: understanding the differences in outcomes between African Americans and whites. Med Clin North Am. 2005;89(4):771–93.

    Article  PubMed  Google Scholar 

  58. Ayanian JZ, Zaslavsky AM, Guadagnoli E, et al. Patients’ perceptions of quality of care for colorectal cancer by race, ethnicity, and language. J Clin Oncol. 2005;23(27):6576–86.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank the staff from Clinical Research Program and Community Benefits Program at Massachusetts General Hospital. The paper was presented at the Annual Meeting of the Society of General Medicine in Pittsburg, PA, on April 10, 2008. The study was funded by: Clinical Innovation Award through the Massachusetts General Hospital, Community Benefits Program at Massachusetts General Hospital, Jane’s Trust, Massachusetts Cancer Prevention Community Research Network, and a grant for the Massachusetts General Primary Care Practice-Based Research Network (NCI 1CA121908).

Conflict of Interest

None disclosed.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Sanja Percac-Lima MD PhD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Percac-Lima, S., Grant, R.W., Green, A.R. et al. A Culturally Tailored Navigator Program for Colorectal Cancer Screening in a Community Health Center: A Randomized, Controlled Trial. J GEN INTERN MED 24, 211–217 (2009). https://doi.org/10.1007/s11606-008-0864-x

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-008-0864-x

KEY WORDS

Navigation