Screening a rural population for CRC & more: GI specialist Dr. Michael Green on the challenges of rural healthcare & COVID-19

Access to healthcare is limited in a rural population, which is concerning when managing colorectal cancer.

Here, Hutchinson (Kan.) Clinic gastroenterologist Michael Green, MD, discussed the challenges of rural healthcare, COVID-19-related screening delays and the future of gastroenterology.

Note: Responses were edited for style and content.

Question: What sort of challenges does the rural health setting pose when screening for CRC?

Dr. Michael Green: Obtaining adequate CRC screening in the rural health setting is often a significant challenge. Many of our patients do not have adequate access to endoscopic CRC screening opportunities. Patients having to travel significant distances the morning of their procedure face many challenges. There is of course the social concern of, "Will I have an accident in transit?" or concern about adequate rest facilities along the route. It is not uncommon to hear patients say they got a hotel the night before their procedure to avoid needing to travel. This, of course, is an extra cost to an already often-expensive experience. Many of our patients in the rural setting are part of an aging population, and there is legitimate concern about driving.

These challenges often mean that we, as physicians caring for patients in more remote settings, need to take advantage of the menu of screening options endorsed by many societies. Often these patients benefit the most from noninvasive screening options. Lack of access to routine screening leads to delayed diagnosis and often, worse outcomes in our patients.

At the Hutchinson Clinic, we have worked to embrace our surrounding communities and bring more patients into the fold of adequate CRC cancer screening simply by being one additional location [where] adequate screening can be achieved. Simply our geographic location and proximity to a variety of underserved locations allows us to bring more patients into the fold.

Q: COVID-19 has created massive backlogs in screening. How are you addressing those?

MG: In order to adequately address the backlog in screening procedures due to the COVID-19 pandemic, we have been aggressively scheduling patients, in addition to having each of our physicians be open to additional procedures. In our facility, we have been able to clear our backlog of procedures over the past several months.

What concerns me is that there is likely a population of patients who have not seen their primary care provider or who are putting off screening and therefore, have not made it into our queue of procedures for screening. So, while it feels good to know that we no longer have a significant backlog, there is likely a significant number of patients who will not receive adequate screening.

We know that COVID-19 likely will lead to a significant number of delayed CRC diagnoses. It has been suggested that as many as 19,000 CRC cases will be impacted by COVID-19.

Q: Do you recommend any colonoscopy screening alternatives for your patient population? Why or why not?

MG: The best screening test is the screening test that gets done. For our patients it is completely appropriate to pursue any screening modality that actually gets completed. If this is a Cologuard, [fecal immunochemical test], or CT colonoscopy, I think any method that we are able to actually get completed is a move in the right direction.

Often in my practice experience it is very challenging to get patients to complete a colonoscopy for a variety of reasons, but when a patient has a positive Cologuard they are beating down the doors to get their procedure completed. While I worry that stool-based testing may only be detecting colon cancer rather than preventing it, I still see incredible benefit in increasing the number of patients who actually undergo adequate screening.

Q: Five years down the road, what do you think the gastroenterology specialty will look like?

MG: It is difficult to predict the landscape of GI in the future. As with many fields of medicine, we are seeing an explosion in data-based decision-making. I often talk to patients about my goal to only ask them to modify their lifestyle or spend their hard-earned money on data-driven advice. The challenge that I think we will continue to see is that as the knowledge base expands, the expertise of specialists will become of increasing importance. When there is an exploding number of data points available to guide decision-making, it often becomes overwhelming for our primary care colleagues. The treatment of GI conditions is becoming more and more specialized, and I think this will only continue as we go forward.

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