Welcome back to Navigation Refresh, a recurring, informative feature for novice and seasoned patient navigators alike. In this issue, we will cover updates relevant to navigating people on the continuum of care for colorectal cancer (CRC) in honor of Colorectal Cancer Awareness Month. We will also discuss emerging challenges, evidence gaps, and key resources for implementation and sustainability.
CRC includes cancers that begin in the colon or rectum, which is part of the large intestine. Most CRC starts as a growth on the lining of the colon or rectum. This is called a polyp. Over time, polyps can become cancerous—although they do not always turn into cancer. If the polyp becomes cancerous and spreads, disease may advance and grow into blood vessels, lymph vessels, and more distant parts of the body.1 CRC incidence increases with age but has been rising in adults younger than 50 years since the 1990s.2 CRC can be caught early through screening and can be treated with surgery, chemotherapy, radiation therapy, targeted therapy, immunotherapy, and other treatments depending on tumor characteristics and stage of disease.
CRC cannot always be prevented. However, regular exercise, a diet centered on vegetables and whole grains, not smoking, and limiting alcohol can reduce a person’s risk for CRC.3
Some research has found that taking aspirin, ibuprofen, or naproxen on a regular basis can lower CRC risk.3 Given the bleeding risks of regular use of aspirin, ibuprofen, and naproxen, however, such a regimen should be recommended and followed by a physician based on the personal risk of the patient.
Early detection of CRC can be achieved with screening. By removing precancerous polyps through a colonoscopy, cancer can be prevented before it even develops.
The US Preventive Services Task Force recommends routine average-risk screening beginning at age 45 through age 75. Screening ages 76 through 85 should be individualized based on comorbidity, prior screening, and patient preference. People who have a first-degree relative with CRC, known hereditary syndromes, and/or inflammatory bowel disease that could heighten their risk may have earlier and more intensive recommendations for screening.4
Acceptable CRC screening strategies include colonoscopy (every 10 years), flexible sigmoidoscopy (every 5 years), CT colonography (every 5 years), multitarget stool DNA testing (every 3 years), and fecal immunochemical test (FIT) annually.4
Patient navigation shows strong evidence of improving uptake of CRC screening in numerous subpopulations, including ethnic minorities, immigrants, lower-income communities, and people with mental health diagnoses.5-10 Multicomponent programs that combine navigation with outreach (mailed FIT kits), reminder systems, culturally tailored education, case management, and barrier removal (transportation, interpreter services) have shown the greatest impact.5-10
Effective navigation includes systematic identification of patients who are overdue for CRC screening, multiple contact attempts to patients using patient-preferred channels, provider reminders and integration with electronic health records to track results and referrals, and workflows ensuring diagnostic colonoscopy scheduling within guideline-consistent time frames after abnormal screens.11,12 Credentialing, training in culturally responsive communication, and clear role definitions have been shown to increase patient navigation program fidelity.
Health systems should prioritize patient navigation for communities with lower screening rates in their catchment, such as rural populations, racial/ethnic minority groups, and younger adults experiencing rising CRC incidence. Tailored interventions addressing context-specific social risks—such as lack of insurance, services unavailable in the patient’s native language, lower health literacy, transportation challenges, and lack of paid leave—are critical.
The increasing availability of blood-based and multicancer early detection tests may introduce patient confusion and system challenges. Primary care providers and navigators will need to help patients understand the strengths and limitations of the tests, arrange confirmatory diagnostic colonoscopy after positive results, and track negative results. Navigators will need updated scripts to provide patients with clear information.
More research is needed to optimize patient reminders based on patient preference (eg, emails, texts, telephone calls, mailed reminders). Research is also needed to support repeat screening based on guidelines and optimal tailoring for subpopulations that have greater challenges to screening adherence given limitations to existing health systems and services.
This edition of Navigation Refresh aligns with Standard 11 (Prevention, Screening, and Assessment) of the Professional Oncology Navigation Task Force (PONT)16 and Patient Navigation Core Competencies Domain 2: Knowledge for Practice.17
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