Skip to main content
Log in

Barriers to Colorectal Cancer Screening in a Primary Care Setting in Turkey

  • Original Paper
  • Published:
Journal of Community Health Aims and scope Submit manuscript

Abstract

Colorectal cancer (CRC) is the third most common form of cancer in men worldwide and the second most common in women. The purpose of this study was to determine both barriers established by primary health care providers (PHCPs) and barriers perceived by them and to produce solutions for achieving the desired results. A four-part questionnaire was administered to family physicians (FPs) and family health personnels (FHPs) in Samsun, Turkey on 01–15 May, 2016. Sixty-six percent of PHCPs were contacted. Data were evaluated as numbers and percentages, and statistical significance was analyzed using the Chi square and t tests. 478 PHCPs participated; 49.4 % were FPs and 50.6 % FHPs. Of the participants, 86.6 % stated that they performed CRC screening on patients. The level of participants knowing that screening should start at age 50 and conclude at age 70 was 49.7 %. The level of subjects requesting the fecal occult blood test (FOBT) at the correct intervals was 29.7 %, but only 6.9 % recommended colonoscopy at the correct intervals. Additionally, 18.2 % of subjects knew that the test used is immunochemical FOBT, and 60.5 % reported not using reminders. PHCPs’ low levels of knowledge, awareness and advice compatible with guidelines concerning CRC screening may represent an obstacle to such screening. Barriers perceived by PHCPs include patients’ inability to access definite medical information, deficiencies in the reminder system and patients’ lack of interest in CRC screening. Additions to the screening program will be useful in overcoming barriers.

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

Access this article

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

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Ferlay, J., Soerjomataram, I., Dikshit, R., et al. (2015). Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. International Journal of Cancer, 136, E359–E386.

    Article  CAS  PubMed  Google Scholar 

  2. Sencan, I., & Ince, G. (2016). Türkiye Kanser İstatistikleri [Turkey Cancer Statistics]. In:Ministry of Health, Turkey Public Health Institute, Ankara.

  3. Sarfaty, M., & Wender, R. (2007). How to increase colorectal cancer screening rates in practice. CA: A Cancer Journal for Clinicians, 57, 354–366.

    Google Scholar 

  4. Schreuders, E. H., Grobbee, E. J., Spaander, M. C., et al. (2016). Advances in fecal tests for colorectal cancer screening. Current Treatment Options in Gastroenterology, 14, 152–162.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Pan, J., Xin, L., Ma, Y. F., et al. (2016). Colonoscopy reduces colorectal cancer incidence and mortality in patients with non-malignant findings: A meta-analysis. American Journal of Gastroenterology, 111, 355–365.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Holme, O., Loberg, M., Kalager, M., et al. (2014). Effect of flexible sigmoidoscopy screening on colorectal cancer incidence and mortality: A randomized clinical trial. JAMA, 312, 606–615.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Giorgi Rossi, P., Vicentini, M., Sacchettini, C., et al. (2015). Impact of screening program on incidence of colorectal cancer: A cohort study in Italy. American Journal of Gastroenterology, 110, 1359–1366.

    Article  PubMed  Google Scholar 

  8. Wools, A., Dapper, E. A., & Leeuw, J. R. (2016). Colorectal cancer screening participation: A systematic review. The European Journal of Public Health, 26, 158–168.

    Article  CAS  PubMed  Google Scholar 

  9. Wardle, J., Von Wagner, C., Kralj-Hans, I., et al. (2016). Effects of evidence-based strategies to reduce the socioeconomic gradient of uptake in the English NHS Bowel Cancer Screening Programme (ASCEND): Four cluster-randomised controlled trials. Lancet, 387, 751–759.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Schreuders, E. H., Ruco, A., Rabeneck, L., et al. (2015). Colorectal cancer screening: A global overview of existing programmes. Gut, 64, 1637–1649.

    Article  PubMed  Google Scholar 

  11. Sabatino, S. A., White, M. C., Thompson, T. D., et al. (2015). Cancer screening test use—United States, 2013. MMWR. Morbidity and Mortality Weekly Report, 64, 464–468.

    PubMed  Google Scholar 

  12. Muliira, J. K., D’souza, M. S., & Ahmed, S. M. (2016). Contrasts in practices and perceived barriers to colorectal cancer screening by nurses and physicians working in primary care settings in Oman. Journal of Cancer Education, 31, 15–25.

    Article  PubMed  Google Scholar 

  13. Omran, S., Barakat, H., Muliira, J. K., et al. (2015). Knowledge, experiences, and barriers to colorectal cancer screening: A survey of health care providers working in primary care settings. Journal of Cancer Education, 30, 53–61.

    Article  PubMed  Google Scholar 

  14. Brown, T., Lee, J. Y., Park, J., et al. (2015). Colorectal cancer screening at community health centers: A survey of clinicians’ attitudes, practices, and perceived barriers. Preventive Medicine Reports, 2, 886–891.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Demyati, E. (2014). Knowledge, attitude, practice, and perceived barriers of colorectal cancer screening among family physicians in national guard health Affairs, Riyadh. International Journal of Family Medicine, 2014, 457354.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Meissner, H. I., Klabunde, C. N., Breen, N., et al. (2012). Breast and colorectal cancer screening: U.S. primary care physicians’ reports of barriers. American Journal of Preventive Medicine, 43, 584–589.

    Article  Google Scholar 

  17. Lansdorp-Vogelaar, I., Van Ballegooijen, M., Zauber, A. G., et al. (2009). Effect of rising chemotherapy costs on the cost savings of colorectal cancer screening. Journal of the National Cancer Institute, 101, 1412–1422.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Klabunde, C. N., Frame, P. S., Meadow, A., et al. (2003). A national survey of primary care physicians’ colorectal cancer screening recommendations and practices. Preventive Medicine, 36, 352–362.

    Article  PubMed  Google Scholar 

  19. Hassan, C., Benamouzig, R., Spada, C., et al. (2011). Cost effectiveness and projected national impact of colorectal cancer screening in France. Endoscopy, 43, 780–793.

    Article  CAS  PubMed  Google Scholar 

  20. Deobald, R., Graham, P., Chad, J., et al. (2013). Colorectal cancer screening practices in Saskatchewan: Survey of family physicians. Canadian Family Physician, 59, e558–e563.

    PubMed  PubMed Central  Google Scholar 

  21. Chapman, K., Nicholls, K., Sullivan, M. M., et al. (2012). Colorectal cancer screening practices in Alabama: A survey of primary care physicians. Journal of Cancer Education, 27, 687–694.

    Article  PubMed  Google Scholar 

  22. Gikas, A., & Triantafillidis, J. K. (2014). The role of primary care physicians in early diagnosis and treatment of chronic gastrointestinal diseases. International Journal of General Medicine, 7, 159–173.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Roter, D. L., Hall, J. A., & Aoki, Y. (2002). Physician gender effects in medical communication: A meta-analytic review. JAMA, 288, 756–764.

    Article  PubMed  Google Scholar 

  24. Shokar, N. K., Nguyen-Oghalai, T., & Wu, H. (2009). Factors associated with a physician’s recommendation for colorectal cancer screening in a diverse population. Family Medicine, 41, 427–433.

    PubMed  Google Scholar 

  25. Perin, D. M., Saraiya, M., Thompson, T. D., et al. (2015). Providers’ knowledge, attitudes, and practices related to colorectal cancer control in Brazil. Preventive Medicine, 81, 373–379.

    Article  PubMed  Google Scholar 

  26. Ramirez, A. G., Wildes, K. A., Napoles-Springer, A., et al. (2009). Physician gender differences in general and cancer-specific prevention attitudes and practices. Journal of Cancer Education, 24, 85–93.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Consedine, N. S., Reddig, M. K., Ladwig, I., et al. (2011). Gender and ethnic differences in colorectal cancer screening embarrassment and physician gender preferences. Oncology Nursing Forum, 38, E409–E417.

    Article  PubMed  Google Scholar 

  28. Xilomenos, A., Mauri, D., Kamposioras, K., et al. (2006). Colorectal cancer screening awareness among physicians in Greece. BMC Gastroenterology, 6, 18.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Cameron, E., Rose, S., & Carey, M. (2014). Assessment of family history of colorectal cancer in primary care: Perceptions of first degree relatives of people with colorectal cancer. Patient Education and Counseling, 94, 427–431.

    Article  PubMed  Google Scholar 

  30. Emery, J. D., Reid, G., Prevost, A. T., et al. (2014). Development and validation of a family history screening questionnaire in Australian primary care. The Annals of Family Medicine, 12, 241–249.

    Article  PubMed  Google Scholar 

  31. Skinner, C. S., Halm, E. A., Bishop, W. P., et al. (2015). Impact of risk assessment and tailored versus nontailored risk information on colorectal cancer testing in primary care: A randomized controlled trial. Cancer Epidemiology Biomarkers & Prevention, 24, 1523–1530.

    Article  Google Scholar 

  32. Wu, R. R., Orlando, L. A., Himmel, T. L., et al. (2013). Patient and primary care provider experience using a family health history collection, risk stratification, and clinical decision support tool: A type 2 hybrid controlled implementation-effectiveness trial. BMC Family Practice, 14, 111.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Green, B. B., Anderson, M. L., Wang, C. Y., et al. (2014). Results of nurse navigator follow-up after positive colorectal cancer screening test: A randomized trial. The Journal of the American Board of Family Medicine, 27, 789–795.

    Article  PubMed  Google Scholar 

  34. Potter, M. B., Namvargolian, Y., Hwang, J., et al. (2009). Improving colorectal cancer screening: A partnership between primary care practices and the American Cancer Society. Journal of Cancer Education, 24, 22–27.

    Article  PubMed  Google Scholar 

  35. Uysal-Sonmez, O., Tanriverdi, O., Uyeturk, U., et al. (2014). Awareness of cancer screening during treatment of patients with renal failure: A physician survey in Turkey. Asian Pacific Journal of Cancer Prevention, 15, 2165–2168.

    Article  PubMed  Google Scholar 

  36. Scheid, D. C., Hamm, R. M., Ramakrishnan, K., et al. (2013). Improving colorectal cancer screening in family medicine: An Oklahoma Physicians Resource/Research Network (OKPRN) study. The Journal of the American Board of Family Medicine, 26, 498–507.

    Article  PubMed  Google Scholar 

  37. Sarfaty, M., Doroshenk, M., Hotz, J., et al. (2013). Strategies for expanding colorectal cancer screening at community health centers. CA: A Cancer Journal for Clinicians, 63, 221–231.

    Google Scholar 

  38. Chambers, J. A., Callander, A. S., Grangeret, R., et al. (2015). Attitudes towards the Faecal Occult Blood Test (FOBT) versus the Faecal Immunochemical Test (FIT) for colorectal cancer screening: Perceived ease of completion and disgust. BMC Cancer, 16, 96.

    Article  Google Scholar 

  39. Norwati, D., Harmy, M. Y., Norhayati, M. N., et al. (2014). Colorectal cancer screening practices of primary care providers: Results of a national survey in Malaysia. Asian Pacific Journal of Cancer Prevention, 15, 2901–2904.

    Article  PubMed  Google Scholar 

  40. Gennarelli, M., Jandorf, L., Cromwell, C., et al. (2005). Barriers to colorectal cancer screening: Inadequate knowledge by physicians. Mount Sinai Journal of Medicine, 72, 36–44.

    PubMed  Google Scholar 

  41. Siwek, J. (2015). Getting medicine right: Overcoming the problem of overscreening, overdiagnosis, and overtreatment. American Family Physician, 91, 18–20.

    PubMed  Google Scholar 

  42. Wong, M. C., Lam, A. T., Li, D. K., et al. (2009). Factors associated with practice of colorectal cancer screening among primary care physicians in a Chinese population: A cross-sectional study. Cancer Epidemiology, 33, 201–206.

    Article  PubMed  Google Scholar 

  43. Klabunde, C. N., Lanier, D., Nadel, M. R., et al. (2009). Colorectal cancer screening by primary care physicians: Recommendations and practices, 2006–2007. American Journal of Preventive Medicine, 37, 8–16.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Zitzelsberger, L., Grunfeld, E., & Graham, I. D. (2004). Family physicians’ perspectives on practice guidelines related to cancer control. BMC Family Practice, 5, 25.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Guiriguet-Capdevila, C., Munoz-Ortiz, L., Rivero-Franco, I., et al. (2014). Can an alert in primary care electronic medical records increase participation in a population-based screening programme for colorectal cancer? COLO-ALERT, a randomised clinical trial. BMC Cancer, 14, 232.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Aubin-Auger, I., Mercier, A., Lebeau, J. P., et al. (2011). Obstacles to colorectal screening in general practice: A qualitative study of GPs and patients. Family Practice, 28, 670–676.

    Article  PubMed  Google Scholar 

  47. Hoffman, R. M., Rhyne, R. L., Helitzer, D. L., et al. (2011). Barriers to colorectal cancer screening: Physician and general population perspectives, New Mexico, 2006. Preventing Chronic Disease, 8, A35.

    PubMed  PubMed Central  Google Scholar 

  48. Hay, J. L., Orom, H., Kiviniemi, M. T., et al. (2015). “I don’t know” my cancer risk: Exploring deficits in cancer knowledge and information-seeking skills to explain an often-overlooked participant response. Medical Decision Making, 35, 436–445.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Sriphanlop, P., Hennelly, M. O., Sperling, D., et al. (2016). Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City. Patient Education and Counseling, 99, 1427–1431.

    Article  PubMed  Google Scholar 

  50. Phillips, L., Hendren, S., Humiston, S., et al. (2015). Improving breast and colon cancer screening rates: A comparison of letters, automated phone calls, or both. The Journal of the American Board of Family Medicine, 28, 46–54.

    Article  PubMed  Google Scholar 

  51. Hendren, S., Winters, P., Humiston, S., et al. (2014). Randomized, controlled trial of a multimodal intervention to improve cancer screening rates in a safety-net primary care practice. Journal of General Internal Medicine, 29, 41–49.

    Article  PubMed  Google Scholar 

  52. Fortuna, R. J., Idris, A., Winters, P., et al. (2014). Get screened: A randomized trial of the incremental benefits of reminders, recall, and outreach on cancer screening. Journal of General Internal Medicine, 29, 90–97.

    Article  PubMed  Google Scholar 

  53. Clouston, K., Katz, A., Martens, P. J., et al. (2014). Does access to a colorectal cancer screening website and/or a nurse-managed telephone help line provided to patients by their family physician increase fecal occult blood test uptake?: Results from a pragmatic cluster randomized controlled trial. BMC Cancer, 14, 263.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Tinmouth, J., Baxter, N. N., Paszat, L. F., et al. (2014). Using physician-linked mailed invitations in an organised colorectal cancer screening programme: Effectiveness and factors associated with response. BMJ Open, 4, e004494.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Hewitson, P., Ward, A. M., Heneghan, C., et al. (2011). Primary care endorsement letter and a patient leaflet to improve participation in colorectal cancer screening: Results of a factorial randomised trial. British Journal of Cancer, 105, 475–480.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  56. Senore, C., Armaroli, P., Silvani, M., et al. (2010). Comparing different strategies for colorectal cancer screening in Italy: Predictors of patients’ participation. American Journal of Gastroenterology, 105, 188–198.

    Article  PubMed  Google Scholar 

  57. Zajac, I. T., Whibley, A. H., Cole, S. R., et al. (2010). Endorsement by the primary care practitioner consistently improves participation in screening for colorectal cancer: A longitudinal analysis. Journal of Medical Screening, 17, 19–24.

    Article  CAS  PubMed  Google Scholar 

  58. Baker, D. W., Brown, T., Buchanan, D. R., et al. (2014). Comparative effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers: A randomized clinical trial. JAMA Internal Medicine, 174, 1235–1241.

    Article  PubMed  Google Scholar 

  59. Green, B. B., Anderson, M. L., Chubak, J., et al. (2016). Impact of continued mailed fecal tests in the patient-centered medical home: Year 3 of the Systems of Support to Increase Colon Cancer Screening and Follow-Up randomized trial. Cancer, 122, 312–321.

    Article  PubMed  Google Scholar 

  60. Aubin-Auger, I., Laouenan, C., Le Bel, J., et al. (2016). Efficacy of communication skills training on colorectal cancer screening by GPs: A cluster randomised controlled trial. European Journal of Cancer Care (England), 25, 18–26.

    Article  CAS  Google Scholar 

  61. Geller, B. M., Skelly, J. M., Dorwaldt, A. L., et al. (2008). Increasing patient/physician communications about colorectal cancer screening in rural primary care practices. Medical Care, 46, S36–S43.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Gupta, S., Brenner, A. T., Ratanawongsa, N., et al. (2014). Patient trust in physician influences colorectal cancer screening in low-income patients. American Journal of Preventive Medicine, 47, 417–423.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Xirasagar, S., Hurley, T. G., Burch, J. B., et al. (2011). Colonoscopy screening rates among patients of colonoscopy-trained African American primary care physicians. Cancer, 117, 5151–5160.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Walker, T., Deutchman, M., Ingram, B., et al. (2012). Endoscopy training in primary care: Innovative training program to increase access to endoscopy in primary care. Family Medicine, 44, 171–177.

    PubMed  Google Scholar 

  65. Mcclellan, D. A., Ojinnaka, C. O., Pope, R., et al. (2015). Expanding access to colorectal cancer screening: Benchmarking quality indicators in a primary care colonoscopy program. The Journal of the American Board of Family Medicine, 28, 713–721.

    Article  PubMed  Google Scholar 

  66. Wilkins, T., Leclair, B., Smolkin, M., et al. (2009). Screening colonoscopies by primary care physicians: A meta-analysis. The Annals of Family Medicine, 7, 56–62.

    Article  PubMed  Google Scholar 

  67. Mcgregor, S., Hilsden, R., & Yang, H. (2010). Physician barriers to population-based, fecal occult blood test-based colorectal cancer screening programs for average-risk patients. Canadian Journal of Gastroenterology and Hepatology, 24, 359–364.

    CAS  Google Scholar 

  68. Leddin, D., Armstrong, D., Barkun, A. N., et al. (2008). Access to specialist gastroenterology care in Canada: Comparison of wait times and consensus targets. Canadian Journal of Gastroenterology and Hepatology, 22, 161–167.

    CAS  Google Scholar 

  69. Schwartz, P. H., Edenberg, E., Barrett, P. R., et al. (2013). Patient understanding of benefits, risks, and alternatives to screening colonoscopy. Family Medicine, 45, 83–89.

    PubMed  Google Scholar 

  70. West, N. J., Boustiere, C., Fischbach, W., et al. (2009). Colorectal cancer screening in Europe: Differences in approach; similar barriers to overcome. International Journal of Colorectal Disease, 24, 731–740.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We are most grateful to Samsun Public Health Director Dr. Mustafa Kasapoglu for his contributions to this study.

Funding

The authors declare that they have no funding or financial support.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Mustafa Kursat Sahin.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicting and competing interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sahin, M.K., Aker, S. & Arslan, H.N. Barriers to Colorectal Cancer Screening in a Primary Care Setting in Turkey. J Community Health 42, 101–108 (2017). https://doi.org/10.1007/s10900-016-0235-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10900-016-0235-1

Keywords

Navigation