The Medical Minute: Colon cancer rates higher in rural areas

For health care professionals, it’s maddening.

The technology needed to stop colorectal cancer before it turns deadly has never been better. Yet in 2024, the American Cancer Society expects it to cause 106,590 new cases and 53,010 deaths. In Pennsylvania, about 34% of those diagnosed with colorectal cancer die from the disease. Though rates have decreased overall, they’re increasing among adults younger than 55.

And in a time when information can circle the globe in nanoseconds, barriers like geography still get between doctors and patients.

Health care professionals are finding higher rates of advanced colorectal cancer in rural areas compared with urban centers, said Dr. Karen Kim, dean of Penn State College of Medicine and Dorothy Foehr Huck and J. Lloyd Huck Chair in Rural Health Research. Also, mortality rates related to the disease are higher in less populated areas “largely because people there tend to be diagnosed in the later stages,” she said.

As a clinician, Kim knows the heartbreak and frustration firsthand. With multiple choices for colorectal cancer screening available, medical science can stop and prevent this fatal disease. But barriers get between her and some of her patients who need it most.

“Unlike some cancers where we think about early detection, with colon cancer it’s really about finding premalignant lesions before they even become cancer,” she said. “It’s so difficult as a gastroenterologist to continue to watch people die from this preventable disease.”

Kim discusses why people in less populated areas are seeing colon cancer more often than people living in cities, and what you can do to ensure your own health.

Why are there more cases in rural areas than in urban centers?

Probably the biggest driver is access. Even in a state like Pennsylvania ― fifth most populous in the country ― hospitals that can provide adequate screening are absent from wide swaths of the landscape.

“There are large health care shortage areas,” Kim said. “Our rural hospitals are suffering from a lack of providers. Even if patients want to get screened, getting there can be a big barrier.”

Rural residents also tend to be older and less likely to practice preventative care than their urban counterparts, according to National Institutes of Health research. Couple that with fewer local cancer doctors ― in 2017, according to the study, only 3% of medical oncologists practice outside of urban areas ― care can be difficult to come by for the populations who are particularly vulnerable to the disease.

But the problem isn’t purely demographic, Kim said. Despite advances in treatment, health care professionals encounter two incorrect but prevailing beliefs among patients about colon cancer.

“One is the belief that if you get it, you’re going to die from it. So why even look?” she said. “And the other is a complete lack of awareness that this is one of the cancers that is really preventable.”

How preventable?

Medical science has become adept at detecting precancerous lesions – what they call a polyp – and if removed, can prevent your risk of cancer. The great news is that there’s a 10- to 15-year window before a polyp becomes cancer so there is a lot of time to prevent cancer through screening, Kim said. Physicians can remove polyps the moment they’re detected during a colonoscopy.

“I think it’s really important when you think about colon cancer for the majority of people, this is completely preventable through screening,” Kim said. “We know the science and the biology. We’ve known it for years and years. And yet still, nationwide, only about 64% of people with colon cancer detect it in a stage where it’s curable or treatable.

In rural communities, she said, that number is significantly less.

If you don’t have access to care, what can you do?

“The nice thing is there’s so many ways to get screened now,” Kim said. “I think the real lesson in colorectal cancer screening is to provide everyone with choices.”

Colonoscopies remain the gold standard for colon cancer screening, and, in fact, other kinds of testing methods often yield results that suggest an immediate colonoscopy is warranted:

• Testing blood samples for the disease isn’t, at the moment, universally covered by insurance and is still somewhat controversial in terms of its effectiveness. “We’re not quite there yet, but this will be the future” Kim said.
• Testing stool samples has proven successful, she said. One type called fecal immunochemical testing, or FIT, asks patients to apply a sample to a card that they mail to lab. The lab checks it for blood, which can be a sign of polyps or colon cancer. “It’s a really nice option because you do this at home,” Kim said. “It’s very, very easy to do, and it’s low cost.” In fact, depending on where you live, you might find fecal immunochemical testing available for free, Kim said. Penn State Health community nurses, for example, sometimes distribute the tests in underserved communities. Check with your local pharmacy. Do this test once every year.
• Another test you may have seen in advertisements is Cologuard. Another mail-in screening that involves submitting your own fecal sample, Cologuard actually searches samples for both blood in your stool and DNA alterations that may be consistent with cancer. These stool-based tests do not require any preparation and can be mailed in, Kim said. Complete a Cologuard test every three years. If either stool-based test is abnormal, you will need a colonoscopy.
• If you chose screening using colonoscopy, it should be done every 10 years if you have no findings during the exam (no polyps or other abnormalities). You should continue getting colonoscopies until you’re 75, even if you’re healthy. Transportation is still a barrier for many people, but check with your provider to see what options might be available. The procedure requires sedation, so in addition to transportation, you’ll also need someone to drive you home.

You should be tested regardless of whether or not you have symptoms, Kim said.

“We used to think about early warning signs – blood in your stool, weight loss, abdominal pain, a change in the caliber of your stool ― they used to be what we talked about for colon cancer screening,” Kim said. “We have now moved completely away from early warning signs because we know we can prevent this before there should be any symptoms whatsoever. The bottom line is that screening saves lives.”

That said, if you’re experiencing symptoms, you should see your doctor.

Screening should begin at the age of 45 for all individuals that do not have genetic and familial risk factors or diseases of chronic inflammation such as inflammatory bowel disease.

Related content:

• The Medical Minute: Colonoscopy is the real ‘superhero’ against colon cancer
• The Medical Minute: Are you at increased risk for colorectal cancer?

The Medical Minute is a weekly health news feature produced by Penn State Health. Articles feature the expertise of faculty, physicians and staff, and are designed to offer timely, relevant health information of interest to a broad audience.

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