Are We Missing the Mark on Colorectal Cancer Screening? Insights from Northern Plains American Indian Communities
"A closer look at screening practices reveals gaps in guideline adherence, highlighting the need for culturally tailored education and improved access to care."
Colorectal cancer (CRC) is a major health concern, and its impact varies significantly among different populations. American Indian and Alaska Native (AI/AN) communities, in particular, face unique challenges related to CRC, including differences in incidence, mortality, age of onset, and stage of diagnosis. Effective screening is crucial for reducing CRC incidence and mortality, but ensuring that these communities receive appropriate and timely screening requires a deep understanding of the local healthcare landscape.
A key factor in promoting CRC screening is the knowledge and practices of healthcare providers. Providers need to be up-to-date on the latest screening guidelines and equipped to address the specific needs and concerns of their patients. However, studies have shown that adherence to recommended screening practices can be inconsistent, particularly in underserved communities.
To address these challenges, the Improving Northern Plains American Indian Colorectal Cancer Screening (INPACS) study was initiated. This project aimed to gain insights into the CRC screening practices of healthcare providers serving Northern Plains AI/AN communities. By understanding the influences on provider behavior, the study sought to inform strategies for improving screening rates and ultimately reducing the burden of CRC in these vulnerable populations.
Unequal Burden and Screening Gaps
The CDC reports that non-Hispanic American Indian and Alaska Native males and females have higher rates of colorectal cancer than non-Hispanic White people. Screening participation has varied substantially across Indian Health Service areas, ranging from 28.1% in the Phoenix Area to 50.5% in the Oklahoma Area, with rates of 35% in Tucson and 41.9% in Albuquerque. A 2026 literature review found that only 7.1% of AI/AN colorectal cancer research addressed diet, 8.2% addressed age, and 3.5% addressed another reported research topic, indicating uneven attention across research areas.
Screening Access Does Not Ensure Equity
Colorectal cancer screening is an established prevention approach, yet American Indians and Alaska Natives continue to experience major screening disparities alongside inequities in colorectal cancer mortality. One national analysis found that these disparities persisted for AIANs even after statistical adjustment for factors that enabled health care access, and AIANs had the lowest screening levels in the comparison. Community leaders and providers likewise describe colorectal cancer as a major AI/AN concern because incidence and mortality remain high while screening rates remain inadequate.
From Perceptions to Community Partnership
Earlier research reported that American Indians and Alaska Natives had lower colorectal cancer incidence rates than both White and Black Americans. More recent community-based efforts have emphasized partnerships in which American Indian community members help develop culturally and locally relevant colorectal cancer screening messages. Public-facing Native health resources identify colonoscopy, flexible sigmoidoscopy, and stool-based testing among the screening options used to identify colorectal cancer. Cherokee Indian Hospital has promoted screening for Native men and women ages 45 to 75 during Colorectal Cancer Awareness Month.
The Persistent Use of Outdated Screening Methods: Why It Matters
The INPACS study revealed a concerning trend: a significant proportion of healthcare providers in the Northern Plains AI/AN communities were still using digital rectal examination (DRE) specimens for fecal occult blood tests (FOBT). Specifically, nearly two-thirds (64.7%) of providers reported performing in-office guaiac-based FOBTs using DRE specimens. This practice is problematic because guidelines recommend against using DRE stool specimens for CRC screening.
- Lack of Awareness: Some providers may not be fully aware of the updated CRC screening guidelines that discourage the use of DRE specimens.
- Habit and Training: DRE stool specimens were a common method for FOBT in the past, and some providers may still be using this approach out of habit or due to their initial training.
- Patient Expectations: Some providers may feel pressure to perform DRE stool specimens for FOBT because patients expect it or because they believe it is better than no screening at all.
- System-Level Factors: Pressure to meet screening targets and a lack of clear communication from healthcare administrators may also contribute to the continued use of this outdated practice.
Participation and Choice in Recent Studies
A 2024 study examining First Nations populations sought to define participation in colorectal cancer screening, noting that screening improves survival but participation rates in these populations are poorly described. Separately, Mayo Clinic reporting examined Alaska Native peoples' perspectives on colorectal cancer screening options. That work focused specifically on factors influencing choices between multitarget stool DNA testing and colonoscopy, showing that the research agenda includes both participation and preferences among screening methods.
Masculinity as a Screening Barrier
A 2022 study found that masculinity-related barriers interfered with ever completing colorectal cancer screening. The finding was consistent with prior literature cited by the study, suggesting that reluctance cannot be explained only by service availability. Screening strategies that overlook gender norms may therefore fail to address an important barrier for some American Indian and Alaska Native men.
Disparity Across Populations
A 2026 review reported consistently elevated colorectal cancer rates in American Indian and Alaska Native communities across publications evaluating or proposing screening methods. Research focused on Alaska Native people has reported that they experience twice the colorectal cancer rate of US Whites. Together, these sources frame screening needs against a disease burden that is particularly pronounced for Alaska Native communities, although the sources address different populations and should not be treated as identical estimates.
Moving Forward: Improving CRC Screening in Northern Plains AI/AN Communities
The findings from the INPACS study highlight the need for targeted interventions to improve CRC screening practices in Northern Plains AI/AN communities. These interventions should focus on:
A More Responsive Screening Strategy
The available material suggests that improving colorectal cancer outcomes will require more than simply recommending standard screening. Participation may depend on whether programs address cultural context, practical access, trust, and individual preferences. Because the evidence summarized here is limited and varies across communities, locally grounded research and community partnership remain important for determining which approaches work best.
Expanding Acceptable Screening Options
US colorectal cancer screening participation remains under 60% and has been stagnant over time, according to a 2024 review. Colonoscopy remains the gold standard for screening in the United States, but Geneoscopy reports that patients frequently avoid it because of its required preparation and procedure-related burdens. Future efforts may therefore focus on reaching underserved groups while making alternative or less burdensome options more accessible and acceptable.
Access Beyond the Clinic
A CDC-supported analysis described access to colorectal cancer screening for American Indians as particularly challenging. The report identified economic and sociocultural barriers that can hinder screening. These barriers indicate that unequal participation reflects broader health care and community conditions, not simply an individual's decision about whether to complete a test.
Screening Recommendations in Native Communities
The American Cancer Society post supplied for this subsection recommends colorectal cancer screening for Alaska Native people age 40 and older. It also describes colon cancer as a leading type of cancer among Alaska Native people. The message illustrates how screening recommendations are communicated through personal and community-facing stories, although the supplied source does not provide additional population statistics.
<ul> <li><b>Provider Education:</b> Ensuring that healthcare providers are up-to-date on the latest CRC screening guidelines and understand the limitations of using DRE specimens for FOBT.</li> <li><b>Community Engagement:</b> Engaging with community members to raise awareness about CRC screening and address any concerns or misconceptions.</li> <li><b>System-Level Changes:</b> Implementing clinic policies that promote recommended screening practices and providing support for providers to adopt these practices.</li> <li><b>Addressing Barriers to Access:</b> Identifying and addressing barriers to CRC screening, such as lack of insurance, transportation, or access to endoscopy services.</li> </ul>
By addressing these challenges, we can work towards improving CRC screening rates and reducing the burden of this disease in Northern Plains AI/AN communities.