By Liora Engel-Smith

The envelopes that may hold the key to detecting colorectal cancer early are unremarkable. Slim but large, they could just as easily hold a medical bill or the details of a new insurance policy.

Instead, the paper envelopes hold tools that are reminiscent of art supplies: a wand or brushes, maybe a card and a prepaid business envelope, the type that you might use to pay a bill.

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This inexpensive setup doesn’t sound like much, but it may hold the key to detecting colon cancer by tracing hidden blood in the feces of patients who won’t, or more likely can’t, get a colonoscopy. Or at least, that’s what providers at Hertford County’s Roanoke Chowan Community Health Center and the medical school at the University of North Carolina at Chapel Hill are hoping for.

A collaboration between the UNC School of Medicine, Roanoke Chowan and another health center in the western part of the state has been distributing mail-in colorectal cancer tests to patients, with the goal of reaching at least 2,500 screenings by 2023, with the aim of increasing access to colorectal cancer screenings across the state.

“There are people who don’t want to do [a colonoscopy],” said Caroline Doherty, chief development and program officer at the center in Ahoskie. “Certainly people who are uninsured can’t afford it. It’s thousands of dollars.”

At roughly $20 apiece, the mail-in test, also known as fecal immunochemical test or FIT, is far cheaper and can be done from home, rather than an ambulatory center or a hospital.

To use FIT, patients catch a little bit of their poop with some toilet paper. Then they smear some of that fecal matter onto a card or tube using a brush or wand. They seal the material and mail it to a lab using the prepaid business envelope. The lab then tests the material for hidden blood, an early sign of potentially malignant tumors. When repeated yearly, FIT is almost as effective as a colonoscopy at detecting early-stage colon cancer.

Under this screening scheme, which is already used in Canada and England, only people whose FIT test shows blood in the stool get colonoscopies.

The test could make a big difference in Hertford County, which is part of a swath of North Carolina and Virginia Counties with some of the highest rates of colorectal cancer deaths in the country. The reasons for the higher death rates are not altogether clear, said Dan Reuland, the UNC physician who oversees the study, but factors such as low screening rates contribute to that disparity.

A not so simple routine

Up until recently, few patients at Roanoke Chowan got their routine colonoscopies, according to Doherty. The screening method itself is part of the problem. An invasive procedure that requires anesthesia, a colonoscopy, now recommended every 10 years for any adult over the age of 45, is uncomfortable. Preparation for the test can also be difficult because it involves the use of laxatives that require a person to stay within running distance of a toilet for a good half a day.

For residents of the rural eastern North Carolina county, transportation can also be a barrier, because most colonoscopies take place at Vidant Medical Center in Greenville, more than an hour south of Ahoskie. The procedure requires sedation, so someone other than the patient has to be available to drive home afterward. That alone could be a challenge for hourly workers and patients who don’t have paid vacation days.

The hurdles don’t end there. Though insurance companies cover the procedure as part of the battery of preventive services mandated under the Affordable Care Act, those without insurance often have to pay out-of-pocket for the screening, which could cost more than $1,000. Even insured patients may end up with a sizable bill if the screening yields polyps that need to be removed.

Reuland hopes to use the data from the tests to prove that FIT can be an effective and cheaper option to screen patients who can’t afford colonoscopies. Some patients, particularly those who are low income, likely won’t come to the clinic enough to even discuss the option of a colonoscopy, he added.

“This test does not say you can’t get a colonoscopy,” he said. “But it’s free, you can do it in your house once a year.”

Providers at Roanoke Chowan have already used the FIT method to raise the screening rate among patients. Before they used the test, Doherty said, fewer than a third of patients were getting screened for colorectal cancer. That number now approaches half the patients, she added. She hopes to up that rate to 80 percent.

From two counties to many?

In September, the North Carolina Department of Health and Human Services received a grant from the Centers for Disease Control and Prevention to help other health centers who serve historically marginalized populations make progress on their colorectal cancer screening. The goal, a departmental spokeswoman said, is to bring the screening rates to at least 60 percent in these communities, as part of a larger effort to raise colorectal cancer screenings rates statewide.

The CDC grant, which includes an infusion of nearly $700,000 in the first year, does not directly mention FIT, but UNC’s Reuland said he is advising the department on the project. He wants other health centers to consider an approach similar to the one at Roanoke Chowan.

“I’m hoping these two projects will sort of come together,” he said.

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Liora Engel-Smith joined NC Health News in July 2019 and covers policies, programs and issues that affect rural areas. She has previously worked for the The Keene Sentinel in New Hampshire and the Muscatine...