Examining the Cost-Effectiveness of Introducing Patient Navigation Services for Colorectal Cancer Screening Among a Low-Income and Uninsured Population

Abstract

Background:

The colorectal cancer (CRC) screening adherence rate among the uninsured population in the United States (US) is lower than the overall rate across all US adults aged 45 to 75.

Objectives:

To assess the cost-effectiveness of community health worker (CHW) navigation services promoting CRC screening in a low-income, uninsured population.

Methods:

Using internal cost and effectiveness data from the Texas A&M Cancer Screening, Training, Education, and Prevention (CSTEP) program, which included 3196 participants, along with published sources such as the U.S. Preventive Services Task Force (USPSTF) recommendations, we estimated incremental cost-effectiveness ratios (ICERs) for CRC screening with CHW navigation versus usual care. The analysis was conducted from a societal perspective using Excel-based modeling in hypothetical cohorts initiating screening at age 45.

Results:

Under base-case assumptions, a 10 percentage-point improvement in CRC screening attributable to the program increased LYG by 0.160 at an additional lifetime cost of $101, resulting in an ICER of $3098 per LYG. One-way and two-way sensitivity analyses were conducted, varying program costs, screening rate improvements, lifetime CRC costs, and life-years gained (LYG).

Conclusion:

Our findings underscore the importance of CHW navigation services incorporating CRC screening promotion strategies tailored to uninsured populations to alleviate disparities in colorectal cancer screening and outcomes. Further research should consider the characteristics of uninsured populations, and the applicability of the program targeted for various types of underserved populations.

Keywords

colorectal cancer screening community health workers patient navigation uninsured low income cost-effectiveness

Introduction

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States (U.S.).¹ The 5-year survival rate for those diagnosed at an early stage is 91%, while it decreases to 13% when diagnosed at a distant stage.² This difference highlights the importance of early detection via CRC screening to enhance survival and decrease potentially high medical expenditures for cancer treatment.^2,3 Despite the benefits of CRC screening, only about 70% of US adults aged 50 to 75 years adhere to the United States Preventive Services Task Force (USPSTF) CRC screening recommendations, which is less than the National Colorectal Cancer Roundtable (NCCRT) goal (80%).^4,5 The issue of CRC screening non-adherence is exacerbated among the uninsured population, who generally face socioeconomic challenges accessing preventive medical services.⁶

The persistence of low CRC screening rates and high CRC-related mortality among underserved populations necessitate urgent measures to promote CRC screening to increase screening rates.^7,8 However, promoting CRC screening adherence for underserved populations is particularly complex because there are intricate contextual barriers to screening, such as lack of facilities, trained clinicians, cognitive factors, education, and stigma, which hinder the ability of these populations to adhere to the screening recommendations.⁹ Many researchers focus on promoting CRC screening via expanding public coverage programs, developing paid leave policies, and addressing social factors affecting poor CRC screening outcomes, but studies of programs that promote CRC screening uptake among the uninsured are limited.^10,11 In particular, there has been little attention on local community-level interventions led by well-trained community health workers (CHW) to help overcome barriers to CRC screening among uninsured populations.

The impact of community-oriented strategies on promoting CRC screening rates among low-income and underserved populations remains unknown. The numerous barriers to CRC screening in this population, such as lack of screening facilities nearby, lack of CRC risk awareness, negative attitudes toward CRC screening, inadequate physician recommendations, language obstacles, and cultural beliefs (stigma and negative attitudes toward CRC), collectively contribute to delayed or missed screenings, resulting in poorer prognosis after being diagnosed with cancer.^9,12-14 The involvement of CHWs in disease screening promotion has been recognized as a promising strategy for mitigating these critical challenges.^15,16

Community health workers are expected to play a critical role in assisting individuals in overcoming these barriers and enhancing their access to CRC screening services within local communities.^15,16 By engaging with underserved populations, Community health workers can build trust, disseminate CRC education and promoting screening participation to contribute to improved CRC outcomes through tailored approaches designed for the local community.^15,16 These efforts enhance cancer awareness, encourage timely health-seeking behaviors, and connect individuals to clinical care—ultimately promoting cancer screening and early detection. The available evidence suggests that active community engagement events in CRC screening can help overcome cognitive barriers and enhance screening rates among underserved populations effectively.^15,16 For example, community CRC screening engagement events have been shown to improve understanding of CRC screening recommendations and increase adherence to recommendations.¹⁶ Moreover, well-implemented referral systems between community and clinical sites can play a proactive role in reducing barriers to accessing screening facilities for underserved populations.¹⁷ Research suggests that patient navigation services, which address social determinants of health, are highly effective in promoting CRC screening.^18,19

A recent systematic review has shown that CHW interventions significantly improve colorectal cancer CRC screening uptake among U.S. racial and ethnic minorities, including Chinese Americans, Hispanics, Vietnamese, African Americans, Filipinos, and Hmong populations. Multicomponent CHW interventions are particularly effective.²⁰ In the U.S., CHW programs not only enhance screening rates at a low per-participant cost but are also cost-saving from a cost-per-QALY perspective.²¹ In contrast, similar outcomes were not observed in the U.K. or France, possibly due to differences in healthcare systems.²¹ These findings highlight the critical role of CHWs in promoting cancer screening adherence among underserved populations in the U.S. However, there is limited research evaluating the cost-effectiveness of patient navigation services for the low-income and uninsured population in the United States.

Study Objective

This study evaluates the cost effectiveness of CHW navigation services for promoting CRC screening among a low-income and uninsured population, thereby improving their long-term CRC outcomes. A decision model is constructed to assess the impact of the CHW intervention on the rate of CRC screening among uninsured persons, compared with the rate of screening without the intervention, starting at age 45, as recommended by USPSTF.²² For both groups, the long-term cost and health effects for those who are screened and those not screened are projected using published estimates of incremental costs and life-years (LYs) gained for a market-share-weighted average of four CRC screening modalities: Fecal immunochemical test (FIT), High-Sensitivity Guaiac-Based Fecal Occult Blood Test (HSgFOBT), multitarget stool DNA test including FIT test (sDNA-FIT), and colonoscopy.⁴ A decision model is used to calculate an incremental cost-effectiveness ratio (ICER) to assess the net additional cost of the CHW intervention relative to LYs gained from the improvement in CRC screening rates attributable to the CHW intervention.

Methods

Population Studied

The CHW navigation program evaluated in this study focused on improving CRC screening in a low-income and uninsured population living in medically underserved areas of Texas. According to the CDC, the CRC screening rate among the uninsured was 39% in 2020, which was significantly lower than the CRC screening rate of 75% among the insured in the United States.²³ The hypothetical cohort evaluated in the model represents a population of low-income and uninsured adults aged 45 to 75 years at average risk for CRC, for whom CRC screening is recommended using any of the screening modalities approved for persons at average CRC risk by the USPSTF.²²

Intervention

This study focuses on CHWs trained to deploy a tailored CHW navigation model to promote cancer screening, including CRC screening, among the low-income uninsured and underinsured population in underserved areas. The navigation plan design and implementation have been operated by the Texas A&M University School of Medicine, School of Nursing, and School of Public Health with clinical support by the Texas A&M Health Family Care Clinic, beginning in 2013.²⁴ The following summary of the operation of the CHW program intervention is based on interviews we conducted with several CHW program participants between May 2023 and July 2023.

In this program, most CHWs are either native or fluent Spanish speakers, allowing them to effectively connect with the target minority populations, particularly in rural Texas. CHWs may join with or without prior experience and receive comprehensive training led by experienced CHWs, both through literature-based instruction and hands-on community engagement. CHWs identify target populations through collaboration with academic institutions, clinical partners, and participation in local outreach events. They engage with the community by attending local gatherings, partnering with vendors and local grocery stores, and distributing educational brochures. Additionally, the program promotes free cancer screening services through indirect media channels such as newspapers, podcasts, and TV segments.

As shown in Figure 1, the CHW navigation program includes five major steps to build up a streamlined navigation service for promoting CRC screening among low-income and uninsured populations. The initial step involves identifying the target population with low CRC screening rates and then designing a tailored navigation strategy to engage with them effectively. Regular weekly meetings ensure alignment with engagement objectives and allow for adjustments in strategies as needed, thereby optimizing the effectiveness of CHW interventions. The second step focuses on empowering CHWs through comprehensive training initiatives. New CHWs receive monthly sessions and receive ongoing education updates related to CRC, ensuring they are well-informed and equipped to provide up-to-date screening information. This approach fosters stronger connections with potential participants and enhances their ability to engage and educate effectively.

Figure 1.

The operation process of the CHW program.

In the third step, the team collaborates with community partners to organize direct and indirect outreach events. For direct outreach, patient navigation methods are developed, and various community partners, including health fairs, food pantries, resource centers, and local grocery stores, are engaged to attract potential participants. Additionally, clinical sites are involved to ensure CHWs possess the latest screening information and establish a referral system connecting CHW navigation with screening facilities. Informative materials such as cancer screening brochures and health education resources are distributed, along with informal counseling, to enhance cancer prevention knowledge among participants. Indirect outreach is also undertaken through diverse media platforms, with partnered physicians and CHWs disseminating screening information via radio, newspapers, and social media, thereby broadening the program’s reach, and encouraging more individuals to seek screening services.

The fourth step involves clinical site CHWs playing a crucial role in the cancer screening process by offering education sessions, conducting focus groups, providing navigation services, sending patient reminders, offering provider consultations or referrals, and conducting knowledge assessments for participants. Finally, the fifth step entails monthly team meetings and the generation of quarterly and annual reports to plan strategies and measure progress toward grant goals, which aim to enhance the quality of health services, particularly cancer screening, for low-income populations in Texas. The CHWs customize colorectal cancer navigation services to encourage CRC screening among the uninsured population. By implementing navigation services, the program is intended to reduce disparities in colorectal cancer screening and establish a sustainable and effective intervention for cancer prevention and early detection among vulnerable populations.

The cost-effectiveness model projects the net present value of medical care costs and expected life-years in with or without the CHW program for a cohort of 1000 uninsured individuals using a lifetime model horizon. The process used to calculate projected costs and effectiveness with and without the CHW program is shown in Figure 2. The net lifetime cost and expected life-year assumptions for being screened or not screened were derived from the published literature reporting net costs and life-years gained for various CRC screening modalities compared to no CRC screening. The decision model defines the form of CRC screening received as a market-share-weighted average of four specific USPSTF-approved CRC screening modalities: Fecal immunochemical test (FIT), High-Sensitivity Guaiac-Based Fecal Occult Blood Test (HSgFOBT), multitarget stool DNA test including FIT test (sDNA-FIT), and colonoscopy. The weights are based on approximate shares of the four alternative modalities observed in nationwide data from commercial and public insurance programs in the United States (ie, FIT 18.9%, HSgFOBT 6.6%, sDNA-FIT 14.2%, and colonoscopy 60.3%).²⁵ The model assumes the CHW intervention increases the rate of CRC screening but does not alter the mix of screening modalities employed among those screened.

Figure 2.

The cost-effectiveness model structure.

The estimated ICERs were calculated as the difference between projected lifetime costs for the 1000-person cohort with and without the CHW program, divided by the difference in projected life-years for the 1000-person cohort with and without the CHW program. Cost-effectiveness was assessed assuming CRC screening starting at age 45, based on updated CRC screening recommendations.

Program Effectiveness Assumption

The primary outcome of the CHW program of interest for the cost-effectiveness model is the improvement in patient adherence to CRC screening recommendations due to the intervention of CHWs among the uninsured population. The assumed probability of being screened without the CHW program is 39%, based on the CRC screening rate of 39% among the uninsured in 2020.²³ The assumed effectiveness of the CHW navigation program in improving the screening rate in the uninsured population is based on an evaluation of the impact of the navigation services provided by Texas A&M University under a program funded by the Cancer Prevention Research Institute of Texas. The CSTEP program includes uninsured or underinsured, low-income individuals aged 45 to 75, in line with CRC screening recommendations, as well as those younger than 45 or older than 75 who are at increased risk due to personal or family history of colorectal cancer.

From June 1, 2022, to May 31, 2023, Community Health Workers in the program directly provided navigation services to 3196 unique individuals. As noted previously in the description of the intervention, potential participants in the CHW navigation program were identified in collaboration with community partners to organize direct and indirect outreach events. There are no reliable data on the demographic characteristics of the uninsured population in Texas within the relevant age range, so the representativeness of the study’s convenience sample cannot be fully assessed. However, as shown in Table 1, among the recruited participants, 6% were aged below 45, 86% aged 45 to 64, and 8% were aged 65 or older. Notably, 72% identified as Hispanic or Latino, and 65% reported Spanish as their primary language. The majority were married, had a household size of fewer than five members, and had attained a high school education or less. Approximately 90% resided in metropolitan areas.

Table 1.

Baseline Participants’ Characteristics.

	Percentage (total number)
Age group
<45	6.09 (29)
45-64	85.92 (409)
65+	7.98 (38)
Gender
Female	71.13 (340)
Male	28.87 (138)
Race
White	82.01 (392)
Black or African American	4.39 (21)
Asian	0.84 (4)
American Indian or Alaska Native	0.21 (1)
Missing/declined	12.55 (60)
Ethnicity
Hispanic/Latino	72.38 (346)
Non-Hispanic Latino	16.74 (80)
Missing/Declined	10.88 (52)
Primary language
English	33.68 (161)
English/Spanish	0.21 (1)
Spanish	65.48 (313)
Other	0.42 (2)
Missing	0.21 (1)
Education
Less than high school	16.42 (78)
High school degree or GED	13.68 (65)
College degree	4.00 (19)
Missing	65.89 (313)
Marital status
Single	7.84 (37)
Married	37.50 (177)
Partner	0.21 (1)
Divorced	4.24 (20)
Widowed	1.27 (6)
Missing	47.25 (223)
Household size
1	16.48 (29)
2	23.30 (41)
3	21.02 (37)
4	18.18 (32)
5	10.80 (19)
6	4.55 (8)
7	3.41 (6)
8	1.14 (2)
9	1.14 (2)
RUCC
Metro	87.60 (431)
Rural	12.40 (61)

Navigation services provided by CHWs through the program resulted in 536 unique participants (17%) receiving CRC screening, but 58 of these 536 participants reported having a previous CRC screening test within the past 5 years, leaving 478 (15% of the total) as non-compliant to regular CRC screening recommendations. However, at least some of the 478 newly screened participants would have been screened without the CHW navigation program. The base-case model assumes that 61% of newly screened participants would not have been screened without the CHW program, based on the overall CRC screening rate of 39% in this population (100% − 39% = 61%). This approximation yields an estimated improvement in the rate of CRC screening of 9 percentage points (61% × 15% = 9%) among those previously non-adherent to CRC screening guidelines potentially attributable to the CHW intervention. This estimate was rounded to a 10 percentage-point improvement for the base-case model and then varied from 2.5 percentage points to 15 percentage points in the sensitivity analyses.

Life-Years Gained Assumption

Our cost-effectiveness model builds upon the framework established by the Cancer Intervention and Surveillance Modeling Network (CISNET) that is used by the USPSTF to assess the lifetime health benefits and costs of CRC screening.²⁶ This framework incorporates numerous factors, including initial and end age, screening frequency, modality, number of life-years gained, colorectal cancer cases and deaths averted, lifetime colonoscopies required, and potential harms associated with different CRC screening strategies. Our model focuses on four recommended screening modalities: FIT every year, HSgFOBT every year, sDNA-FIT triennially, and colonoscopy every 10 years. For simplicity, other screening modalities were excluded from the analysis because they are rarely used. The primary measure of health benefits in our model is the expected gain in life-years for average-risk adults who are screened, as compared with those not screened, starting at age 45. To evaluate the effectiveness of the navigation model, as noted, we defined a weighted-average composite of CRC screening strategies, based on observed shares in nationwide data from commercial and public insurance programs in the United States.

As shown in Table 2, the USPSTF model concludes that initiating annual FIT at the age of 45 for a cohort of 1000 individuals would result in an additional accrual of 318 life-years gained over a lifetime horizon, compared to no screening.²⁶ In addition, adopting a screening approach involving annual HSgFOBT, triennial sDNA-FIT, and colonoscopy every 10 years, starting at age 45 would yield gains of 298 303 and 337 life-years, respectively.²⁶ Using the assumed modality shares, the weighted average LYG from screening compared with no screening starting at age 45 is 326 years for a 1000 person cohort, or 0.326 LYG per person.²⁶

Table 2.

Model Effectiveness Assumptions.

	Base case
Life years gained per 1000 individuals screened
FIT annually at age 45	318
HSgFOBT annually at age 45	298
SDNA-FIT triennially at age 45	303
Colonoscopy every 10 years at age 45	337
Screening percentage improvement	10
Total estimated lifetime costs with 3% discount rate
No screening	$5610
FIT annually at age 45	$3757
HSgFOBT annually at age 45	$6069
sDNA-FIT triennially at age 45	$7473
Colonoscopy every 10 years at age 45	$5465

Published estimates of lifetime costs were standardized by inflating to 2023-equivalent dollars using the medical care component of the Consumer Price Index (CPI-Medical).

Appendix A shows that the implementation of CRC screening starting at age 45 is projected to prevent 50, 42, 57, and 61 cases of CRC among 1000 individuals at average risk over a lifetime horizon for screening using FIT, HSgFOBT, sDNA-FIT, and colonoscopy, respectively.²⁶ Based on the USPSTF model, the weighted average projected effect of the four CRC screening strategies initiated at age 45 would be to avert 28 CRC-related deaths among 1000 individuals at average risk, respectively. All these cost and effectiveness estimates assume that the specific initial CRC screening modality employed is maintained over time, meaning that subsequent testing intervals and follow-up care adhere to recommendations from age 45 to 75.

Cost Assumptions

The direct cost associated with the implementation of the CHW navigation service was retrospectively gathered from the Cancer Prevention and Research Institute of Texas (CPRIT) program that utilized CHWs to promote CRC, breast, liver, and skin cancer screening for the uninsured population in Texas.²⁴ Program expenditures included the cost of navigation services, which encompassed CHW training, outreach and stakeholder engagement, consultation for participants, referral, clinical site support, evaluation, materials (brochures and stationery), employee insurance, faculty evaluation for assessing residents’ socioeconomic and insurance status, and marketing through broadcasting and newspapers. Program cost estimation was based on CHW salaries, cost of materials, outreach expenses (including newspaper and broadcasting costs), and insights from stakeholder interviews to determine the time allocated to tasks within the colorectal cancer screening project retrospectively. The value of time was estimated based on the average hourly salary for each role in the project, as detailed in Table 3. The hourly rate CHWs was estimated as $16/hour for contract CHWs and $20/hour for trained and experienced full-time CHWs.²⁴ The salary level was based on their work experience and whether the CHW had received specific training for cancer screening.

Table 3.

Expenditures for the CHW Navigation Program.

	Base case
CHW intervention program costs
Assessment of outreach and engagement need	$42 816
CHW training	$7008
Outreach and engagement	$63 360
Clinical site support	$76 800
Evaluation	$8040
Marketing via broadcasting	$200
Brochures + stationary^27,28	$3907
Employee insurance²⁹	$81 820
Estimated total	$283 951
Wage rate assumptions
Full time CHW (experienced)	$20/hr
Contracted CHW	$16/hr
Assistant professor evaluator²⁶	$45/hr
New program output in a year
CHW trained (1 year)	4
Number of people indirect exposure	56 129
Number of people direct exposure	3735
Number of unique persons receiving CRC screening	536

The cost of CHWs for the program depended on their salary and the number of hours spent participating in CHW meetings, outreach programs, training programs, and travel expenses for CHWs. Program expenditures are divided into four segments: (1) assessment of outreach and engagement needs; (2) CHW training, outreach and engagement; (3) clinical site support; and (4) evaluation. Each of these segments requires allocation of CHW workload attributable to the promotion of CRC screening among other cancer screening initiatives. Overall, it is estimated that the assessment of outreach and engagement needs required the engagement of two full-time CHWs working 60 to 80 hours per month at a rate of $20 per hour, along with the engagement of six independent CHW contractors working 8 hours per month at a rate of $16 per hour. This training regimen necessitates 4 hours of engagement per week for each of the six fixed-time CHW contractors, with an additional 2 to 8 hours per month per contracted CHW as needed. Each full-time clinical CHW will be expected to work 160 hours per month. During evaluation sessions, the engagement of a full-time PhD-level evaluator, such as an Assistant Professor from the School of Medicine, is necessary. The median salary for such a position in Texas is approximately $100 000 per year, equating to a rate of $45 per hour.²⁷ Additionally, a full-time CHW working 20 hours per month will be required to assist with evaluation tasks.

The marketing expenditure was estimated based on an interview with the Program Manager for this program. The brochure of CSTEP free cancer screening events is estimated to cost $0.14 each, and an estimated 5000 brochures were used for engagement events per year.²⁸ Finally, the estimated costs of office supplies and insurance are based on estimates for small business²⁹ (ie, $1069/person/year for 3 CHWs located in fixed office sites) and 10 full-time and part-time CHW employees’ health insurance ($8182/year).³⁰

The overall estimated cost of the CHW program was $283 951. The CHWs were engaged in promoting screening for four cancers: colorectal cancer, breast cancer, liver cancer, and skin cancer. The model assumes that the overall cost is allocated equally to these four cancers, resulting in an overall cost estimate of $70 988 for promoting CRC screening. The CHW promotional effort was associated with 536 program participants receiving CRC screening, which yields an estimate of $132 per person screened. Sensitivity analysis varies the estimated cost per person screened from $66 to $528.

The present value of the direct cost of CRC screening for those screened includes costs for CRC screening procedures, CRC cancer treatments, and related health services over time. The assumed present value of the cost of CRC screening per person for each of the four screening modalities was obtained from published literature. The assumed present value of lifetime CRC cost per person in 2023-equivalent dollars for those not screened was $5554, whereas the assumed lifetime per-person cost for FIT, colonoscopy, sDNA tests, and FOBT at age 45 was $3757, $5465, $7473, and $6096, respectively.^31,32 The reference lifetime cost estimates are discounted at an annual rate of 3%, in accordance with the methodological guidelines outlined in the “Recommendations for Conduct, Methodological Practices, and Reporting of Cost-effectiveness Analyses.”³³

Analysis

The base-case parameterization of the model was used to calculate ICERs for the CHW intervention, compared with usual care (no navigation program), for CRC screening starting at age 45. Alternative scenarios were evaluated as a series of one-way sensitivity analyses. For example, the base-case assumption that the CHW intervention improved overall CRC screening rates in the target population by 10 percentage points was varied from a low of 2.5% to a high of 15%. Similarly, sensitivity analyses varied the base-case assumption of $132 in CHW implementation costs per person screened from $66 to $528 and varied the projected LYG and net cost of screening compared with no screening per person from 75% to 125% of the baseline assumption. Two-way sensitivity analyses for selected scenarios were also performed. All model analysis was conducted using Microsoft Excel version 16.66.1.³⁴

Results

Table 4 presents the base-case model estimates of the present value of lifetime costs, defined as lifetime costs of CRC treatment and lifetime costs of screening if screened, and the projected gain in life expectancy from screening (versus no screening) for model cohorts with and without the CHW navigation intervention for CRC screening starting at age 45. The higher costs and improved LYG estimates for the CHW program intervention reflect the role of the CHW program in increasing the share of cohort members who receive CRC screening compared with no screening.

Table 4.

Base Case Costs and Effectiveness of CRC Screening With and Without CHW Navigation Program for Uninsured Populations.

Screening strategy	LYG from CRC screening	Lifetime cost	Incremental LYG	Incremental cost	ICER (CHW vs no CHW)
No CHW program	0.127	$5554	—	—	—
CHW program	0.160	$5672	0.033	$118	$3611

Under base-case assumptions, CHW promotion of CRC screening for the uninsured population starting at age 45 is expected to result in a gain of 0.160 life-years per person. If the CHW intervention improves the CRC screening rate by 10 percentage points, based on a weighted average of previously published cost estimates across four modalities of CRC screening, the present value of lifetime costs is estimated as $5672 per person in the intervention cohort. For the usual care (no intervention) cohort, with an assumed 39% CRC screening rate, the present value of lifetime costs is $5554 per person.

The estimated ICER for the CHW program, obtained by dividing the additional expenditure from the intervention by the increase in life-years gained resulting from improved CRC screening rates, is $3611/LYG under base-case assumptions. This suggests that the CHW program improves adherence to CRC screening recommendations among an uninsured population with an incremental cost per life-year gained well below the traditional willingness-to-pay threshold of $50 000/LYG. However, it should be noted that “$50 000/LYG” is essentially an arbitrary benchmark thought to derive from historical cost-effectiveness analyses of dialysis for end-stage renal disease in the 1970s, and may be considered a conservative willingness-to-pay benchmark if for no other reason it has not been adjusted over time for inflation.³⁵ Nonetheless, it remains the most cited standard for cost-effectiveness analysis in the United States.³⁶

One-Way Sensitivity Analysis

Key base-case model parameter assumptions were modified one at a time to provide one-way sensitivity analyses. Table 5 illustrates the impact on estimated ICERs from changing the assumed effectiveness of the CHW navigation service from a 2.5, 5.0, or 15 percentage-point increase in CRC screening adherence rates, and from increases and decreases from base-case values for the assumed costs of the CHW program per person, costs of CRC screening, and LYG compared. The ICERs under alternative assumptions about program effectiveness in improving patients’ adherence (2.5, 5, or 15 percentage point increase) range between $2262 and $15 758 per LYG. ICERs assuming program costs are $66, $264, $396 or $528 per person range from $1587 to $15 758 per LYG.

Table 5.

Results for One-Way Sensitivity Analyses ICER.

ICER of CHW vs non CHW program	Screening starting at age 45
2.5 percentage point increase in CRC screening rate	$15 758
5 percentage point increase in CRC screening rate	$7660
15 percentage point increase in CRC screening rate	$2262
Cost of program $66/person	$1587
Cost of program $264/person	$7660
Cost of program $396/person	$11 709
Cost of program $528/person	$15 758
Lifetime cost of screening (75% base-case)	Cost saving
Lifetime cost of screening; (125% base-case)	$7804
Lower LYG/person screened (0.245; 0.224)	$4815
Higher LYG/person screened (0.408; 0.374)	$2889

Assuming the projected lifetime cost of screening is 75% of the base-case assumption results in net cost savings starting, whereas assuming lifetime costs of screening are 125% of the base-case assumption, the estimated ICER is $7804/LYG. None of the ICERs for the CHW intervention in these alternative model scenarios exceed the traditional WTP threshold of $50 000 per life-year gained. This finding suggests that a program utilizing CHWs to promote CRC screening is likely to be cost-effective across a variety of plausible model scenarios.

Two-Way Sensitivity Analysis

To further assess the robustness of the model results to the assumed values for key model parameters, Table 6 presents the estimated ICERs for model scenarios altering base-case assumptions for CHW program cost and program effectiveness at the same time. A “worst case” scenario, which assumes a 2.5 percentage point increase in the CRC screening rate resulting from the CHW intervention and a program cost of $528 per person, resulted in ICERs of $64 346/LYG, whereas for a “best case” scenario, which assumes program costs of $66 per person and a 15 percentage-point increase in CRC screening adherence rate and the ICER results in an ICER of $912/LYG.

Table 6.

Two-Way Sensitivity Analysis, Program Cost, and Effectiveness.

ICER of CHW vs non CHW program	Screening staring at age 45
$528 program cost per person + 2.5 percentage point increase in CRC screening rate	$64 346
$396 program cost per person + 2.5 percentage point increase in CRC screening rate	$48 150
$264 program cost per person + 2.5 percentage point increase in CRC screening rate	$31 954
$66 program cost per person + 2.5 percentage point increase in CRC screening rate	$7660
$528 program cost per person + 5 percentage point increase in CRC screening rate	$31 954
$396 program cost per person + 5 percentage point increase in CRC screening rate	$23 856
$264 program cost per person + 5 percentage point increase in CRC screening rate	$15 758
$66 program cost per person + 5 percentage point increase in CRC screening rate	$3611
$528 program cost per person + 15 percentage point increase in CRC screening rate	$10 360
$396 program cost per person + 15 percentage point increase in CRC screening rate	$7660
$264 program cost per person + 15 percentage point increase in CRC screening rate	$4961
$66 program cost per person + 15 percentage point increase in CRC screening rate	$912

The two-way sensitivity analysis shows that increases in assumed program cost have a meaningful impact on ICERs when the CHW program is assumed to be relatively ineffective in improving CRC screening rates (ie, increase screening rate by 2.5 or 5 percentage points). Conversely, the ICERs are more robust to changes in assumed program costs if the CHW program is assumed to be relatively more effective (ie, a 15 percentage-point increase in CRC screening rates).

Results for additional two-way sensitivity analyses focused on the assumed net cost and effectiveness of CRC screening, compared to no screening, are reported in Table 7. The estimated ICERs for the CHW program are sensitive to the assumed net cost of CRC screening (75% or 125% of the base-case net cost assumption) and the assumed value of LYG from screening vs. no screening (75% or 125% of the base-case LYG assumption). However, across all two-way scenario changes, the estimated ICERs are below the usual $50 000/LYG WTP threshold, and scenarios with lower assumed screening costs coupled with higher assumed CHW program effectiveness suggest the CHW intervention may be cost saving.

Table 7.

Two-Way Sensitivity Analysis: Screening Cost and Life-Years Gained Assumptions.

ICER of CHW vs non CHW program	Screening starting at age 45
75% screening cost + 2.5 percentage point increase in CRC screening rate	$11 566
75% screening cost + 5 percentage point increase in CRC screening rate	$3468
75% screening cost + 15 percentage point increase in CRC screening rate	Cost-saving
125% screening cost + 2.5 percentage point increase in CRC screening rate	$19 951
125% screening cost + 5 percentage point increase in CRC screening rate	$11 853
125% screening cost + 15 percentage point increase in CRC screening rate	$6454
Lower (0.12; 0.11) of life year gain + $528 program cost per person	$21 011
Lower (0.12; 0.11) of life year gain + $396 program cost per person	$15 612
Lower (0.12; 0.11) of life year gain + $264 program cost per person	$10 214
Lower (0.12; 0.11) of life year gain + $66 program cost per person	$2116
Higher (0.2; 0.18) of life year gain + $528 program cost per person	$12 607
Higher (0.2; 0.18) of life year gain + $396 program cost per person	$9367
Higher (0.2; 0.18) of life year gain + $264 program cost per person	$6128
Higher (0.2; 0.18) of life year gain + $66 program cost per person	$1269

Discussion

This study aimed to explore the implementation of CHW navigation services for a low-income and uninsured population and assess its impact on patients’ adherence to CRC screening recommendations. According to estimates provided by the CSTEP CHW program, approximately 56 000 individuals would be indirectly exposed to colorectal cancer education and screening information dissemination within a year. Additionally, an estimated 4000 potential patients would receive direct exposure to this educational content and screening information.

Our findings suggest that introducing CHW navigation programs for an uninsured population starting at age 45 is cost-effective (ICERs under a $50 000/LYG WTP threshold) under most model scenarios using plausible assumptions about the effectiveness of the CHW program, CHW program costs per person, the present value of lifetime costs of CRC screening, and LYG from CRC screening versus no CRC screening. Under “worst-case” scenarios for CHW program costs and effectiveness, estimated ICERs are approximately equal to the traditional $50 000/LYG threshold, whereas under “best-case” scenarios, the CHW program is projected to be cost saving. Racial minorities have the highest proportion of uninsured individuals and face the greatest risk of being diagnosed with colorectal cancer (CRC) at a later stage.^37-39 These populations often have unique characteristics and face specific barriers at both the individual and provider levels, which may differ from the scenario addressed by this CHW program intervention.^40-49

To address the heterogeneity of disadvantaged groups challenges, patient navigation services play a crucial role in promoting compliance with CRC screening among underserved populations through culturally specific interventions such as consistently endorsed by minority community leaders to facilitate patients’ acceptance and understanding of the screening procedures, thereby increasing their compliance with screening recommendations and follow-up care.^49-55 Hence, patient navigation services are not only effective tools for promoting health but are also indispensable in multicultural communities. In our model, the ICERs for implementing patient navigation services to promote CRC screening are below the usual WTP thresholds. This highlighted the cost-effectiveness and feasibility of such interventions among uninsured populations.

While there may be concerns that the effectiveness of this CHW navigation program could vary due to regional differences in uninsured populations and the inherent heterogeneity in CHW program implementation, systematic reviews have consistently demonstrated the effectiveness of CHW interventions across diverse minority populations in both rural and urban settings.²⁰ Mojica et al⁵⁶ reported that Community Health Worker (interventions increased colorectal cancer screening uptake by 12% to 20% among Vietnamese and Latino populations. Similarly, Feltner et al⁵⁷ found that educational interventions for adults residing Appalachian areas improved patient-physician relationships, reducing barriers such as low cancer awareness, discomfort, and embarrassment associated with CRC screening. Additional evidence demonstrates that CHW-led education combined with navigation services not only enhances screening rates but also contributes to reductions in CRC incidence and mortality across diverse racial and ethnic minority populations.^58,59 Consistent with prior evidence, our findings further support the feasibility of CHW navigation for uninsured minority populations in underserved areas and underscore its broader applicability in promoting cancer screening across various populations and contexts.

Limitations

While our study suggests the patient navigation model using CHWs among the low-income and uninsured population is likely to be cost-effective, it is important to acknowledge several limitations. Uninsured populations often live in underserved regions with limited CRC screening facilities and health workers, which can significantly influence navigation service expenditures based on accessibility to health services, local labor costs, and relevant policies.^60-63 The estimated program expenditure in our analysis is based on a pilot study in central Texas, which may not reflect the program cost per person in a larger scale patient navigation program implementation within Texas, and may not represent likely navigation program costs for the rest of the United States.

This study used estimates of life-years gained and lifetime cost of CRC-related medical services produced by USPSTF, which is a source of two key limitations. The first is that the USPSTF estimates are derived from decision models that assume individuals who initiate a specific CRC modality (eg, colonoscopy) will adhere to recommendations for that modality over time (eg, repeat colonoscopies at recommended intervals). However, in usual practice, many individuals do not adhere to follow-up recommendations, or they may switch from one screening modality to another over time. As a result, the model may overestimate the life years gained from improvements in initial CRC screening rates and underestimate the increase in lifetime CRC costs for the intervention cohort.

Another limitation is that the USPSTF estimates are based on the racial distribution of the entire population in the United States: non-Hispanic White (58.9%), Black (13.6%), Hispanic (19.1%) and Other races (8.4%).⁵⁵ However, for the uninsured population in the United States, about 45% are White, 14% are Black, 34% are Hispanic, and approximately 8% are other races.⁶⁴ Variations in genetic predispositions, adenoma polyp occurrence rates, CRC incidence, histology types, and responses to treatment across racial and ethnic groups further contribute to wide variation in cost estimations. Many African-Americans have genetic risk factors leading to a higher occurrence of CRC, more aggressive progression of CRC, and lower response to cancer therapies.⁶⁵ The incidence and mortality rate of CRC are highest among African American and American Indian (41.9/100 000 and 39.3/100 000, respectively) and lowest among Hispanic and Asian (16.8/100 000 and 14.0/100 000, respectively).⁶⁶ In addition, Hispanic, AI/AN and African American have 21% to 23.2% higher probability of receiving CRC diagnoses at a late stage; meanwhile, Black and AI/AN populations have significantly worse CRC survival rates than White populations.^60,67-69 The variation of these risk factors across races contributes to disparities of CRC prognosis and relevant expenditure which further results in uncertainty of effectiveness estimates.

Finally, we used the estimated improvement in CRC screening adherence rates based on patient navigation services provided to low-income, uninsured populations in Central Texas, using a small sample size. Most participants were Hispanic and resided in Health Professional Shortage Areas (HPSAs). Power analysis was not performed in this study, which may limit the generalizability of the findings. In addition, we specifically offered free FIT and colonoscopy as components of the navigation services. However, it is crucial to acknowledge that the effectiveness of patient navigation services may vary based on factors such as race, CRC screening strategies, and geographic location, leading to a wider range of estimated effectiveness for patient navigation programs. Research indicated that the utilization of navigation services for both American Indian and tribal communities increased the knowledge of CRC screening and consequently increased 37 percentage point increase in the CRC screening rate.⁷⁰ In addition, the navigation service with different screening strategies (FOBT or colonoscopy) show a significant difference in increased CRC screening adherence among African American with adequate health literacy.⁷¹ Another clinical trial also shows traditional patient navigation did significantly promote the use of endoscopic but not stool-based screening among the senior Latino population, while mobile navigation service did improve the uptake of FIT for Hispanic and AI/AN adults.^72-74 Based on the evidence presented, the effectiveness of patient navigation services varies across different races, barriers and CRC screening procedures. This variation in effectiveness may lead to a wider difference in estimated service effectiveness and estimated LYG, which limits this study’s generalizability. In this study, we conducted one-way and two-way sensitivity analyses, adjusting the variance of program cost, life-year gain and program effectiveness estimates. This approach enabled us to evaluate a range of potential and address uncertainties in estimation.

Conclusion

Although detecting colorectal cancer at an early stage can reduce harm, less than 40% of the uninsured population in the United States aged 50 to 75 years follow CRC screening recommendations. It is critical to develop a tailored screening protocol targeting underserved populations. In this study, our model results suggest that implementing patients’ navigation services starting at age 45 and 50 for these marginalized populations would be cost-effective under numerous model scenarios. By considering the variations in estimated program expenditures and the expected improvement in adherence rates of patient navigation services, this research may provide insights into the widespread application of analogous programs across different states, funding agencies, and relevant research institutions. In this study, the estimated startup cost for implementing a Community Health Worker program to promote four cancer screening services and reach approximately 4000 underserved individuals within a year is around $70 000. However, program costs and effectiveness may vary based on the number of individuals reached, the degree of program tailoring, population characteristics, local CHW salaries, and the ongoing resources required to support CHW program operations. To ensure long-term impact, policymakers should prioritize the scalability and sustainability of CHW programs, particularly in efforts to improve colorectal cancer screening adherence among uninsured and underrepresented populations.

Footnotes

Appendix

Appendix A

Baseline Assumptions, Natural History Parameters, and Life-Year Estimation Inputs.

	Base case	References
Natural History based on 1975-1979 SEER
Life Expectancy (y) at age 40	40.2	Knudsen et al²⁶
Colorectal Cancer Cases per 1000 over lifetime	81
Colorectal Cancer Deaths per 1000 over lifetime	33
Numbers of CRC cases averted per 1000 individuals screened over lifetime
FIT annually at age 45	50	Knudsen et al²⁶
HSgFOBT annually at age 45	42
sDNA-FIT triennially at age 45	47
Colonoscopy every 10 years at age 45	61
FIT annually at age 50	47
HSgFOBT annually at age 50	39
sDNA-FIT triennially at age 50	44
Colonoscopy every 10 years at age 50	58
Numbers of CRC death averted per 1000 individuals screened over lifetime
FIT annually at age 45	26	Knudsen et al²⁶
HSgFOBT annually at age 45	24
sDNA-FIT triennially at age 45	25
Colonoscopy every 10 years at age 45	28
FIT annually at age 50	25
HSgFOBT annually at age 50	23
sDNA-FIT triennially at age 50	24
Colonoscopy every 10 years at age 50	27
Numbers of complication of colorectal cancer screening per 1000 individuals over lifetime
FIT annually at age 45	11	Knudsen et al²⁶
HSgFOBT annually at age 45	10
sDNA-FIT triennially at age 45	10
Colonoscopy every 10 years at age 45	16
FIT annually at age 50	10
HSgFOBT annually at age 50	9
sDNA-FIT triennially at age 50	10
Colonoscopy every 10 years at age 50	14
Numbers of colonoscopy needed for per 1000 individuals over lifetime
FIT annually at age 45	1682	Knudsen et al²⁶
HSgFOBT annually at age 45	1535
sDNA-FIT triennially at age 45	1661
Colonoscopy every 10 years at age 45	4248
FIT annually at age 50	1496
HSgFOBT annually at age 50	1347
sDNA-FIT triennially at age 50	2221
Colonoscopy every 10 years at age 50	3464

Acknowledgements

The authors express their gratitude for the contributions of Texas A&M University’s College of Medicine, School of Public Health, and the community health workers, partner clinics and community stakeholders who are part of this program. They assisted in engaging participants, delivering navigation services, and offering free cancer screenings. Special thanks to Dr. Anna Lichorad and Dr. Jason McKnight, for their expert oversight and guidance throughout the project.

ORCID iDs

Wen Hsin Chen

Robert Ohsfeldt

Arica Brandford

Ethical Considerations

This study received ethical approval from the IRB ID: IRB2022-0543 on August 11, 2022 from Institutional Review Board at Texas A&M University.

Author Contributions

Conceived and designed the experiments: WHC and RO. Analyzed the data: WHC and RO. Wrote the first draft of the manuscript: WHC, RO, MC and ES. Contributed to the writing of the manuscript: WHC, RO, MC, and ES. Agree with manuscript results and conclusions: WHC, RO, MC, and ES. Jointly developed the structure and arguments for the paper: WHC, RO, MC, and ES. Made critical revisions and approved final version: WHC, RO, MC, ES, MS, AB and JB. All authors reviewed and approved of the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Cancer Prevention and Research Institute of Texas (grant numbers PP220013) Program Director: Jason McKnight, MD.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Written informed consent and questionnaire inclusion are not applicable, as neither were used in this study.

References

Siegel

Wagle

Cercek

Smith

Jemal

Colorectal cancer statistics, 2023. CA Cancer J Clin. 2023;73(3):233-254.

Mueller

Shaik

Addepalli

Malik

Schiefelbein

Obstructing Stage IV Adenocarcinoma of the transverse colon in a young patient with vitiligo. Cureus. 2023;15(7):e42679.

Screening for colorectal cancer: U.S. Preventive services task force recommendation statement. Ann Intern Med. 2008;149(9):627-637.

Kowalkowski

Austin

Guo

Miller-Wilson

DaCosta Byfield

Patterns of colorectal cancer screening and adherence rates among an average-risk population enrolled in a national health insurance provider during 2009-2018 in the United States. Prev Med Rep. 2023;36:102497.

American Cancer Society National Colorectal Cancer Roundtable. 80% in every community. February 4, 2025. Accessed July 6, 2025. https://nccrt.org/our-impact/80-in-every-community/

Joseph

King

Dowling

Thomas

Richardson

LC.

Vital signs: colorectal cancer screening test use—United States, 2018. MMWR Morb Mortal Wkly Rep. 2020;69(10):253-259.

Parikh

Robinson

Zaydfudim

Penson

Whiteside

MA.

The effect of health insurance status on the treatment and outcomes of patients with colorectal cancer. J Surg Oncol. 2014;110(3):227-232.

Zhu

Parks

Weiser

Jacobson

Limburg

Finney Rutten

LJ.

Barriers to utilization of three colorectal cancer screening options—data from a national survey. Prev Med Rep. 2021;24:101508.

Muthukrishnan

Arnold

James

AS.

Patients’ self-reported barriers to colon cancer screening in federally qualified health center settings. Prev Med Rep. 2019;15:100896.

10.

Hotca

Bloom

Runnels

, et al. The impact of medicaid expansion on patients with cancer in the United States: a review. Curr Oncol. 2023;30(7):6362-6373.

11.

Callison

Pesko

Phillips

Sosa

JA.

Cancer screening after the adoption of paid-sick-leave mandates. N Engl J Med. 2023;388(9):824-832.

12.

Issaka

Bell-Brown

Snyder

, et al. Perceptions on barriers and facilitators to colonoscopy completion after abnormal fecal immunochemical test results in a safety net system. JAMA Netw Open. 2021;4(8):e2120159.

13.

Puli

Lussiez

MacEachern

, et al. Barriers to colorectal cancer screening in US immigrants: a scoping review. J Surg Res. 2023;282:53-64.

14.

Wang

Roy

Kim

Farazi

Siahpush

Barriers of colorectal cancer screening in rural USA: a systematic review. Rural Remote Health. 2019;19(3):5181.

15.

Rana

Chan

DNS

Nguyen

Choi

WKW

. Effectiveness of community health worker-led interventions in enhancing colorectal cancer screening uptake in racial and ethnic minority populations: a systematic review and meta-analysis. Cancer Nurs. 2024;47(5):368-376.

16.

De La Torre

Dumbauld

Haughton

, et al. Development of a group-based community health worker intervention to increase colorectal cancer screening among Latinos. Hisp Health Care Int. 2021;19(1):47-54.

17.

Redwood

Toffolon

Flanagan

, et al. Provider- and system-level barriers and facilitators to colonoscopy and multi-target stool DNA for colorectal cancer screening in rural/remote Alaska native communities. Int J Environ Res Public Health. 2023;20(22):7030.

18.

Bernardo

Zhang

Beverly Hery

Meadows

Paskett

. The efficacy and cost-effectiveness of patient navigation programs across the cancer continuum: A systematic review. Cancer. 2019;125(16):2747-2761.

19.

Gervès-Pinquié

Girault

Phillips

Raskin

Pratt-Chapman

Economic evaluation of patient navigation programs in colorectal cancer care, a systematic review. Health Econ Rev. 2018;8(1):1-12.

20.

Shah

Nakagawa

Lieblong

BJ.

Examining aspects of successful community-based programs promoting cancer screening uptake to reduce cancer health disparity: a systematic review. Prev Med. 2020;141:106242.

21.

Attipoe-Dorcoo

Chattopadhyay

Verughese

Ekwueme

Sabatino

Peng

Engaging community health workers to increase cancer screening: a community guide systematic economic review. Am J Prev Med. 2021;60(4):1-11.

22.

Colorectal Cancer: Screening. Recommendation: Colorectal Cancer: Screening . United States Preventive Services Taskforce. May 18, 2021. Accessed July 6, 2025. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening.

23.

Use of colorectal cancer screening tests. Accessed April 17, 2025. https://www.cdc.gov/colorectal-cancer/use-screening-tests/?

24.

Texas cancer screening, training, education and prevention program. https://cstep.tamu.edu/index.html

25.

Fisher

Princic

Miller-Wilson

Wilson

Fendrick

Limburg

Utilization of a colorectal cancer screening test among individuals with average risk. JAMA Netw Open. 2021;4(9):e2122269.

26.

Knudsen

Rutter

Peterse

, et al. Colorectal cancer screening an updated modeling study for the US preventive services task force. J Am Med Assoc. 2021;325(19):1998.

27.

Asst. Professor—Medicine Salary in Houston, Texas. Accessed April 17, 2025. https://www.salary.com/research/salary/benchmark/asst-professor-medicine-salary/houston-tx

28.

DM Variances. Accessed April 27, 2025. https://brainly.com/question/33654281

29.

Williams

. Unveiling office supply costs: exploring the average monthly expenditure. Accessed April 17, 2025. https://www.acp.com/blog/office-supply-budget

30.

Average annual single premium per enrolled employee for employer-based health insurance. Accessed April 27, 2025. https://www.kff.org/other/state-indicator/single-coverage/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

31.

Ladabaum

Mannalithara

Meester

RGS

Gupta

Schoen

RE.

Cost-effectiveness and national effects of initiating colorectal cancer screening for average-risk persons at age 45 years instead of 50 years. Gastroenterology. 2019;157(1):137-148.

32.

Ebner

Kisiel

Barnieh

, et al. The cost-effectiveness of non-invasive stool-based colorectal cancer screening offerings from age 45 for a commercial and medicare population. J Med Econ. 2023;26(1):1219-1226.

33.

Sanders

Neumann

Basu

, et al. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses. J Am Med Assoc. 2016;316(10):1093.

34.

Microsoft Excel. https://www.microsoft.com/en-us/microsoft-365/excelf

35.

Hirth

Chernew

Miller

Fendrick

Weissert

WG.

Willingness to pay for a quality-adjusted life year: in search of a standard. Med Decis Making. 2000;20(3):332-342.

36.

Neumann

Cohen

Weinstein

MC.

Updating cost-effectiveness—the curious resilience of the $50,000-per-qaly threshold. N Engl J Med. 2014;371(9):796-797.

37.

Latoya Hill

Artiga

Damico

. Health coverage by race and ethnicity, 2010-2023. Accessed April 27, 2025. https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/

38.

Petrick

Barber

Warren Andersen

Florio

Palmer

Rosenberg

Racial disparities and sex differences in early- and late-onset colorectal cancer incidence, 2001-2018. Front Oncol. 2021;11:734998.

39.

Warner

Tamimi

Hughes

, et al. Time to diagnosis and breast cancer stage by race/ethnicity. Breast Cancer Res Treat. 2012;136(3):813-821.

40.

Cancer and American Indian and Alaska Native People. Accessed April 27, 2025. https://www.cdc.gov/cancer/health-equity/american-indian-alaska-native.html#:~:text=American%20Indian%20and%20Alaska%20Native%20people%20have%20the%20highest%20rate,high%20among%20Alaska%20Native%20people.

41.

Garcia

Pruitt

Singal

Murphy

CC.

Colorectal cancer incidence among Hispanics and non-Hispanic Whites in the United States. Cancer Causes Control. 2018;29(11):1039-1046.

42.

Demb

Gupta

Racial and ethnic disparities in colorectal cancer screening pose persistent challenges to health equity. Clin Gastroenterol Hepatol. 2020;18(8):1691-1693.

43.

Filippi

Braiuca

Cully

, et al. American Indian perceptions of colorectal cancer screening: viewpoints from adults under age 50. J Cancer Educ. 2013;28(1):100-108.

44.

Daley

James

Filippi

, et al. American Indian community leader and provider views of needs and barriers to colorectal cancer screening. J Health Dispar Res Pract. 2012;5(2):1-2.

45.

Mojica

Vargas

Bradley

Parra-Medina

Barriers and facilitators of colonoscopy screening among Latino men in a colorectal cancer screening promotion program. Am J Mens Health. 2023;17(3):1-12.

46.

Byrd

Calderón-Mora

Salaiz

Shokar

NK.

Barriers and facilitators to colorectal cancer screening within a Hispanic population. Hisp Health Care Int. 2019;17(1):23-29.

47.

Liu

Schuchard

Burston

Yamashita

Albert

Interventions to reduce healthcare disparities in cancer screening among minority adults: a systematic review. J Racial Ethn Health Disparities. 2021;8(1):107-126.

48.

Jetelina

Yudkin

Miller

, et al. Patient-reported barriers to completing a diagnostic colonoscopy following abnormal fecal immunochemical test among uninsured patients. J Gen Intern Med. 2019;34(9):1730-1736.

49.

Sarfaty

Feng

Choice of screening modality in a colorectal cancer education and screening program for the uninsured. J Cancer Educ. Spring 2006;21(1):43-49.

50.

Mohl

Ciemins

Miller-Wilson

Gillen

Luo

Colangelo

Rates of follow-up colonoscopy after a positive stool-based screening test result for colorectal cancer among health care organizations in the US, 2017-2020. JAMA Netw Open. 2023;6(1):e2251384.

51.

Hassan

Kaminski

Repici

How to Ensure patient adherence to colorectal cancer screening and surveillance in your practice. Gastroenterology. 2018;155(2):252-257.

52.

Murphy

Sigel

Yang

, et al. Adherence to colorectal cancer screening measured as the proportion of time covered. Gastrointest Endosc. 2018;88(2):323-331.e2.

53.

Rubin

Okitondo

Haines

Ebell

Interventions to increase colorectal cancer screening adherence in low-income settings within the United States: a systematic review and meta-analysis. Prev Med. 2023;172:107522.

54.

Cha

Cohen

RA.

Demographic variation in health insurance coverage:United States, 2021. Natl Health Stat Report. 2022;(177):1-14.

55.

QuickFacts United States. https://www.census.gov/quickfacts/fact/table/US/RHI825222

56.

Mojica

Morales-Campos

Carmona

Ouyang

Liang

Breast, cervical, and colorectal cancer education and Navigation. Health Promotion Practice. 2015;17(3):353-363.

57.

Feltner

Ely

Whitler

Gross

Dignan

Effectiveness of community health workers in providing outreach and education for colorectal cancer screening in Appalachian Kentucky. Social Work in Health Care. 2012;51(5):430-440.

58.

Nguyen

Tsoh

Woo

, et al. Colorectal cancer screening and Chinese Americans: efficacy of lay health worker outreach and print materials. Am J Prev Med. 2017;52(3):e67-e76.

59.

Grubbs

Polite

Carney

Jr , et al. Eliminating racial disparities in colorectal cancer in the real world: it took a village. J Clin Oncol. 2013;31(16):1928-1930.

60.

Pruitt

Davidson

Gupta

Yan

Schootman

Missed opportunities: racial and neighborhood socioeconomic disparities in emergency colorectal cancer diagnosis and surgery. BMC Cancer. 2014/12/09 2014;14(1):927.

61.

Chen

Bloom

Brandford

, et al. Persistent poverty, rural location, and racial segregation are factors in colorectal cancer screening in low-income and uninsured populations. J Adv Pract Oncol. Published online May 4, 2025.

62.

Lee

KMN

Hunleth

Rolf

, et al. Distance and transportation barriers to colorectal cancer screening in a rural community. J Prim Care Community Health. 2023;14:1-17.

63.

Michaud

Estabrooks

Dai

, et al. Cost-effectiveness analysis of implementing a multisectoral program for colorectal cancer screening in an African American community. AJPM Focus. Published online June 2025:100388.

64.

Samantha Artiga

Garfield

. Estimates of eligibility for ACA coverage among the uninsured by race and ethnicity. Accessed April 27, 2025. https://www.kff.org/racial-equity-and-health-policy/issue-brief/estimates-of-eligibility-for-aca-coverage-among-the-uninsured-by-race-and-ethnicity/

65.

Williams

Paredes

Thaker

Genetics of colorectal cancer racial disparities. Gene Expr. IntechOpen; 2022.

66.

Carethers

JM.

Racial and ethnic disparities in colorectal cancer incidence and mortality. Adv Cancer Res. 2021;151:197-229.

67.

Primm

Malabay

Curry

Chang

Who, where, when: colorectal cancer disparities by race and ethnicity, subsite, and stage. Cancer Med. 2023;12(13):14767-14780.

68.

Augustus

Ellis

NA.

Colorectal cancer disparity in African Americans: risk factors and carcinogenic mechanisms. Am J Pathol. 2018;188(2):291-303.

69.

Menon

Lance

Szalacha

, et al. Adaptation of colorectal cancer screening tailored navigation content for American Indian communities and early results using the intervention. Implement Sci Commun. 2022;3(1):1-6.

70.

Frerichs

Beasley

Pevia

, et al. Testing a culturally adapted colorectal cancer screening decision aid among American Indians: results from a pre-post trial. Health Equity. 2020;4(1):91-98.

71.

Horne

Phelan-Emrick

Pollack

, et al. Effect of patient navigation on colorectal cancer screening in a community-based randomized controlled trial of urban African American adults. Cancer Causes Control. 2015;26(2):239-246. 0

72.

Enard

Nevarez

Hernandez

, et al. Patient navigation to increase colorectal cancer screening among Latino Medicare enrollees: a randomized controlled trial. Cancer Causes Control. 2015;26(9):1351-1359.

73.

Rozario

Walton

Kang

Padilla

BI.

Colorectal cancer screening: a quality improvement initiative using a bilingual patient navigator, mobile technology, and fecal immunochemical testing to engage hispanic adults. Clin J Oncol Nurs. 2021;25(4):423-429.

74.

Muller

Robinson

Smith

, et al. Text message reminders increased colorectal cancer screening in a randomized trial with Alaska Native and American Indian people. Cancer. 2017;123(8):1382-1389.