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Understanding Patients’ Experiences of Diagnosis and Treatment of Advanced Colorectal Cancer in a Safety-Net Hospital System: A Qualitative Study

Leal, Isabel M. Ph.D.1,3; Kao, Lillian S. M.D., M.S.1,2; Karanjawala, Burzeen M.D.1; Escamilla, Richard J. B.S.1; Ko, Tien C. M.D.1; Millas, Stefanos G. M.D.1

Diseases of the Colon & Rectum: April 2018 - Volume 61 - Issue 4 - p 504-513
doi: 10.1097/DCR.0000000000000967
Original Contributions: Socioeconomic
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BACKGROUND: Greater understanding of barriers to screening of colorectal cancer among lower socioeconomic, particularly Hispanic, patients is needed to improve disparities in care.

OBJECTIVE: This study aimed to explore patients’ perceptions and experiences of care seeking for colorectal cancer to identify barriers to early diagnosis and treatment.

DESIGN: This explorative qualitative study was conducted as a focused ethnography of patients diagnosed with advanced-stage colorectal cancer.

SETTINGS: This study was conducted at an urban safety-net hospital.

PARTICIPANTS: Thirty lower-income, primarily minority, patients diagnosed with stage III and IV colorectal cancer without prior colorectal cancer screening were selected.

MAIN OUTCOME MEASURES: The primary outcomes measured were participants’ perceptions and experiences of colorectal cancer and barriers they faced in seeking diagnosis and treatment

RESULTS: Data analysis yielded 4 themes consistently influencing participants’ decisions to seek diagnosis and treatment: 1) limited resources for accessing care (structural barriers, including economic, health care and health educational resources); 2) (mis)understanding of symptoms by patients; misdiagnosis of symptoms, by physicians; 3) beliefs about illness and health, such as relying on faith, or self-care when symptoms developed; and 4) reactions to illness, including maintenance of masculinity, confusing interactions with physicians, embarrassment, and fear. These 4 themes describe factors on the structural, health care system, provider and patient level, that interact to make engaging in prevention foreign among this population, thus limiting early detection and treatment of colorectal cancer.

LIMITATIONS: This study was limited by selection bias and the lack of generalizability.

CONCLUSION: Improving screening rates among lower-income populations requires addressing barriers across the multiple levels, structural, personal, health care system, that patients encounter in seeking care for colorectal cancer. Acknowledging the complex, multilevel influences impacting patient health care choices and behaviors allows for the development of culturally tailored interventions, and educational, financial, and community resources to decrease disparities in cancer screening and care and improve outcomes for these at-risk patients. See Video Abstract at

1 Department of General Surgery, The University of Texas Health Science Center, Houston, Texas

2 Center for Surgical Trials and Evidence-based Practice, The University of Texas Health Science Center, Houston, Texas

3 Department of Psychological, Health and Learning Sciences, University of Houston, Houston, Texas

Funding/Support: None reported.

Financial Disclosures: None reported.

Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Boston, MA, May 30 to June 3, 2015.

Correspondence: Stefanos G. Millas, M.D., 5656 Kelley St, Ste 30S 62008. Houston, TX 77026. E-mail:

© The ASCRS 2017