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RESEARCH 

Colorectal Adenoma Detection Rate in 

Northeast Texas – Outcome from 

Community Service Project Using the Fecal 

Immunochemical Test and Colonoscopy 
Gabriela Orsak1, Harrison Ndetan1, Carlton Allen2, Karan P. Singh1, Paul McGaha3 

1 University of Texas Health Science Center at Tyler, Department of Epidemiology and Biostatistics, 

Tyler, TX, USA 2 University of Texas Health Science Center at Tyler, Center for Rural and 

Community Health, Tyler, TX, USA 3 University of Texas Health Science Center at Tyler, Department of 

Community Health, Tyler, TX, USA 

*Corresponding author email: gabriela.orsak@uthct.edu  

ABSTRACT 
Colorectal cancer (CRC) is the fourth most frequently diagnosed cancer in the United States. CRC 

incidence rates in Northeast Texas, a primarily rural region of the state, far exceed state and national 

averages. The current study sought to determine the proportion of polyps found in a sample of 5,391 

individuals living in Northeast Texas using either colonoscopy or fecal immunochemical testing. In 

addition, the role of insurance to CRC screening was also investigated. An adenomatous polyp was 

detected in 44.7% participants in the colonoscopy group and in 2.6% of participants undergoing FIT 

testing. Additionally, participants in the colonoscopy group who were un- or under-insured were 30% 

more likely to have an adenomatous polyp detected. While a larger proportion of participants had an 

adenomatous polyp detected in the colonoscopy group, many including the un- or under-insured are 

not able to afford, at which point FIT testing may be a better option. 

KEYWORDS:  
Colorectal cancer; adenoma; rural; colonoscopy; fecal immunochemical test 

 

Citation: Orsak G et al (2019) Colorectal Adenoma Detection Rate in Northeast Texas – Outcome from 

Community Service Project Using the Fecal Immunochemical Test and Colonoscopy, Research Reports 3: 

e1-e10. doi:10.9777/chd.2019.1009.  

 

 



 
 
 
 
 

 

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INTRODUCTION 

Northeast Texas is a primarily rural, medically 

underserved, region of Texas with many health 

disparities (Nehme et al., 2016). A recent report 

published on the health status of this region found 

that if Northeast Texas was its own state, it would 

be ranked 45th in all-cause mortality (Nehme et al., 

2016). Access to primary or specialty care in this 

underserved region is limited due to a lack of 

providers. In addition other barriers to care exist, 

such as distance to specialty care, high rates of 

poverty, and an older population (Nehme et al., 

2016). Around 21% of Northeast Texas adults 

report not visiting a doctor in the past 12 months 

due to cost. One such condition that 

disproportionately affects this area, primarily 

affects older adults and requires regular screening 

for prevention is colorectal cancer (CRC). 

CRC is the fourth most frequently diagnosed 

cancer in the United States (U.S. Cancer Statistic 

Working Group, 2016) with an age-adjusted 

incidence rate of 38.27 per 100,000 (National 

Cancer Institute, 2017a). While these rates are 

similar to those observed in the state of Texas 

(38.1; Texas Cancer Registry, 2018b), rates of CRC 

in the primarily rural region of Northeast Texas 

(Regions 4 and 5) far exceed the state rate and 

national averages (age adjusted incidence in 

Region 4 = 43.3, Region 5 = 43.6; Texas Cancer 

Registry, 2018b) This follows a similar trend of CRC 

mortality, where rates in Northeast Texas (15.8 – 

16.9; Texas Cancer Registry, 2018a) far exceed the 

state (14.4; Texas Cancer Registry, 2018a) and 

national (14.1; National Cancer Institute, 2017b) 

averages. As in most cancers, CRC morbidity and 

mortality can be reduced or even prevented if CRC 

is diagnosed early. 

CRC typically develops from adenomatous polyps 

(American Cancer Society, 2017). These polyps are 

precancerous polyps that can develop into CRC. 

Therefore, the detection and subsequent removal 

of adenomatous polyps prevents CRC (American 

Cancer Society, 2018). This has been achieved 

through preventive screenings with the use of the 

fecal immunochemical test (FIT) and colonoscopy. 

However, with a high poverty rate, difficulty 

accessing specialty care (distance to provider and 

lack of provider), and an older population in 

Northeast Texas, receiving preventive care for CRC 

can be challenging. 

Colonoscopy is invariably considered the gold 

standard for CRC screening (Friedrich et al., 2015; 

Lieberman et al., 2012). Colonoscopy is able to 

identify and remove polyps that can be divided 

into the following types: 1) hyperplastic (polyps 

with no malignant potential), 2) adenomatous 

(polyps with malignant potential), and 3) 

malignancies (Lieberman et al., 2012). Detection 

and removal of adenomatous polyps can prevent 

these polyps from progressing into malignancies 

and hence reduce or prevent mortality (Lieberman 

et al., 2012). However, colonoscopy is an invasive 

procedure, with many barriers that tend to prevent 

many individuals from completing the procedure. 

For example, the need for sedation, arranging 

transportation to and from the hospital, missing 

work, etc. which are typical experiences with the 

procedure. 

FIT testing, on the other hand, has attracted a lot 

of interest and seemed to be better accepted 

(Segnan et al., 2007) by the general public. This 

procedure is less invasive and less time consuming 

than colonoscopy but is not complete CRC 

screening method on its own (Quintero et al., 

2012). With FIT, participants send a stool sample to 



 
 
 
 
 

 

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RESEARCH 

a laboratory from the convenience of their home. 

The test identifies the stool sample as either 

normal or abnormal. If the test comes back 

abnormal, participants are urged to undergo a 

colonoscopy in order to detect and remove 

potential polyps. Thus, this test enables only 

participants with abnormal FIT test results to have 

undergoing the less desired colonoscopy. 

The current goal set by the U.S. Department of 

Health and Human Services in the Healthy People 

2020 is to achieve a 70.5% CRC screening rate. 

However, even with the availability of both 

screening methods, CRC screening rates remain 

suboptimal in the general public (62.4%; U.S. 

Department of health and Human Services, 2018) 

and in rural communities (58.2%; U.S. Department 

of Health and Human Services), with rates being 

even lower in Northeast Texas (44.63%; Hall, 2018). 

They are even much lower among the uninsured 

(25.1%). The high CRC prevalence and yet low 

screening rates in the Northeast Texas region is a 

growing concern. While the reason for this 

remains elusive, a few factors typical of a rural 

setting, may potentially be incriminated. Having 

other health burdens coupled with low health 

literacy, preventive care is hardly a priority. The 

region is vast in size and consists of rural counties 

with few small metropolitan statistical areas. Poor 

access to safe and affordable transportation 

presents an extra challenge to residents who must 

often travel long distances to a healthcare facility. 

Due to fewer available providers compared to 

urban settings, waiting periods to get an 

appointment is generally longer (Texas Medical 

Board, 2017). The region is predominantly 

inhabited by low-to moderate income individuals 

and families living below the federal poverty line, 

(The Henry J. Kaiser Family Foundation, 2014) 

making it difficult for them to afford health 

insurance. 

CRC detection rates for rural residents are not well 

established. In addition, with the emergence of FIT 

testing, detection rates for rural residents have not 

been established. Particularly, the role of insurance 

to CRC screening in this setting has never been 

investigated. As a consequence, the current study 

sought to: 

1. Investigate CRC adenoma detection rates in 

primarily rural Northeast Texas by FIT test and 

colonoscopy. 

2. Examine the impact of not having health 

insurance on adenoma detection rates. 

MATERIALS AND METHODS 

The study was part of a community outreach 

program for CRC screening in 19 counties of 

Northeast Texas organized by the Northeast Texas 

Center for Rural and Community Health 

(NETCRCH) at the University of Texas Health 

Science Center at Tyler (UTHSCT). The project was 

funded by the Cancer Prevention Research 

Institute of Texas (CPRIT) and was deemed exempt 

by the UTHSCT Institutional Review Board (IRB). 

Study participants were recruited either by 

referrals from UTHSCT clinics (general population) 

or through community outreach events organized 

by NETCRCH which targeted un- or under-insured 

individuals. With the exception of some small 

metropolitan statistical areas, the catchment area 

consisted of rural communities with little or no 

access to public transportation. Data was collected 

between 2014 and 2017. It includes all 

colonoscopies and FIT tests performed at UTHSCT. 

A resident of Northeast Texas was considered 

eligible to participate in the study if the resident 



 
 
 
 
 

 

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RESEARCH 

was 44 to 76 years of age, spoke English or 

Spanish, and was currently undergoing a 

colonoscopy and/or FIT test. Individuals previously 

diagnosed with CRC were considered ineligible. 

Figure 1 describes the flow of participants through 

the study. The final study sample consisted of 

5,391 participants. If participants were seen at the 

UTHSCT clinics and met all inclusion/exclusion 

criteria, they were recommended/referred for 

colonoscopy and/or FIT test regardless of payer 

source. Participants were offered colonoscopy 

and/or FIT test based on their preference and/or 

provider recommendation. If participants were 

deemed un- or under- insured and unable to pay 

for services, screenings were provided free-of-

charge, as a part of the CPRIT grant, otherwise 

they had to pay for their screening. Participants 

recruited through clinics or outreach events that 

were a part of the CPRIT grant were provided an 

additional gift card of $20 for transportation upon 

completion of a colonoscopy. Participants who 

elected to take the FIT test were scheduled for 

colonoscopy if they had an abnormal FIT result 

(and subsequently received the same $20 gift card 

for transportation upon completion of 

colonoscopy).

 

 

Figure 1. CONSORT Diagram 

Outcome and other variables of interest 

The key outcome variables of interest for this study 

were the results of the FIT test and colonoscopy. 

FIT test 

Participants who completed a FIT test received a 

normal or abnormal result. If an abnormal result 

was received, participants were scheduled for a 

follow-up colonoscopy. For analytical purpose, the 

results of the FIT test were categorized as: 1) 

normal, 2) hyperplastic polyp only, 3) 

adenomatous polyp, 4) malignancy and 5) 

abnormal FIT test result, but no follow-up result 

with colonoscopy. 

Colonoscopy 

Colonoscopy outcomes were divided into four 

categories: 1) normal, 2) hyperplastic polyp only, 3) 

adenomatous polyp, and 4) malignancy. 



 
 
 
 
 

 

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RESEARCH 

Demographic and medical information 

Demographic (gender, race/ethnicity) and medical 

information (insurance status, family history of 

cancer) were gathered through patient record and 

electronic medical record. Insurance status, 

gender, previous screening, and family history of 

colon cancer were coded as dichotomous, 

race/ethnicity was coded as Non-Hispanic White, 

Non-Hispanic Black, Hispanic, and Asian. 

Meanwhile age was retained as continuous. 

Statistical Analysis 

Data was analyzed using Statistical Package for 

Social Science (SPSS) version 23.(IBM corporation, 

2015) Descriptive statistics are reported for 

demographic and medical variables, including 

prevalence rates of neoplasms (Table 1). 

Table 1. Demographic and Other Distributions of Study Participant Who Originally Opted for FIT and 

Colonoscopy for Colorectal Cancer Screening (Outcome of a Northeast Texas Community Service Project). 

Variable  Overall 

n (%) 

FIT test** 

n (%) 

Colonoscopy 

n (%) 

p-value* 

Overall  5,391 2,108 (39.1) 3,283 (60.9) <0.001 

Age Mean (SD)  59.0 (6.6) 57.5 (5.6) 60.0 (6.9) <0.001 

Gender     

Male  1,978 (36.7) 665 (31.5)  1,313 (40.0) <0.001 

Female 3,413 (63.3) 1,443 (68.5)  1,970 (60.0)  

Race/Ethnicity    <0.001 

Non-Hispanic White 3,057 (56.7) 1,081 (51.3)  1,976 (60.2)  

Non-Hispanic Black 1,119 (20.8) 332 (15.7)  787 (24.0)  

Asian  40 (0.7) 16 (0.8)  24 (0.7)  

Hispanic 1,170 (21.7) 676 (32.1)  494 (15.0)  

Missing  5 (0.1)  3 (0.1)  2 (0.1)  

Insurance Status    <0.001 

Un- or Under- Insured 3,033 (56.3) 1,962 (93.1)  1,071 (32.6)  

Insured 2,358 (43.7) 146 (6.9)  2,212 (67.4)  

Previous screening    <0.001 

No 2,429 (45.1) 1,218 (57.8)  1,211 (36.9)  

Yes 1,667 (30.9) 439 (20.8)  1,228 (37.4)  

Did not provide an 

answer/missing 

1,295 (24.0) 451 (21.4)  844 (25.8)  

Family history of colon screenings    < .001 

No 4,210 (78.1) 1,546 (73.3)  2,664 (81.1)  

Yes  463 (8.6) 97 (4.6)  366 (11.2)  

Did not provide an 

answer/missing 

 718 (13.3) 465 (22.1)  253 (7.7)  

Details of test results     

Normal  1,913 (90.7)  1,472 (45.2)  

Hyperplastic polyp  11 (0.5)  285 (8.8)  

Adenomatous polyp  53 (2.6)  1,467 (45.0)  

Malignancy  2 (0.1)  33 (1.0)  



 
 
 
 
 

 

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Abnormal FIT test result, but no 

follow-up with colonoscopy 

  129 (6.1)   

Missing Ɨ    26 (0.9)  

*p-value for Age was based on analysis of variance, and for the rest were based on the Pearson’s chi-square test. 

**FIT: Fecal Immunochemical Test. Of the 247 who tested abnormal, 129 failed to follow-up with colonoscopy and 118 underwent colonoscopy follow-

up (resulting in 52 normal and 66 abnormal results) with details as specified in the table. 

Ɨ Final result for colonoscopy not available due to poor bowel prep 

Demographic and other differences in the distribution 

of the results of the FIT test and colonoscopy were 

assessed using the Pearson’s chi-square test or a 

binomial test of proportion. The multinomial logistic 

regression model that controlled for gender, age, 

race/ethnicity, previous screening, and family history 

of colon cancer was applied to generate odds ratio 

(OR) and 95% confidence interval (CI) that assesses 

the likelihood that individuals who received any of the 

abnormal screening results (FIT and colonoscopy) 

were un-/under-insured compared to those who 

were insured. 

RESULTS 

Descriptive Statistics 

The general characteristics of the study sample is 

depicted in Table 1. Of the 5,391 participants, 3,057 

(56.7%) were non-Hispanic White, 1,119 (20.8%), 

non-Hispanic Black, 1,170 (21.7%) Hispanic, 40 

(0.7%) Asian, and 5 (0.1%) were of unknown 

race/ethnicity. The mean age was 59 ± 6.6 years. 

They were predominantly females (n = 3,413, 

63.3%), with a slight majority being un- or under- 

insured (n = 3,033, 56.3%). A family history of 

colon cancer was identified in 463 (8.6%) 

individuals. 

Originally, a majority of the study participants 

elected to undergo a colonoscopy screening 

(3,283, 60.9%) compared to FIT test (2,108, 39.1%), 

a statistically significant difference (p < 0.001). 

There was also statistically significant differences in 

the demographics of these individuals. The FIT 

group was generally younger (p < .001), with fewer 

males (p <0.001) and being un- or under- insured 

(p < 0.001), compared to the colonoscopy group. 

Finally, a larger proportion of colonoscopy results 

(1,785, 54.2%) were found to be abnormal than FIT 

test results (195, 9.3%) as compared to having a 

normal result, a statistically significant difference (p 

<0.001). 

FIT Test Results 

Of the 2,108 who underwent FIT testing originally, 

247 (11.7%) had abnormal results. Of those 

deemed abnormal, subsequent colonoscopies 

identified both normal and abnormal outcomes. 

Of the 247 with abnormal FIT results, 129 (52.2%) 

receiving an abnormal result, but failed to undergo 

a colonoscopy for further diagnosis. The remaining 

118 (47.8%) who opted for a follow-up 

colonoscopy screening reported the following 

results: 53 (44.9%) normal, 11 (9.3%) hyperplastic 

polyp, 54 (45.8%) adenomatous polyp, and 2 

(1.6%) malignancies (Table 1). Finally, likelihood 

ratio tests revealed a non-significant effect of 

insurance status on FIT test result (p = 0.419). 

Colonoscopy Results 

Results of colonoscopy revealed, 1,472 (44.8%) 

had a normal results, 285 (8.6%) had a 

hyperplastic polyp, 1,467 (44.7%) had an 

adenomatous polyp, and 33 (1%) had a 

malignancy (Table 1). Likelihood ratio tests 

revealed a significant difference in colonoscopy 

outcome among the insured and un-/under-

insured, p = 0.047. There was a statistically 



 
 
 
 
 

 

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RESEARCH 

significant 30% increased odds of having an 

adenomatous polyp among the un-/under-insured 

as compared to the insured [OR = 1.30, 95% CI: 

1.05, 1.61]. No significant differences were found 

for those with a hyperplastic polyp or a 

malignancy. Results are displayed in Table 2. 

Table 2. Odds Ratios and 95% Confidence Intervals of Multinomial Logistic Regression Results  

  Examining Effect of Insurance Status on Colonoscopy Group. 

Colonoscopy group results 

Variable Hyperplasia Adenoma Malignancy 

Gender 0.95 [0.70, 1.29] 0.72 [0.60, 0.86]* 1.28 [.48, 3.37] 

Age 0.99 [0.96, 1.01] 1.04 [1.02, 1.05]* 1.04 [.97, 1.13] 

Family History of Colon Cancer 1.14 [0.75, 1.73] 1.03 [0.79, 1.34] 1.03 [.29, 3.61] 

Previous screening 1.43 [1.03, 2.05]* 0.91 [0.73, 1.13] 0.93 [.31, 2.78] 

Non-Hispanic Black 0.78 [0.54, 1.11] 0.85 [0.69, 1.05] 0.47 [.13, 1.63] 

Asian 0.38 [0.05, 2.97] 0.45 [0.17, 1.23]  

Hispanic 0.53 [0.33, 0.85]* 0.61 [0.47, 0.80]* 0.26 [.05, 1.23] 

Insurance status 0.98 [0.69, 1.39] 1.30 [1.05, 1.61]* 0.60 [.20, 1.76] 

Note. Race/ethnicity was compared to Non-Hispanic White; Results of colonoscopy group are compared to normal results; Insurance status coded 

as 0 for insured and 1 for uninsured; family history of cancer coded as 0 for no and 1 for yes; previous screening coded as 0 for no and 1 for yes; 

results with no odds ratio and 95% confidence interval entered were not able to be calculated due to low sample sizes; * p <0 .05 

DISCUSSION 

Tests that can identify adenomatous 

(precancerous) polyps before they become 

cancerous are crucial to reduce health disparities 

among rural residents. The current study found a 

very high adenoma detection rate. While results 

differ from study to study, different studies report 

prevalence rates as low as 1.3% (Gupta et al., 

2013), or as high as 58%, (Øines et al., 2017) 

although most rates vary between 25 to 50% 

(Bretthauer et al., 2016; Giacosa et al., 2004; 

Hilsden et al., 2016; IJspeert et al., 2015; Øines et 

al., 2017; Quintero et al., 2012),depending on 

country where study was conducted or other 

factors. However, studies focus on adenoma 

detection rates identified via colonoscopy in 

primarily urban settings and research among 

underserved rural populations is sparse. Further, 

studies are limited on FIT test adenoma detection 

rates due to its nascence, especially among 

underserved rural populations. The high 

prevalence rates detected add to the current 

literature on rural populations and are important 

to note, especially when compared to a recent 

randomized control trial conducted in a different 

part of the state. Specifically, a similar study 

conducted in southern Texas found adenoma 

detection rates that ranged between .8% for FIT 

test and 1.3% for colonoscopy (Gupta et al., 2013). 

While the study did not examine differences 

among insurance rates and was conducted in a 

primarily urban setting, the adenoma detection 

rates for the current study were much higher, with 

rates ranging from 2.6% for FIT test and 44.7% for 

colonoscopy. These results shine to light: 1) the 

large disparity in adenoma detection rates when 

using a FIT test as compared to a colonoscopy and 

2) the large adenoma detection rate in this 

primarily rural setting. 

While the adenoma detection rate was lower for 

FIT testing when compared to colonoscopy, a 

previous study found that the FIT test results are 



 
 
 
 
 

 

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not as high as colonoscopy (Quintero et al., 2012). 

However, the discrepancy between adenoma 

detection rate between FIT and colonoscopy 

varied only by a small amount (.9% for FIT vs. 1.9% 

for colonoscopy), (Quintero et al., 2012) while the 

current study found a much larger variation. Other 

potential explanations may be that for example the 

FIT test group consisted of participants who were 

younger and more likely to be female, both factors 

that contribute to adenoma detection (Corley et 

al., 2013). 

Nevertheless, the FIT test provides many practical 

benefits that warrant its use, especially among low 

income populations. First, the FIT test is less 

burdensome on participants and allows for not 

having to take off of work or figuring out 

transportation. Second, it is a far less costly 

procedure (Corley et al., 2013) that can therefore 

be disseminated to a larger public health 

population. However, it is suggested that a FIT test 

need be completed every year (Corley et al., 2013). 

This might prove to be burdensome for many, as 

compared to a colonoscopy which needs to be 

completed every few years (depending upon 

physician recommendation for follow-up). Due to 

this burden the un-/under-insured may not 

complete FIT testing as often as recommended 

after their initial FIT test, with the potential of 

future adenomas or malignancies being 

undetected until it is too late. 

Proportions of adenomas detected were higher for 

colonoscopies, with almost half of all participants 

having an adenomatous polyp detected. The 

removal of these polyps will help to hopefully 

reduce the rate of colorectal cancer among this 

population, although such outcomes could not be 

surmised by the current study. 

Being un-/under-insured played a very important 

role in colonoscopy, but not FIT test results. The 

un-/under-insured were more likely to have an 

adenomatous polyp detected for colonoscopy. 

While insurance status did not have an effect on 

FIT test results, a large proportion of participants 

with abnormal results failed to follow-up for 

subsequent colonoscopy. An abnormal FIT test 

result without follow-up colonoscopy to further 

diagnose and/or remove potential polyps deems 

the FIT test impractical. It is especially important to 

note since all FIT tests and colonoscopies were 

provided free-of-charge to the un-/under-insured 

and a transportation gift card was provided for the 

un-/under-insured who underwent a colonoscopy, 

therefore reducing the additional barrier of cost to 

this population. However, we were not able to 

reduce the barrier of having to take time off of 

work to undergo a colonoscopy. 

IMPLICATIONS AND LIMITATIONS 

The current research has implications for public 

health policy and/or initiatives in rural, 

underserved regions. Both FIT test and 

colonoscopy proved to have many benefits, as 

well as disadvantages. While colonoscopies allow 

participants to undergo just one procedure and 

allow for removal of polyp at the time of the visit, 

they are costly and may not be able to be 

implemented on a larger scale for the un-/under-

insured. On the other hand, FIT tests are not cost 

prohibitive and are able to reach a larger 

population, especially among the un-/under- 

insured. It is important that if public health 

programs elect to disseminate a FIT test program 

that emphasis be placed on the importance of 

retesting the same individuals every year, to insure 

a higher efficacy of the test. This warrants a cost-

effectiveness or return-on-investment analysis to 



 
 
 
 
 

 

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assess the efficacy of a FIT test outreach program 

as compared to a colonoscopy outreach program 

in order to see true implications for public health 

policy and/or initiatives. 

The current study was not able to examine 

differences among those with an abnormal FIT test 

result due to low number of participants receiving 

a positive FIT test result. However, future research 

will analyze these differences as well as assess the 

duration of time to follow-up. The current study 

was also not able to assess whether the removal of 

adenomatous polyps resulted in decreased CRC 

detection. However, this is outside of the scope of 

the study as follow-up with this patient population 

will warrant years of future research. Finally, unlike 

the Gupta et al.(Gupta et al., 2013) study, the 

current study gave participants the option to 

choose between colonoscopy and FIT test, which 

could have resulted in biased results when 

comparing abnormal rates for FIT as compared to 

colonoscopy. However, adenoma detection rates 

were still high for both FIT and colonoscopy when 

compared to previously mentioned studies and 

warrant attention (Gupta et al., 2013; Quintero et 

al., 2012). 

Acknowledgements 

This study was funded by the Cancer Prevention & 

Research Institute of Texas (PP140018) and the 1115 

Medicaid Waiver. 

 

Conflict of interest 
The authors declare that no competing or conflict of 

interests exists. The funders had no role in study 

design, writing of the manuscript, or decision to 

publish. 

 

 

Authors’ contributions 
Carlton Allen and Paul McGaha contributed to the 

acquisition of data and the conduct of the project. 

Karan Singh, Harrison Ndetan, and Gabriela Orsak 

contributed to the statistical analysis of the project 

and generated the initial draft of the article.  

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