In this study of Black/African-American patients served at FQHCs who were at average risk for CRC, stool-based DNA is generally acceptable. Some had exposure to this form of testing from commercials and direct-to-consumer advertisements, but were not aware of the accuracy, less frequent screening compared to FIT, and convenience. Many highlighted the high accuracy, convenience, privacy, and simple instructions of stool-based DNA as positive reasons for this screening modality. Questions regarding the use of DNA were levied to focus groups, but examination of one’s DNA was not a pervasive concern. A concern for this method was if the test was positive, a colonoscopy would be needed. Based on the positive subjective perceptions and benefits outweighing the drawbacks in this method of screening, it was deemed that stool-based DNA is acceptable to this population.

The overall preferred screening method was colonoscopy (60.3%), followed by stool-based DNA (33.8%) and FIT (5.9%). It is important to highlight that these preferences were ascertained later in the focus group after education had been provided. These findings are novel compared to most other studies in the literature, as most studies have evaluated preferences prior to stool-based DNA testing being approved by the FDA in 2014 [18,19,20,21,22]. For example, Schroy et al. in 2006 showed colonoscopy and stool-based DNA tests were preferred over FOBT, but their cohort was not stratified for a Black population [18]. Hawley et al. in 2008 did not include stool-based DNA as an option, but found in their sub-cohort, who are Black, flexible sigmoidoscopy and colonoscopy were favored compared to FIT and FOBT [19]. Shokar et al. investigated subjective feelings and preferences (not including stool-based DNA) with a Black population and found FOBT was preferred over colonoscopy [20]. However, after receiving education, preferences switched to colonoscopy over FOBT [20]. Palmer et al. performed a similarly structured study to ours, finding colonoscopy was the preferred screening method over FOBT, flexible sigmoidoscopy, and barium enema [21]. Lastly, Chablani et al. analyzed a cohort of Black and Latino participants, using focus groups that assessed preference between four screening methods, finding colonoscopy was preferred followed by stool-based DNA then others [22]. This study did not analyze the Black population separately for preference [22].

Our study highlights not only colonoscopy was preferred over stool-based DNA and FIT, but also demonstrates preferences based on age and gender for the first time in a Black population. In Fig. 1, older demographics preferred colonoscopy compared to younger participants (68% vs. 52%, respectively). An even larger difference between younger and older populations was observed in stool-based DNA (48% vs. 22%, respectively). When looking at the large difference, many felt positively about colonoscopy and stool-based DNA testing’s high accuracy. The sensitivity and specificity of these methods for detecting CRC have been well demonstrated [15]. The sensitivity and specificity of these tests are respectively: 0.89–0.95 and 0.89–0.94 for colonoscopy, 0.93 and 0.85 for stool-based DNA, plus 0.74 and 0.94 for FIT [7]. Many participants desired the modality that would rule out CRC, which deterred from FIT.

However, the younger population did feel invasiveness of a test was important compared to the older demographic (12% vs. 0%, respectively). Younger cohorts (3%) did not find “physician-performed” as important compared to older groups (13%). Preferring noninvasive testing without a physician performing the exam could be factors why the younger cohort favored stool-based DNA over colonoscopy. Interestingly, the factor of one-stop shop or “cutting out the middleman” was highlighted most frequently by the younger cohort (33%) compared to the older population (16%). This factor referred to colonoscopy, where one could have testing, removal, and diagnostics in one procedure without needing additional screening if positive on FIT/stool-based DNA.

As noted above, the most cited factor was convenience. Convenience was never mentioned in reference to colonoscopy, only FIT and stool-based DNA. As the younger populations are more likely employed, the convenience of testing at home is appealing. Compared to colonoscopy, where one misses work, arranges for transportation, and drinks preparation material the day before, stool-based DNA testing or FIT may be more feasible. This was the highest impact factor for all groups besides younger men (20%). Younger women, older men, and older women all had higher rates at 44%, 35%, and 43%, respectively.

The FIT was the least preferred test, with only 11% of the older age group choosing it. Factors impacting choice for the FIT test positively included convenience, only mentioned by the older demographic. Many other participants felt that this method was “messy” because one scoops their own stool comparatively to stool-based DNA, which is collected via a hat. The decreased accuracy also deterred participants.

Between genders, there were no consistent differences that were observed across age ranges. The only isolated difference seen was seen between younger men (20%) and younger women (44%) stating convenience as an important factor.

Throughout focus groups discussions, one recurrent subtheme was low awareness. There was minimal knowledge of one’s risk for CRC, such as the concept of average versus high risk. An example included one young woman who stated “I knew my mom went to get a colonoscopy… I really didn’t know, didn’t understand, and I got a lot of information. I really appreciate this [focus group].” Another participant in the older women group remarked about preventative screenings, saying she had no “understanding of that’s [screening] was what we deserved.”

An important additional discussion point with this population is cost though it was not a pervasive concern among participants. All three modalities are covered by insurance. Furthermore, the Affordable Care Act requires Marketplace insurance plans and most private insurance to cover CRC screening for average-risk patients of age without cost sharing/co-payment. This was discussed during groups with the facilitator when educating about the various options ($30 for FIT, $600 for stool-based DNA, and minimum $1600 for colonoscopy out of pocket). For an uninsured patient, the FIT test would be the most affordable option. Both FQHC’s in this study had an uninsured population of < 17%.

Many participants asked detailed questions about testing methods, as many had never been screened. For example, many did not know that positive FIT/stool-based DNA tests would necessitate diagnostic colonoscopies. None of the participants had experience with stool-based DNA screening. Several were appreciative of the focus groups because they “used to think all of them [CRC screenings] gave the same information.”

Given the need for education as well as the number of CRC screening tests available, we believe it is critical for shared decision making to be a priority to increase CRC screening. The American Cancer Society and Center for Disease Control and Prevention created a “80% by 2018” goal for 80% of recommended adults to be screened, but as of 2023, 67% were screened [5, 23]. On our observational findings, participants had lower awareness and chose their preference based on education, which has been demonstrated in prior studies [20]. During focus groups, participants placed emphasis on experiences by members of their community, good or bad. If we can increase education with a trusted member of the community, such as a community health worker, we may be able to increase screening for this vulnerable population through team-based care. Use of community-based navigation to increase screening has been shown before, and our study supports this claim [24, 25]. Overall, this study highlighted that while colonoscopy was preferred in this population of Black American patients, stool-based DNA testing was acceptable, and team-based care is a valuable resource to increase CRC screening through education.