REVIEW

Colorectal Cancer Screening Among Korean Americans:A Systematic Review

Kyeung Mi Oh • Kathryn H. Jacobsen

Published online: 28 August 2013

� Springer Science+Business Media New York 2013

Abstract The incidence of colorectal cancer (CRC)

among Korean Americans (KAs) has increased in recent

years, even as the rate in nearly ever other population

group in the United States has decreased. Reversing this

trend will require improving screening rates, but a variety

of sociocultural factors may inhibit this goal. We con-

ducted a systematic review of the published literature on

cancer screening among KAs, and identified thirteen eli-

gible studies that examined CRC screening. KAs have

CRC screening rates that are significantly lower than the

national average. Only about one in four KAs ages 50 and

older reports having ever had a fecal ocult blood test

(FOBT) and only about 40 % have ever had a sigmoidos-

copy or colonoscopy. KA adults are also significantly less

likely than the general US population to say they have

heard of FOBT, sigmoidoscopy, or colonoscopy. In the KA

population, screening rates are higher among adults with

higher socioeconomic status, greater acculturation to the

United States, more cancer knowledge, more social sup-

port, and better access to healthcare services. Improving

cultural and financial access to health education and

healthcare services may increase CRC screening among

KAs and reduce the incidence of the disease.

Keywords Korean Americans � Colorectal cancer �Screening

Introduction

The number of Asian Americans living in the United States

(US) has increased significantly over the past decade to

about 14.7 million [1]. Korean Americans (hereafter

‘‘KAs’’) are the fifth largest Asian American subgroup, and

about 1.4 million KAs now reside in the US, a more than

30 % increase in population over the past 10 years [1].

About 71 % of KAs were born in Korea; 25 % arrived in

the US in 2000 or more recently [2, 3]. More than 70 % of

KAs speak Korean at home. About 75 % of KAs prefer to

visit Korean-speaking doctors [4, 5]. A state-wide survey in

California found that about one in three KAs reports

problems understanding the health information provided in

doctors’ offices and clinics [6], and other studies have

found that even KAs who speak English at an intermediate

level may not feel comfortable communicating in English

with health professionals [1, 7]. These communication

barriers may make it difficult for KAs to access healthcare

services and may therefore put KAs at increased risk of

poor health outcomes.

Few health statistics specific to KAs are available, in

large part because national statistics in the US aggregate

data from more than 60 Asian nationalities into one cate-

gory [8]. However, KAs appear to have an unusually high

burden from cancer. While heart disease is the leading

cause of death for all of the aggregated population groups

in the US, including Asian Americans as a whole [9],

cancer is the leading cause of death for KAs [10, 11].

Colorectal cancer (CRC) is the second most commonly-

diagnosed form of cancer among both male and female

K. M. Oh (&)

School of Nursing, George Mason University, 4400 University

Drive MS 3C4, Fairfax, VA 22030, USA

e-mail: koh5@gmu.edu

K. H. Jacobsen

Department of Global and Community Health, George Mason

University, 4400 University Drive MS 5B7, Fairfax,

VA 22030, USA

e-mail: kjacobse@gmu.edu

123

J Community Health (2014) 39:193–200

DOI 10.1007/s10900-013-9758-x

KAs, after lung cancer for men and breast cancer for

women [12]. The CRC incidence rate among KAs is gen-

erally found to be intermediate between low rates in Korea

and higher rates in the US [13]. However, as KAs accul-

turate to the US, their cancer rates are shifting toward those

of the general US population [13]. Between 1992 and 2002,

colon cancer incidence rates increased by 43 % for KA

males and 24 % for KA females and rectal cancer inci-

dence increased by 27 % in KA males and 56 % in KA

females [13]. This increasing trend is the opposite of the

general US population, for which CRC rates have steadily

decreased over the past decade [14, 15]. Female KAs have

a lower colon cancer incidence rate than white non-His-

panics (33.1 vs. 42.8 per 100,000 in 2000–2002) and also

have a somewhat lower mortality rate (12.8 vs. 15.7 per

100,000), but male KAs and white non-Hispanic Ameri-

cans now have similar CRC incidence rates (approximately

57.8 and 59.1 per 100,000, respectively) and mortality rates

(19.1 and 21.3 per 100,000) [11].

CRC screening has been shown to decrease mortality

from CRC though early detection and removal of precan-

cerous or cancerous lesions [16–20]. The American Cancer

Society recommends having fecal ocult blood test (FOBT)

annually, sigmoidoscopy every 5 years, or colonoscopy

every 10 years [21]. More precisely, the U.S. Preventive

Services Task Force (USPSTF) recommends screening for

CRC beginning at age 50 (with earlier and more frequent

screening tests for those with greater risk factors or evi-

dence of polyps) using high-sensitivity FOBT annually,

sigmoidoscopy every 5 years combined with high-sensi-

tivity FOBT every 3 years, or colonoscopy every 10 years

[22]. The Healthy People 2020 national goals for CRC

screening set a targeted participation rate of 70.5 % among

those ages 50 and older [23]. However, despite the high

burden from cancer among KAs, cancer screening rates

among KAs are consistently reported to be lower than the

goals specified in Healthy People 2020 [23–30].

Relatively few previous studies have examined the

screening practices of KAs or the factors that influence

decisions about screening by this population, and no pre-

viously published paper has specifically synthesized this

information. Therefore, this paper uses a systematic review

method to examine the prevalence of CRC screening

awareness and practices among KAs and to identify the

factors influencing CRC screening that could be addressed

in future interventions for KA populations.

Methods

Nine databases were searched using the search string

‘‘cancer AND screening AND Korean American’’: Med-

line, the Cumulative Index to Nursing and Allied Health

Literature (CINAHL), the Educational Resources Infor-

mation Center (ERIC), the American Psychological Asso-

ciation’s PsycNet and PsycINFO, and four EBSCO

databases (Academic Search Complete, Communication

and Mass Media Complete, Health Source: Nursing/Aca-

demic Edition, and the Psychology and Behavioral Sci-

ences Collection). The search was conducted in May 2013,

and publication date and language restrictions were not

imposed. After removal of duplicate hits, these searches

yielded 73 potentially eligible studies.

All of these articles were screened using a pre-selected

list of inclusion and exclusion criteria. Nineteen articles did

not meet the inclusion criteria and were excluded: 15

studies that did not evaluate cancer screening, two studies

that included KAs only as part of aggregate measure for

Asian Americans, one not about KAs, and one review

article. The reference lists of articles cited in the 54

remaining articles about cancer screening among KAs were

reviewed, and an additional six eligible studies were

identified. Of these 60 studies, 14 included questions about

CRC. After excluding one study that interviewed only

physicians, thirteen studies are included in this analysis.

Results

Table 1 summarizes the characteristics of the thirteen

included studies. The thirteen publications represent ten

studies, since four of the papers analyzed data from various

waves of the California Health Interview Survey (CHIS).

Only one of the ten was an intervention study; the

remaining used interviews or self-report questionnaires to

gather data. All but one study included both men and

women, and nearly all focused exclusively on the age

groups that are recommended to receive CRC screening

tests. Two studies noted that they specifically studied

underserved populations [31, 32], but KA populations are

generally considered to be underserved minority popula-

tions in the US in terms of access to health so this may not

be an important distinction.

Table 2 presents self-reported CRC screening awareness

and practices related to four different tests: digital rectal

exam (DRE), FOBT, sigmoidoscopy, and colonoscopy.

Less than 15 % of KAs reported having had DRE [33], and

only about 28 % of men and 10 % of women who had not

had DRE reported having ever heard of the test [34].

The proportion of KA participants who reported having

ever had FOBT ranged from about 10 to 50 % for various

studies [33–39]. However, no more than 20 % of study

participants reported having had FOBT in the past year

[35–37, 39]. As a comparison, about 55 % of non-Hispanic

whites report having ever had FOBT and about 25 % report

having had a test within the past year [36, 40]. About 40 %

194 J Community Health (2014) 39:193–200

123

of KAs who had not had FOBT had heard about it [34, 39],

whereas about 60 % of older adults in a national sample

reported having heard of the test [41].

Most studies grouped sigmoidoscopy and colonoscopy

for analysis. About 40 % of KA participants in various

studies reported having ever had one of these procedures

[35–37, 39], and slightly lower proportion reported having

had the test within 5 years [35, 37, 39] or 10 years [36]. In

contrast, about 55 % of non-Hispanic whites report having

ever had one of these procedures [36, 40]. Only about 25 %

of KAs who had not had sigmoidoscopy or colonoscopy

reported having ever heard of one of these tests, which

suggests that nearly half of KA adults in the target age

range for screening do not know about these tests [39].

Nationally, about 80 % of older adults in the US have

heard of colonoscopy and about 30 % have heard of sig-

moidoscopy [41].

About 25–50 % of KA participants reported having ever

had FOBT, sigmoidoscopy, or colonoscopy [28, 35–37,

42]. About 10–40 % of those ages 50 and older reported

having had one of these tests within the past 5 or 10 years

[28, 31, 36, 37, 39]. The one study that specifically

examined compliance with current national screening

guidelines found that 52 % of KA participants had received

FOBT within 1 year or sigmoidoscopy within 5 years or

colonoscopy within 10 years [43]. In that same study, the

rates among Asian and among non-Hispanic white Amer-

icans were 58 and 66 %, respectively [43]. Nationally,

compliance with USPSTF CRC screening recommenda-

tions among adults aged 50–75 years is 47 % for Asian

Americans and 59 % for the general US population [44].

Table 3 summarizes the factors that positively influence

uptake of CRC screening services among KAs. Adults who

are older, married, higher income, and own a car are more

likely to have received CRC screening [31, 35, 38]. Ability

to take time off of work, being unemployed or retired, or

receiving government assistance also increase the likeli-

hood of having been screened for CRC [31, 37, 38].

Acculturation also plays a role: those who have lived in the

US longer, have spent a higher proportion of their lives in

the US, and are fluent in English all report higher screening

rates [31, 34, 35, 38, 39].

A knowledge of general cancer warning signs or of CRC

information is associated with higher screening rates, as is

Table 1 Summary of included studies (n = 13)

Reference Study design Location Data

collection

year(s)

Number

of KA

participants

Sexes Ages

Lee and Im [35] Both interviews and self-administered

questionnaires

New York city

metropolitan area

2009 281 M/F 50–88

Oh et al. [39] Both interviews and self-administered

questionnaires

Washington, DC,

metropolitan area

2006–2007 167 M/F 50?

Homayoon et al. [43] California Health Interview Survey

(CHIS): population-based random-digit-

dial telephone interview

California 2007 340 M/F 50?

Ryu et al. [14] California Health Interview Survey

(CHIS): population-based random-digit-

dial telephone interview

California 1999–2009 Unknown M/F 50?

Maxwell et al. [28] California Health Interview Survey

(CHIS): population-based random digit

dial telephone survey

California 2001–2005 675 M/F 50?

Wong et al. [36] California Health Interview Survey

(CHIS): population-based random-digit-

dial telephone interview

California 2001 254 M/F 50?

Ma et al. [32] Community-based participatory

intervention

Not listed 2007 167 M/F 50?

Jo et al. [31] Face-to-face interviews Los Angeles, CA 2003 151 M/F 40–70

Juon et al. [38] Face-to-face interviews Maryland 1999 205 M/F 60–89

Maxwell et al. [37] Face-to-face interviews Los Angeles, CA 1995–1996 229 F 50?

Kim et al. [34] Face-to-face interviews Chicago area, IL Unknown 263 M/F 40–69

Sarna et al. [33] Self-administered questionnaires Los Angeles, CA 1995–1996 140 M/F 40?

Ma et al. [42] Survey with face-to-face instruction Philadelphia, PA; New

Jersey; New York

city, NY

2005–2006 384 (ages 18?) M/F 50?

KA Korean Americans

J Community Health (2014) 39:193–200 195

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Table 2 Self-reported CRC screening awareness and practices among KAs

Test Timeframe Proportion

(%)

Ages Sex References

Digital rectal exam (DRE) Have heard of this test (among those

never tested)

28 40–69 M [34]

10 40–69 F [34]

Ever tested 14 40? F [33]

11 40? M [33]

Fecal occult blood test

(FOBT)

Have heard of this test (among those

never tested)

56 40–69 M [34]

31 40–69 F [34]

42 50? M/F [39]

Ever tested 49 50–88 M/F [35]

26 40? M/F [33]

23 50? M/F [36]

22 50? F [37]

18 60–89 M/F [38]

17 50? M/F [39]

11 40–69 M [34]

9 40–69 F [34]

Tested in the past 1 year 20 50–88 M/F [35]

14 50? F [37]

12 50? M/F [36]

4 50? M/F [39]

Tested in the past 2 years 31 50–88 M/F [35]

17 50? F [37]

Sigmoidoscopy Ever tested 15 40? M/F [33]

11 60–89 M/F [38]

Sigmoidoscopy or

colonoscopy

Have heard of this test (among those

never tested)

24 50? M/F [39]

Ever tested 35 50–88 M/F [35]

46 50? M/F [39]

41 50? F [37]

38 50? M/F [36]

Tested in the past 5 years 34 50–88 M/F [35]

42 50? M/F [39]

37 50? F [37]

Tested in the past 10 years 34 50? M/F [36]

FOBT or sigmoidoscopy

or colonoscopy

Ever tested 50 50–88 M/F [35]

34 50? M/F [28]

49 50? M/F [36]

41 50? F [37]

26 50? M/F [42]

FOBT or sigmoidoscopy/colonoscopy

within the past 1 year

12 50? M/F [32]

FOBT within the past 1 year or sigmoidoscopy/

colonoscopy within the past 5 years

44 50? M/F [39]

38 50? F [37]

17 40–70 M/F [31]

22 50–70 M/F [31]

6 40–49 M/F [31]

FOBT within the past 1 year or sigmoidoscopy/

colonoscopy within the past 10 years

41 50? M/F [36]

18 50? M/F [28]

11 50? M/F [28]

FOBT within the past 1 year or sigmoidoscopy

within the past 5 years, or colonoscopy

within the past 10 years

52 50? M/F [43]

196 J Community Health (2014) 39:193–200

123

specific knowledge about CRC screening tests, where to go

for testing, and the age at which testing should begin [28,

31, 34, 39]. Those who perceive CRC to be a serious dis-

ease, are confident that the screening test is effective,

consider the test to be affordable, and do not report fearing

pain or embarrassment related to the test are more likely to

have received CRC screening [28, 31, 35]. A variety of

perceptions about social support are also influential,

including being encouraged to seek screening by a family

member, friend, or physician; discussing CRC screening

with a family member or friend who has been tested for

CRC; feeling that the family would be supportive if the test

Table 3 Factors positively affecting colon cancer screening among KAs

Category Predictive factor References

Demographic/

socioeconomic

Older age [31, 35]

Being married [38]

Higher income [31, 35]

Being unemployed, retired, or on government assistance [31, 37, 38]

Having a personal car for transportation [31]

Ability to take time off of work* [31]

Acculturation Longer duration living in the US [31, 34, 35, 38,

39]

Higher proportion of life spent in the US [38, 39]

Better English fluency [31, 38]

Knowledge Having a general knowledge of CRC, risk factors, screening, and treatment [31]

Having knowledge of cancer warning signals [34]

Knowing where to go for testing* [31]

Aware of screening test [28, 39]

Knows the age at which testing should begin [39]

Attitudes/perceptions Believing CRC to be severe [35]

Having confidence in the screening test [35]

Considering the test to be affordable* [31]

Not having fear of pain or embarrassment* [28]

Not reporting a sense of helplessness [35]

Not reporting a sense of fatalism [35]

Social support Encouraged to seek screening by a family member or friend* [31]

Physician recommendation to have CRC screening [31]

Hearing positive information about screening from a friend or family member who has had

CRC screening*

[31]

Not having a fear of being burden to the family if diagnosed with cancer* [31]

Believing that the usual healthcare provider is trustworthy* [31]

Health care access/health

history

Having health insurance [14, 31, 35, 38,

39]

Having a usual healthcare provider [31]

Having regular check-ups [17, 18, 22]

Using a Western doctor rather than home care, traditional medicine, or a Western pharmacy [34]

Having a greater number of visits to a healthcare professional in the past 12 months [39]

Having an existing health problem* [28]

Having multiple chronic conditions [38]

Having poor health status# [38]

Having a personal history of cancer [35]

Having symptoms of CRC (e.g. bloody stool) [31, 38]

All factors were significantly associated with increased colon cancer screening rates via bivariate or multivariate analysis at p \ 0.05, except for

those marked with *, which were identified from descriptive or qualitative results# Health status was identified as a barrier for CRC screening practice using FOBT, but it was also identified as a facilitator for CRC screening

practices using sigmoidoscopy

J Community Health (2014) 39:193–200 197

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detected cancer; and believing that the usual healthcare

provider is trustworthy [31].

Having routine access to health services—having health

insurance, a usual healthcare provider, access to a Western

healthcare provider, more frequent visits to health care

providers, and regular check-ups—increases the likelihood

of having been screened for CRC [14, 31, 34, 35, 37–39]. A

history of poor health status—having one or more existing

chronic health problem, a personal history of cancer, or

symptoms of CRC—increases the likelihood of having

been screened for CRC, while having no current health

problems or complaints is associated with lower screening

rates [28, 31, 35, 38].

Only one intervention study among KAs was available

for review. Ma et al. [32] developed a culturally-tailored,

church-based program based on community input and rec-

ommendations that provided CRC education in Korean and

also provided assistance with navigating the healthcare

system through screening reminders and assistance with

scheduling clinical appointments, completing registration

paperwork, transportation to the clinical site, and translation

and communication of results. The control group received

general Korean-language health education information.

Members of the active intervention group reported higher

perceived susceptibility to CRC, more benefits of screening,

and fewer barriers to screening after the intervention than

they had on pre-tests [32]. 1 year after the intervention,

77 % of the intervention group and only 11 % of the con-

trols had completed some form of CRC screening.

Discussion

Previous studies have found that Asian Americans have

lower CRC screening rates than non-Hispanic white

Americans [43, 44]. The review suggests that KAs have

even lower rates of CRC screening knowledge and uptake

than Asian Americans as a whole. The rate of FOBT among

KAs was especially low compared to the general US pop-

ulation, but the endoscopy rate was also below average.

Lack of acculturation to the US seems to be a critical

barrier to receiving preventive health services. Among all

immigrants, those who have been in the US for 10 years or

more are significantly more likely than more recently

arrived persons to have received CRC screening (38.7 vs.

22.5 %) [45]. More specifically, preventive medicine is an

unfamiliar concept to many Korean American immigrants.

While many KAs, especially those who are elderly, take

steps to maintain their health and prevent illness, few

consider screening for disease in the absence of symptoms

to be important or valuable [46]. As a result, KAs who feel

healthy—those who report being free of pain and having no

obvious signs of disease—are less likely than others to seek

out preventive healthcare services such as screening.

Additionally, many KAs visit traditional medical practi-

tioners for most health concerns rather than relying on

Western medical care [47], so they may not be advised to

seek screening tests or know how to access them.

Increasing uptake of CRC screening by KAs will require

targeted health education about CRC and the importance of

early cancer detection.

Besides experiencing problems related to cultural access

to healthcare, costs may be a concern for many KAs.

Previous studies in a variety of ethnic and cultural groups

have found that having health insurance is a major pre-

dictor of receiving recommended screening tests [45, 48,

49]. KAs have one of the lowest rates of medical insurance

of any population group in the US [50]. In 2010, 46 % of

adult KAs aged 18–64 years had no health insurance,

compared to the US uninsured rate of 22.3 % [51]. The

lack of health insurance among those ages 50–64 who are

recommended for screening but may not yet be eligible for

Medicare has been tied to being recent immigrants and

working in small retail businesses that do not provide

company-sponsored insurance plans [28, 31, 39, 52–55].

The Affordable Care Act, if implemented in its current

form, may increase access to preventive services for this

currently underserved population.

This comprehensive systematic review of the literature

on CRC screening among Korean American men and

women highlights the low screening rates in this population

and points to the need for culturally sensitive interventions

to improve adherence to recommendations for CRC

screening and prevention. The modifiable protective factors

listed in Table 3 point to a variety of mechanisms for

improving screening rates among KAs: providing cultur-

ally-tailored cancer education to KA adults, including spe-

cific information about CRC and about how to access CRC

screening; using social networks, such as churches and

cultural organizations, to encourage cancer screening and

other types of preventive healthcare; and improving access

to and trust between KA patients, traditional medical prac-

titioners, and Western clinicians in addition to reducing cost

barriers through improved health insurance coverage.

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