Colorectal cancer (CRC) is among the top five leading causes of cancer-related death in men and women in the United States (US).^1,2 Various CRC screening tests are available and multiple studies have shown them to be effective in reducing CRC-associated morbidity and mortality.^2–7 Despite the benefits of CRC screening, national screening rates are lower than the Healthy People 2030 target of 74.4%.^8,9 Disparities exist in CRC screening rates among people of color, those with lower socioeconomic status, and those who reside in rural and medically underserved areas, contributing to higher CRC-associated morbidity and death in those populations.^9–12 Meta-analyses evaluating interventions to enhance CRC screening in the US found that mailed reminders with home-based CRC screening kits, patient navigation, and general CRC education significantly increased screening rates.^13,14 While these interventions are effective, they can be resource-intensive and constrained by the setting in which they are delivered, limiting their reach and ability to close health inequity gaps. More strategies and novel settings are needed to increase equitable access and opportunities for CRC screening for underserved patients, particularly those living in rural or low-resource settings in the US.

CRC screening tests are typically administered and distributed in primary care clinics, but due to poor access to primary care in health professional shortage areas, equitable distribution of CRC screening could be hindered.¹⁵ Since more than 95% of the US population lives less than 10 miles from a community pharmacy and individuals in rural areas visit community pharmacies more often than primary care settings, community pharmacies could be ideal in promoting equitable access to CRC screening.^16,17 Over the past decades, pharmacies have increased the number of screening and preventive services they provide, such as influenza tests, rapid COVID tests, health and wellness counseling, and genetic testing.^18,19 Fecal immunochemical testing (FIT) is one of the recommended CRC screening modalities. FIT-based intervention programs have shown the use of FITs to be successful in increasing access to CRC screening for patients with low socioeconomic status and who reside in rural areas.^14,20,21 FITs have been successful at increasing access to CRC screening because they are inexpensive, easy to store, do not require a prescription to dispense, and can be completed at home and mailed directly to a community laboratory for processing, making them a viable service for community pharmacies to provide.^7,22

Recently, epidemiological evidence suggests that CRC rates have been rising among young adults, indicating an increased need in early CRC detection.^23–25 As formative research is exploring the possibility of expanding certain types of screening services in pharmacies, like FIT, it is important for pharmacists to understand how to provide these screening services or be a source of information if the patient has questions.^26–29

Although community pharmacies have the potential to substantially increase access to CRC screening through home-based tests like FIT, little is known about community pharmacists’ knowledge of CRC screening. Assessing knowledge is essential to understanding the educational and training needs of pharmacists who want to implement CRC screening services.

This study aimed to understand community pharmacists’ knowledge about CRC screening guidelines for FIT.

To our knowledge, this is the first national survey to evaluate community pharmacists’ understanding of CRC screening guidelines. Examining community pharmacists’ knowledge about CRC screening is important to evaluate their educational needs so they can be effective at implementing and providing CRC screening services for their eligible patients. Our study demonstrates that many community pharmacists have some knowledge of CRC screening guidelines (such as that FIT can be done at home). However, only a small proportion correctly answered questions about the age to start routine screening and the frequency of FIT screening, demonstrating a gap in knowledge about CRC screening guidelines. Community pharmacists who were board-certified or had more years of practice had more CRC screening knowledge, which could be attributed to the level of exposure afforded by additional training and time spent in clinical practice. Increasing educational outreach about screening and avenues for CRC screening training could be of great value to community pharmacists to keep abreast with current guidelines and be another source of patient education and counseling—independent of whether they supply FITs to their patients.

Past studies that have investigated pharmacy-based CRC screening services found them to be successful.^37–40 In one of the studies involving a partnership between the School of Pharmacy and the Colon Cancer Prevention Program at the University of Connecticut, community pharmacists were credentialed in CRC epidemiology, screening, and appropriate counseling methods before delivering FITs to eligible patients.³⁹ Similarly, the study by Santolaya and colleagues included training on providing FIT for community pharmacists before they delivered the intervention.⁴⁰ These studies highlight the importance of training for community pharmacists as a precondition for successfully implementing CRC screening in their pharmacies.^39,40 However, there was no indication these past studies assessed pharmacists’ CRC and CRC screening knowledge gaps. Our study results show that there are some CRC knowledge gaps among pharmacists nationally, underscoring that widespread adoption of CRC screening services will require some form of education and training for community pharmacy staff.

The Exploration, Preparation, Implementation, Sustainment (EPIS) framework^41,42 posits that for an evidence-based intervention to be successfully implemented, like FIT delivery in pharmacies, those involved with the program implementation need to be adequately trained to deliver the intervention. Our current study, which utilizes the EPIS framework, builds upon formative research our study team has conducted for the PharmFIT^™ program. The findings from our formative research involving interviews and a national survey showed that patients, community pharmacists, and primary care physicians (PCPs) support PharmFIT^™.^{27–29,34,43} However, these studies revealed that all three groups (patients, community pharmacists and physicians) expect community pharmacists to receive adequate training on CRC screening guidelines and modalities before implementing this cancer prevention program.^{27–29,34,43} Our formative research, along with this current study, further supports the need to develop comprehensive continuing education and training for community pharmacy staff, which can be offered through continuing pharmacy education (CPE) so they can confidently implement and deliver CRC screening services in their pharmacies.

For example, the American College of Gastroenterology (ACG) and the American Journal of Gastroenterology (AJG) offer continuing medical education (CME) to physicians to expand their CRC knowledge.^44,45 CPE tailored to community pharmacists could be delivered as professional development sessions at conferences or webinars through state and national associations, using educational content in sessions offered by ACG/AJG that are pharmacist-specific.³⁹ For example, in the Connecticut study, community pharmacists were given hands-on training and mock-practice sessions to develop CRC counseling skills, which would be crucial components to consider when developing a training that is both knowledge- and skill-based.³⁹ We found that community pharmacists have some knowledge about the guidelines, but there is still a need to address the knowledge gaps identified in this study. Additionally, knowledge alone might not be enough to build competency. So, future training should be structured to build skills (e.g. communication skills) that would lead to competency in delivering CRC screening services while also considering the pharmacy’s context and patient population.

This study has notable strengths, including the analysis of a large national sample of community pharmacists with a good representation of those who primarily practice in independent pharmacies (31%, 181/578), which disproportionately provide healthcare for medically underserved communities.^46–48 Additionally, our survey was developed by a multidisciplinary team of researchers, pharmacy, and medical practitioners who informed the development of survey items that assess CRC screening guideline knowledge.

Our study also had limitations. First, we did not obtain responses from community pharmacists from all 50 US states, which may skew our survey findings. However, our survey findings are likely still generalizable since our respondents represented all US regions. Second, we were unable to assess community pharmacists’ desire for training types and components, which could have provided a better understanding of educational needs to facilitate pharmacy-based CRC screening implementation. Our team is developing CPE with guidance from practicing pharmacists, and our future studies will expand upon our formative work to identify formats for effective training programs and methods for education dissemination. Our research team will continue this investigation through an implementation trial where we will test the effectiveness of PharmFIT^™.

Our study revealed that community pharmacists have some knowledge about CRC screening and that those with more years of practice or were board-certified had more CRC screening knowledge. Our other formative research showed that patients, community pharmacists, and PCPs support pharmacy-based CRC screening services with the caveat that community pharmacists are well-trained to deliver the service.^27,28,34,43 Hence, to ensure successful implementation and uptake of a pharmacy-based CRC screening program such as PharmFIT^™, community pharmacists need to receive continued education and training to stay updated with CRC screening guidelines.