It's the cancer with the yuck factor, that part of the anatomy lots of people would rather ignore.
And too many are ignoring it possibly to death: Nearly 42 million Americans over 50 aren't getting checks for colorectal cancer, the nation's No. 2 cancer killer.
Now in five states, a government-funded project is beginning to offer free testing for the poor, part of a new push to better fight one of the few cancers that can be prevented, not just treated, if screening uncovers the earliest signs of trouble.
Money isn't the only barrier. This is a cancer that can silently lurk in anyone, particularly during middle age and beyond. Black Americans are especially at risk.
Yet colorectal cancer doesn't get the attention of breast and prostate cancers that claim fewer lives.
"It's a part of the body they don't want anybody to mess with," says Bruce Jenkins of the Missouri health department's "Screening for Life" program, which this month began the free screening for low-income residents of St. Louis. "No matter how silly it sounds, it's just reality that people think that way."
Many at risk don't know there are screening tests, and those who do "I think have the idea that it's worse than it really is," adds Dr. Daniel Blumenthal of Atlanta's Morehouse School of Medicine, who is researching how to improve screening rates among black men and women.
"Even I was surprised when I had my colonoscopy. I had imagined something pretty awful and it really wasn't at all" — a message Blumenthal calls vital to spread.
Some 148,600 Americans will be diagnosed with colorectal cancer this year, and more than 55,000 will die.
Up to 60 percent of those deaths could be prevented if everyone over age 50 underwent routine screening, the Centers for Disease Control and Prevention says. Yet just over half get tested.
Screening offers more than a chance at early treatment. The disease usually starts with growths called polyps that can take a decade to turn cancerous. Find and remove them in time, and you can avoid cancer altogether.
Medicare pays for colorectal screening, but that federal insurance program is for people 65 and older, a long wait for the low-income 50-year-old with no insurance.
Enter the CDC's new free-screening project, the first major federal effort to target that population — and one that, if it works, might one day be expanded nationwide.
Participants in Suffolk County, N.Y., and Baltimore will receive colonoscopies, where doctors use a long, flexible tube to visually inspect the colon. In three other sites — St. Louis, Seattle/King County, Wash., and statewide in Nebraska — most participants will receive at-home fecal tests to detect hidden blood in the stool.
Colonoscopies are more expensive, $700 to $1,000, and require a day at the doctor's office and more intense preparation, but they're needed only once every 10 years. The fecal occult blood test is needed annually but is simpler to perform and much cheaper, $10 to $20.
Reaching those at risk
Recent public education campaigns have largely focused on colonoscopies, such as when host Katie Couric underwent one on NBC's "Today" show. But for the average person, the fecal test is just as effective, so consumers need to understand they have a choice, says Nebraska program director Melissa Leypoldt.
Beyond price is how to reach those most at risk to tell them to get screened. It's not clear how well doctors urge colorectal screening, and those who need the message may not see a doctor regularly anyway.
"We have to make an impact somewhere outside of the doctor office," stresses Morehouse's Blumenthal, who is enlisting black ministers in his own CDC-funded research on ways to counter colorectal cancer's racial disparity.
A doctor's advice may be easier to shrug off than hearing how someone you respect professionally or socially fought this disease, adds William Murrain, a Morehouse colleague and health-care consultant from Conyers, Ga., who survived colorectal cancer in 2002 — and has since recruited dozens of members of his Rotary and scuba-diving clubs to get tested.
Murrain, now 61, had gotten an exam called a sigmoidoscopy two years earlier, but it only inspects the bottom portion of the colon for cancer, and thus missed his tumor.
"You don't tend to think it would affect you ... until somebody brings it home to you, says, 'I'm a cancer survivor.'"