Colorectal Cancer in African Americans: An Update

Demographic and psychosocial factors associated with limited health literacy in a community-based sample of older Black Americans

OBJECTIVES

Individuals with limited health literacy often experience suboptimal health outcomes. This study examined the frequency of limited health literacy and demographic and psychosocial factors associated with limited health literacy in a sample of older Black Americans.

METHODS

Participants (n = 330) enrolled in a community-based intervention to promote colorectal cancer (CRC) screening completed baseline surveys assessing health literacy with the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) test, CRC awareness, cancer fatalism, Preventive Health Model (PHM) constructs, and demographics.

RESULTS

Approximately 52% of participants had limited health literacy, the REALM-R score was 5.4 (SD = 2.7). Univariable correlates of limited health literacy were gender, employment, income, prior screening, cancer fatalism, CRC awareness, and PHM constructs (religious beliefs, salience/coherence, perceived susceptibility). Multivariable correlates of limited health literacy were male gender (OR = 2.3, CI = 1.4-3.8), unable to work (OR = 2.8, CI = 1.3-6.1), lower household income (OR = 3.0, CI = 1.6, 5.5), and higher PHM religious beliefs (OR = 1.1, CI = 1.0-1.2).

CONCLUSION

Limited health literacy was associated with multiple complex factors. Interventions should incorporate patient health literacy and low-literacy materials that can be delivered through multiple channels.

PRACTICE IMPLICATIONS

Future studies are needed to understand the role of health literacy in an individual's health behavior and the provision of effective healthcare.

A Single-Center Retrospective Chart Review to Determine Whether the Presence of Comorbidities Affects Colon Cancer Screenings in African Americans

Colon cancer is the third leading cause of cancer-related death in African Americans. Although the rates of colon screenings have risen, African Americans remain to be underscreened, and are more likely to present with advanced lesions. This population has a higher prevalence of inflammatory comorbidities, and their effects on screenings have not been fully explored. Along with higher rates of comorbidities, the Southeastern United States is one region for the highest rates of colorectal cancer. The purpose of this study was to determine whether people with comorbidities were more likely to have a screening colonoscopy. Convenience sampling was used to procure 408 patients. The median age was 55 years, and the majority were females (52.2%), who were obese (29.2%), and nonsmokers (52.2%). The most common comorbidity was hypertension (70.3%), followed by osteoarthritis (39%), and diabetes (25.5%). There is a well-documented trend between certain inflammatory comorbidities and higher death rates in patients with colorectal cancer. Clarifying the relationship between comorbidities and cancer starts with screening as many patients as possible. Therefore, interventions that support increasing the number of colorectal cancer screenings are imperative in order to improve morbidity and mortality in this despaired population.

Estimating the impact of insurance expansion on colorectal cancer and related costs in North Carolina: A population-level simulation analysis

Although screening is effective in reducing incidence, mortality, and costs of treating colorectal cancer (CRC), it remains underutilized, in part due to limited insurance access. We used microsimulation to estimate the health and financial effects of insurance expansion and reduction scenarios in North Carolina (NC). We simulated the full lifetime of a simulated population of 3,298,265 residents age-eligible for CRC screening (ages 50-75) during a 5-year period starting January 1, 2018, including polyp incidence and progression and CRC screening, diagnosis, treatment, and mortality. Insurance scenarios included: status quo, which in NC includes access to the Health Insurance Exchange (HIE) under the Affordable Care Act (ACA); no ACA; NC Medicaid expansion, and Medicare-for-all. The insurance expansion scenarios would increase percent up-to-date with screening by 0.3 and 7.1 percentage points for Medicaid expansion and Medicare-for-all, respectively, while insurance reduction would reduce percent up-to-date by 1.1 percentage points, compared to the status quo (51.7% up-to-date), at the end of the 5-year period. Throughout these individuals' lifetimes, this change in CRC screening/testing results in an estimated 498 CRC cases averted with Medicaid expansion and 6031 averted with Medicare-for-all, and an additional 1782 cases if health insurance gains associated with ACA are lost. Estimated cost savings - balancing increased CRC screening/testing costs against decreased cancer treatment costs - are approximately $30 M and $970 M for Medicaid expansion and Medicare-for-all scenarios, respectively, compared to status quo. Insurance expansion is likely to improve CRC screening both overall and in underserved populations while saving money, with the largest savings realized by Medicare.

Individual and Geospatial Characteristics Associated With Use and Nonuse of the Fecal Immunochemical Test (FIT) for Colorectal Cancer Screening in an Urban Minority Population

PURPOSE

Initiatives by the Centers for Disease Control and Prevention as well as the National Colorectal Cancer Roundtable aim to increase the rate of colorectal cancer (CRC) screening. We assess individual and geographic characteristics associated fecal immunochemical test (FIT) CRC screening over 3 years.

METHODS

This is a retrospective study of 1500 FIT kits which were mailed or opportunistically handed to eligible participants in Brooklyn, New York from January 2014 to December 2016. Eligibility criteria included increased risk for colon cancer, uninsured or underinsured, and a minimum age of 50 years to warrant CRC screening. We looked at the association of individual demographic characteristics and FIT screening by logistic regression using SPPS version 23 software. In addition, using ArcGIS, we coded patients address and layered census tract population information to find associations.

RESULTS

In total, 1367 Cancer Services Participants met our study criteria. The study sample was predominantly female (95.2%) and minority (46% African American, 24.7% Hispanic, 17.3% Caucasian, 11.4% Asian) and on average 59 years old (SD, 5.7). A large majority (73%) had household incomes below $20,000/year. Approximately half (49.9%) of all Cancer Services Participants returned their FIT kit. In participants who did not return their FIT kit, the majority were African American (41%), followed by Hispanics (26.5%), Caucasians (20.6%), and Asians (11.8%). Multivariable logistic regression showed that a screening history of prior colonoscopy or FIT, gender, ethnicity, and educational attainment were significantly associated with FIT CRC screening uptake (P<0.05). Geospatial mapping showed clusters of low screening uptake in areas of high poverty. Hot-spot analysis identified areas of significant vulnerability.

CONCLUSIONS

FIT uptake remains suboptimal. Individual predictors as well as area poverty is associated with low screening uptake. Geospatial mapping is an effective tool for evaluating CRC screening uptake.

Morbidity and Mortality After Surgery for Nonmalignant Colorectal Polyps: A 10-Year Nationwide Analysis

OBJECTIVES

Rates of surgery for nonmalignant colorectal polyps are increasing in the United States despite evidence that most polyps can be managed endoscopically. We aimed to determine nationally representative estimates and to identify predictors of in-hospital mortality and morbidity after surgery for nonmalignant colorectal polyps.

METHODS

Data were analyzed from the National Inpatient Sample for 2005-2014. All discharges for adult patients undergoing surgery for nonmalignant colorectal polyps were identified. Rates of in-hospital mortality and postoperative wound, infectious, urinary, pulmonary, gastrointestinal, or cardiovascular adverse events were calculated. Multivariable logistic regression using survey-weighted data was used to evaluate covariables associated with postoperative mortality and morbidity.

RESULTS

An estimated 262,843 surgeries for nonmalignant colorectal polyps were analyzed. In-hospital mortality was 0.8% [95% confidence interval: 0.7%-0.9%] and morbidity was 25.3% [95% confidence interval: 24.2%-26.4%]. Postoperative mortality was associated with open surgical technique (vs laparoscopic), older age, black race (vs non-Hispanic white), Medicaid use, and burden of comorbidities. Female sex and private insurance were associated with lower risk. Patients developing a postoperative adverse event had a 106% increase in mean hospital length of stay (10.3 vs 5.0 days; P < 0.0001) and 91% increase in mean hospitalization cost ($77,015.24 vs $40,258.30; P < 0.0001).

DISCUSSION

Surgery for nonmalignant colorectal polyps is associated with almost 1% mortality and common morbidity. These findings should inform risk vs benefit discussions for clinicians and patients, and although confounding by patient selection cannot be excluded, the risks associated with surgery support consideration of endoscopic resection as a potentially less invasive therapeutic option.

Investigation on the hereditary basis of colorectal cancers in an African population with frequent early onset cases

Background

Approximately 25% of colorectal cancer patients in sub-Saharan Africa are younger than 40 years, and hereditary factors may contribute. We investigated the frequency and patterns of inherited colorectal cancer among black Zimbabweans.

Methods

A population-based cross-sectional study of ninety individuals with a new diagnosis of colorectal cancer was carried out in Harare, Zimbabwe between November 2012 and December 2015. Phenotypic data was obtained using interviewer administered questionnaires, and reviewing clinical and pathology data. Cases were screened for mismatch repair deficiency by immunohistochemistry and/or microsatellite instability testing, and for MLH1, MSH2 and EPCAM deletions using multiplex ligation-dependent probe amplification. Next generation sequencing using a 16-gene panel was performed for cases with phenotypic features consistent with familial colorectal cancer. Variants were assessed for pathogenicity using the mean allele frequency, phenotypic features and searching online databases.

Results

Three Lynch syndrome cases were identified: MSH2 c.2634G>A pathogenic mutation, c.(1896+1_1897–1)_(*193_?)del , and one fulfilling the Amsterdam criteria, with MLH1 and PMS2 deficiency, but no identifiable pathogenic mutation. Two other cases had a strong family history of cancers, but the exact syndrome was not identified. The prevalence of Lynch syndrome was 3·3% (95% CI 0·7–9·4), and that of familial colorectal cancer was 5·6% (95% CI, 1·8–12·5).

Conclusions

Identifying cases of inherited colorectal cancer in sub-Saharan Africa is feasible, and our findings can inform screening guidelines appropriate to this setting.

Anatomic Distribution of Colorectal Adenocarcinoma in Young Patients

BACKGROUND

The incidence of colorectal cancer has increased in the younger population. Studies show an increased prevalence of left-sided tumors in younger patients; however, exact anatomic distribution is not known.

OBJECTIVE

We sought to determine the anatomic distribution of colorectal cancer in young patients and to calculate the proportion of tumors that would be within reach of a flexible sigmoidoscopy.

DESIGN

The National Cancer Database (2004-2015) was used to identify patients with colorectal cancer.

SETTINGS

This was a multicenter study using national data.

PATIENTS

The study included 117,686 patients under the age of 50 years diagnosed with colorectal cancer and 1,331,048 patients over the age of 50 years diagnosed with colorectal cancer.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of left-sided tumors in patients under the age of 50 years.

RESULTS

A total of 74.4% of patients under age 50 years and 56.1% of patients over age 50 years had left-sided colorectal cancer.

LIMITATIONS

The study is a retrospective review and does not exclude young patients who developed colorectal cancer with familial syndromes with a colorectal cancer disposition.

CONCLUSIONS

A total of 74.4% of colorectal cancers diagnosed before age 50 years are left sided. In light of recent changes to screening recommendations, distribution of disease in young patients is important to both provider and patient education and decision-making. See Video Abstract at http://links.lww.com/DCR/A966.

Interactivity in a Decision Aid: Findings From a Decision Aid to Technologically Enhance Shared Decision Making RCT

INTRODUCTION

Colorectal cancer screening (CRCS) remains underutilized. Decision aids (DAs) can increase patient knowledge, intent, and CRCS rates compared with "usual care," but whether interactivity further increases CRCS rate remains unknown.

STUDY DESIGN

A two-armed RCT compared the effect of a web-based DA that interactively assessed patient CRC risk and clarified patient preference for specific CRCS test to a web-based DA with the same content but without the interactive tools.

SETTING/PARTICIPANTS

The study sites were 12 community- and three university-based primary care practices (56 physicians) in southeastern Michigan. Participants were men and women aged 50-75 years not current on CRCS.

INTERVENTION

Random allocation to interactive DA (interactive arm) or non-interactive DA (non-interactive arm).

MAIN OUTCOME MEASURES

Primary outcome was medical record documentation of CRCS 6 months after the intervention. Secondary outcome was patient decision quality (i.e., knowledge, preference clarification, and intent) measured immediately before and after DA use, and immediately after the office visit. To determine that either DA had a positive effect on CRCS adherence, usual care CRCS rates were determined from the three university-based practices among patients eligible for but not participating in the study.

RESULTS

Data were collected between 2012 and 2014; analysis began in 2015. At 6 months, CRCS rate was 36.1% (95% CI=30.5%, 42.2%) in the interactive arm (n=284) and 40.5% (95% CI=34.7%, 46.6%) in the non-interactive arm (n=286, p=0.29). Usual care CRCS rate (n=440) was 18.6% (95% CI=15.2%, 22.7%), significantly lower than both arms (p<0.001). Knowledge, attitude, self-efficacy, test preference, and intent increased significantly within each arm versus baseline, but the rate was not significantly different between the two arms.

CONCLUSIONS

The interactive DA did not improve the outcome compared to the non-interactive DA. This suggests that the resources needed to create and maintain the interactive components are not justifiable.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01514786.

Colorectal cancer screening from 45 years of age: Thesis, antithesis and synthesis

Colorectal cancer incidence and mortality in patients younger than 50 years are increasing, but screening before the age of 50 is not offered in Europe. Advanced-stage diagnosis and mortality from colorectal cancer before 50 years of age are increasing. This is not a detection-bias effect; it is a real issue affecting the entire population. Three independent computational models indicate that screening from 45 years of age would yield a better balance of benefits and risks than the current start at 50 years of age. Experimental data support these predictions in a sex- and race-independent manner. Earlier screening is seemingly affordable, with minimal impediments to providing younger adults with colonoscopy. Indeed, the American Cancer Society has already started to recommend screening from 45 years of age in the United States. Implementing early screening is a societal and public health problem. The three independent computational models that suggested earlier screening were criticized for assuming perfect compliance. Guidelines and recommendations should be derived from well-collected and reproducible data, and not from mathematical predictions. In the era of personalized medicine, screening decisions might not be based solely on age, and sophisticated prediction software may better guide screening. Moreover, early screening might divert resources away from older individuals with greater biological risks. Finally, it is still unknown whether early colorectal cancer is part of a continuum of disease or a biologically distinct disease and, as such, it might not benefit from screening at all. The increase in early-onset colorectal cancer incidence and mortality demonstrates an obligation to take actions. Earlier screening would save lives, and starting at the age of 45 years may be a robust screening option.

Rise Up, Get Tested, and Live: an Arts-Based Colorectal Cancer Educational Program in a Faith-Based Setting

Engaging community members in efforts to reduce cancer-related health disparities through community mini-grant programs has been shown to have meaningful impact. A predominantly African-American church in South Carolina was awarded a community mini-grant to increase awareness about colorectal cancer (CRC) screening among disproportionally high-risk African-American communities through culturally appropriate arts-based cancer education. The church's pastor, health and wellness ministry, and drama ministry created a theatrical production called Rise Up, Get Tested, and Live. Over 100 attendees viewed the play. A pre/post-test evaluation design assessed the effectiveness of the production in increasing participants' knowledge about CRC and examined their intentions to be screened. Results showed increased knowledge about CRC, increased awareness and understanding about the importance of CRC screening, and favorable intentions about CRC screening. Findings suggest that arts-based cancer education may be an effective tool for the dissemination of information about CRC screening.

Influence of race and geographic setting on the management of gastric adenocarcinoma

BACKGROUND AND OBJECTIVES

Conflicting evidence indicates that both race and geographic setting may influence the management of malignancies such as gastric adenocarcinoma (GAC).

METHODS

We designed a retrospective cohort study utilizing data from the Surveillance, Epidemiology, and End Results program to identify patients with resectable GAC (N = 15 991). Exposures of interest were race and geographic region of diagnosis (West [WE], Midwest [MW], South [SO], or Northeast [NE]). Endpoints included: (1) recommendation against surgery and (2) gastric adenocarcinoma-specific survival (GACSS). Multivariable logistic and Cox regression models were used to identify pertinent associations.

RESULTS

A total of 15 991 patients were included (2007-2015). In adjusted analysis, African American individuals more frequently received a recommendation against surgical resection than White (adjusted odds ratio [aOR] = 0.86; 95% confidence interval [CI], 0.76-0.98), Asian American (aOR = 0.55; 95% CI, 0.46-0.65), and American Indian (aOR = 0.50; 95% CI, 0.31-0.82) individuals. In addition to race-based discrepancies, there was a significant association between geography and management: individuals diagnosed with GAC in the SO were more likely to receive a recommendation against surgery (odds ratio = 1.35; 95% CI, 1.23-1.49) and exhibited poorer GACSS as compared with those in the WE, MW, or NE regions.

CONCLUSIONS

Race and geographic region of diagnosis affect treatment recommendations and GACSS among individuals with resectable tumors. African Americans with resectable cancers are more likely to receive a recommendation against surgery than individuals of other racial groups.

Nationwide, Longitudinal Trends in CT Colonography Utilization: Cross-Sectional Survey Results From the 2010 and 2015 National Health Interview Survey

PURPOSE

Colon cancer screening reduces deaths from colorectal cancer. Screening rates have plateaued; however, studies have found that giving patients a choice between different screening tests improves adherence. CT colonography is a minimally invasive screening test with high sensitivity for colonic polyps (>1 cm). With increasing insurance coverage of CT colonography nationwide, there are limited estimates of CT colonography utilization over time. Our purpose was to estimate CT colonography utilization over time using nationally representative cross-sectional survey data.

METHODS

We utilized 2010 and 2015 National Health Interview Survey cross-sectional data. Participants between ages 50 and 75 without colorectal cancer history were included. Accounting for complex survey design elements, logistic regression analyses evaluated changes in CT colonography utilization over time, adjusted for potential confounders, and stratified by insurance and age.

RESULTS

Overall, 21,686 respondents were included (8,965 in 2010, 12,721 in 2015). Reported CT colonography utilization decreased from 1.2% to 0.9% (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.86-0.98). Stratified analyses revealed no changes in utilization in patients with private insurance (P = .35) and in patients younger than 65 (P = .07). Overall awareness of CT colonography decreased from 20.5% to 15.9% (OR 0.93, 95% CI 0.91-0.95). Reported optical colonoscopy utilization increased from 57.9% to 63.6% (OR 1.03, 95% CI 1.02-1.05).

CONCLUSION

Despite increasing self-reported utilization of optical colonoscopy from 2010 to 2015, survey results suggest that CT colonography awareness (∼16%) and utilization (∼1%) remain low. Improved public awareness and coverage expansion to Medicare-aged populations will promote improved CT colonography utilization and overall colorectal cancer screening rates.

Participation and Ease of Use in Colorectal Cancer Screening: A Comparison of 2 Fecal Immunochemical Tests

INTRODUCTION

The impact of fecal immunochemical test (FIT)-based colorectal cancer (CRC) screening on disease incidence and mortality is affected by participation, which might be influenced by ease of use of the FIT. We compared the participation rates and ease of use of 2 different FITs in a CRC screening program.

METHODS

There were two study designs within the Dutch CRC screening program. In a paired cohort study, all invitees received 2 FITs (OC-Sensor, Eiken, Japan, and FOB-Gold, Sentinel, Italy) and were asked to sample both from the same stool. Ease of use of both FITs was evaluated by a questionnaire. In a randomized controlled trial, invitees were randomly allocated to receive one of the 2 FITs to compare participation and analyzability.

RESULTS

Of 42,179 invitees in the paired cohort study, 21,078 (50%) completed 2 tests and 20,727 (98%) returned the questionnaire. FOB-Gold was reported significantly easier to use. More participants preferred FOB-Gold (36%) than OC-Sensor (5%), yet most had no preference (59%; P < 0.001). In the randomized trial, 936 of 1,923 invitees (48.7%) returned the FOB-Gold and 940 of 1,923 invitees (48.9%) returned the OC-Sensor, a difference of -0.2% (confidence interval, -3.4% to 3.0%), well within the pre-specified 5% noninferiority margin (P = 0.001). Only one FOB-Gold (0.1%) and 4 OC-Sensors (0.4%) were not analyzable (P = 0.18).

CONCLUSIONS

Although FOB-Gold was significantly but marginally considered easier to use than OC-Sensor, the number of analyzable tests and the participation rates in organized CRC screening are not affected when either of the FITs is implemented as a primary screening test.

Progress of colorectal cancer screening in United States: Past achievements and future challenges

The United States has seen progress with colorectal cancer with both falling incidence and mortality rates. Factoring into this decline, the significance of early detection and removal of precancerous lesions through screening must be underscored. With the advancement of screening modalities, attention has been directed towards optimizing the quality of screening and detecting adenomas. Colorectal cancer screening has been a major agenda item for national gastroenterology societies, culminating in a major victory with passage of the Balanced Budget Act that allowed for Medicare coverage of colorectal cancer screening. Colonoscopy as the primary screening modality was solidified in the 1990s after landmark studies demonstrated its superiority over modalities for detecting precancerous polyps. Despite progress, colorectal cancer screening disparities between race and gender continue to exist. Legislative efforts are on-going and include the SCREEN Act and Dent Act that aim to further improve access to screening. The National Colorectal Cancer Roundtable has launched colorectal cancer screening initiatives targeting at risk populations. Today, the current goal of these initiatives is to reach colorectal screening rate of 80% of eligible patients by 2018. With these initiatives, efforts to narrow the gaps in screening disparities and lower overall mortality have been prioritized and continued by the medical community. This review article details colorectal cancer screening progress to date and highlights major studies and initiatives that have solidified its success in the United States.

Roles for Interleukin 17 and Adaptive Immunity in Pathogenesis of Colorectal Cancer

Sporadic colorectal cancer is one of the most common and lethal cancers worldwide. The locations and functions of immune cells in the colorectal tumor microenvironment are complex and heterogeneous. T-helper (Th)1 cell-mediated responses against established colorectal tumors are associated with better outcomes of patients (time of relapse-free or overall survival), whereas Th17 cell-mediated responses and production of interleukin 17A (IL17A) have been associated with worse outcomes of patients. Tumors that develop in mouse models of colorectal cancer are rarely invasive and differ in many ways from human colorectal tumors. However, these mice have been used to study the mechanisms by which Th17 cells and IL17A promote colorectal tumor initiation and growth, which appear to involve their direct effects on colon epithelial cells. Specific members of the colonic microbiota may promote IL17A production and IL17A-producing cell functions in the colonic mucosa to promote carcinogenesis. Increasing our understanding of the interactions between the colonic microbiota and the mucosal immune response, the roles of Th17 cells and IL17 in these interactions, and how these processes are altered during colon carcinogenesis, could lead to new strategies for preventing or treating colorectal cancer.

2017 Emily Couric Memorial Lecture: Colorectal Cancer: Polyps, Prevention, and Progress

Colorectal cancer remains the second‐leading cause of cancer death in the United States—but efforts over the past two decades have resulted in tremendous progress in understanding the biology of how this disease develops, increasing screening rates, and decreasing incidence and mortality in those age 50 years and older. The drivers of this movement have been outstanding leadership, innovation, and collaboration. As we move forward to tackle issues such as the increasing incidence of this disease in younger adults, the need to address disparities in care and outcomes, and our shared goal to reach 80% screening rates, it's important to understand and appreciate the story of our past success in order to advance our future efforts.

Cost Effectiveness of Gastric Cancer Screening According to Race and Ethnicity

BACKGROUND & AIMS

There are marked racial and ethnic differences in non-cardia gastric cancer prevalence within the United States. Although gastric cancer screening is recommended in some regions of high prevalence, screening is not routinely performed in the United States. Our objective was to determine whether selected non-cardia gastric cancer screening for high-risk races and ethnicities within the United States is cost effective.

METHODS

We developed a decision analytic Markov model with the base case of a 50-year-old person of non-Hispanic white, non-Hispanic black, Hispanic, or Asian race or ethnicity. The cost effectiveness of a no-screening strategy (current standard) for non-cardia gastric cancer was compared with that of 2 endoscopic screening modalities initiated at the time of screening colonoscopy for colorectal cancer: upper esophagogastroduodenoscopy with biopsy examinations and continued surveillance only if intestinal metaplasia or more severe pathology is identified or esophagogastroduodenoscopy with biopsy examinations continued every 2 years even in the absence of identified pathology. We used prevalence rates, transition probabilities, costs, and quality-adjusted life years (QALYs) from publications and public data sources. Outcome measures were reported in incremental cost-effectiveness ratios, with a willingness-to-pay threshold of $100,000/QALY.

RESULTS

Compared with biennial and no screening, screening esophagogastroduodenoscopy with continued surveillance only when indicated was cost effective for non-Hispanic blacks ($80,278/QALY), Hispanics ($76,070/QALY), and Asians ($71,451/QALY), but not for non-Hispanic whites ($122,428/QALY). The model was sensitive to intestinal metaplasia prevalence, transition rates from intestinal metaplasia to dysplasia to local and regional cancer, cost of endoscopy, and cost of resection (endoscopic or surgical).

CONCLUSIONS

Based on a decision analytic Markov model, endoscopic non-cardia gastric cancer screening for high-risk races and ethnicities could be cost effective in the United States.

Pediatric Nonalcoholic Fatty Liver Disease in New York City: An Autopsy Study

OBJECTIVE

To assess the prevalence and severity of nonalcoholic liver disease (NAFLD) in children in a diverse population sample in New York City.

STUDY DESIGN

Liver specimens were examined from children 2-19 years old who died of unexpected causes within 48 hours of medical presentation and underwent autopsy in New York City from 2005 to 2010. Records were reviewed for age, sex, weight, height, and race. Two hepatopathologists evaluated each liver specimen to determine pathologic diagnosis.

RESULTS

The final study cohort (n = 582) was 50% black, 33% Hispanic, 12% white, 3% Asian, and 2% other; 36% had a body mass index >85%. There were 26 cases of NAFLD (4.5%) of which 10 had nonalcoholic steatohepatitis (1.7%). There were no cases with severe fibrosis or cirrhosis. One percent (3/290) of black children had NAFLD and none had nonalcoholic steatohepatitis. White and Hispanic children had the highest percentages of NAFLD at 8.3% and 7.9%, respectively. In multiple logistic regression models, we observed that body mass index z-score (P < .001) was associated with NAFLD, and that white (P = .003) and Hispanic (P = .005) children had higher odds of having NAFLD compared with black children.

CONCLUSIONS

This review of liver tissue demonstrates a lower prevalence and severity of NAFLD in black children compared with the general obese pediatric population. Hispanic children did not have a significantly increased rate of NAFLD compared with white children, most likely related to the large proportion of Caribbean Hispanic children in New York City.

Trends and disparities in the utilization of hypofractionated neoadjuvant radiation therapy for rectal cancer in the United States

Background

Neoadjuvant conventionally fractionated radiotherapy (CFRT) versus hypofractionated radiotherapy (HFRT) for rectal cancer (RC) is among the most controversial and debatable areas of radiotherapeutic management. This is the only known study evaluating the utilization of neoadjuvant HFRT for RC in the United States, and focuses on trends and health disparities.

Methods

The National Cancer Data Base was queried [2004-2015] for newly-diagnosed cT3-T4 N_any or cT_any N1-2 M0 rectal adenocarcinoma undergoing neoadjuvant RT, with or without chemotherapy, followed by resection. Following analysis based on temporal trends, multivariate logistic regression determined factors associated with receipt of HFRT.

Results

Altogether, 29,994 patients met study criteria: 29,724 (99%) were treated with CFRT, and 270 (1%) with HFRT. Temporally, utilization of HFRT rose significantly, from 0.2% in 2004 to 2.0% in 2015, with the steepest slope at most recent time periods. HFRT was more likely administered to older patients, those with more comorbidities, and node-positive disease (P<0.05 for all). There were racial differences, as African-Americans were independently less likely to receive HFRT (P=0.043). The two strongest predictors of HFRT administration (by odds ratio) were time period and therapy at academic centers (P<0.05 for all).

Conclusions

Although HFRT is underutilized in the US, its use is rising and has increased nearly tenfold over the last decade. Disparities in HFRT delivery are emphasized, especially concerning disease-/patient-specific factors, socioeconomic status, and race. These data may serve as a benchmark for future investigation as well as for health disparities in the radiotherapeutic treatment of RC.

Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society

In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250-281. © 2018 American Cancer Society.

Design and methodology of a study on colorectal cancer in Johannesburg, South Africa

Background and Aim

Cancer is one of the foremost causes of morbidity and mortality worldwide. Globally, colorectal cancer (CRC) is the third most diagnosed and fourth most important cause of cancer death. A total of 70% of all CRC‐related deaths occur in low‐ and middle‐income countries. In Sub‐Saharan Africa (SSA), estimating the burden of CRC is difficult. Only 27 of 43 SSA countries have formalized cancer registration systems; data quality is variable and national coverage rare.

Methods

This is a multidisciplinary, longitudinal cohort study started in January 2016. Patients >18 years with histologically confirmed primary adenocarcinoma of the colon and rectum, diagnosed within the previous 12 months, are eligible. Participants were assessed and were followed up for 3 years. Baseline information, including demographics, socioeconomic status, family history, medical and surgical non‐cancer‐related history, dietary history, colonoscopic findings, staging at presentation, treatment, and disease recurrence, is collected, as well as blood tests and histology results. Outcomes include disease recurrence (local and metastatic) and survival.

Results and Conclusion

This study aims to describe the clinical presentation, management, and outcomes of adults with CRC in a multiethnic, urban South African population. It will be the first prospective study to describe clinical presentation, demographics, risk factors, treatment, and outcomes according to population group, from both private and state health‐care facilities in Johannesburg, South Africa. The results of this study will be relevant not only to South Africa but also to other SSA countries undergoing similar rates of rapid urbanization and epidemiological transition.

This paper summarizes the design and methodology being used for a prospective cohort study of colorectal cancer (CRC) in Johannesburg, South Africa. It aims to describe the clinical presentation, management and outcomes of adults with CRC in a multi‐ethnic, urban South African population. It will be the first prospective study to describe clinical presentation, demographics, risk factors, treatment and outcomes according to population group, from both private and state healthcare facilities.

Socioeconomic and ethnic inequities within organised colorectal cancer screening programmes worldwide

OBJECTIVE

Colorectal cancer (CRC) screening programmes can reduce CRC mortality. However, the implementation of a screening programme may create or exacerbate socioeconomic and ethnic health inequities if participation varies by subgroup. We determined which organised programmes characterise participation inequities by socioeconomic and ethnic subgroups, and assessed the variation in subgroup participation among programmes collecting group-specific data.

DESIGN

Employing a literature review and survey among leaders of national or regional screening programmes, this study identified published and unpublished data on participation by socioeconomic status and ethnicity. We assessed programmes offering faecal occult blood tests (FOBT) for screening. Primary outcome was screening participation rate.

RESULTS

Across 24 organised FOBT-screening programmes meeting the inclusion criteria, participation rates ranged from 21% to 73%. Most programmes (13/24, 54%) did not collect data on participation by socioeconomic status and ethnicity. Among the 11 programmes with data on participation by socioeconomic status, 90% (28/31 publications) reported lower participation among lower socioeconomic groups. Differences across socioeconomic gradients were moderate (66% vs 71%) to severe (35% vs 61%). Only six programmes reported participation results by ethnicity. Ethnic differences were moderate, though only limited data were available for evaluation.

CONCLUSIONS

Across organised CRC screening programmes worldwide, variation in participation by socioeconomic status and ethnicity is often not assessed. However, when measured, marked disparities in participation by socioeconomic status have been observed. Limited data were available to assess inequities by ethnicity. To avoid exacerbating health inequities, screening programmes should systematically monitor participation by socioeconomic status and ethnicity, and investigate and address determinants of low participation.

Evaluation of Colorectal Cancer Incidence Trends in the United States (2000-2014)

Colorectal cancer (CRC) incidence rates have declined in recent years for people of all races/ethnicities; however, the extent to which the decrease varies annually by demographic and disease-related characteristics is largely unknown. This study examines trends and annual percent change (APC) in the incidence among persons diagnosed with CRC in the United States of America from 2000-2014. The data obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program were analyzed, and all persons (N = 577,708) with malignant CRC recorded in the SEER 18 database from 2000 to 2014 were characterized according to sex, race, age at diagnosis, disease site and stage. Incidence rates and APC were calculated for the entire study period. Overall, the incidence rate of CRC decreased from 54.5 in 2000 to 38.6 per 100,000 in 2014, with APC = -2.66 (p < 0.0001). Decline in rates was most profound between 2008 and 2011 from 46.0 to 40.7 per 100,000 (APC = -4.04; p < 0.0001). Rates were higher for males (vs. females; rate ratio (RR) = 1.33) and for blacks (vs. whites; RR = 1.23). Proximal colon cancers at the localized stage were the predominant cancers. An increase in rate was observed among people younger than 50 years (6.6 per 100,000, APC= 1.5). The annual rate of CRC has decreased over time. However, the development and implementation of interventions that further reduce the disparities among demographic and disease-related subgroups are warranted.

Systematic review of colorectal cancer screening guidelines for average-risk adults: Summarizing the current global recommendations

AIM

To summarize and compare worldwide colorectal cancer (CRC) screening recommendations in order to identify similarities and disparities.

METHODS

A systematic literature search was performed using MEDLINE, EMBASE, Scopus, CENTRAL and ISI Web of knowledge identifying all average-risk CRC screening guideline publications within the last ten years and/or position statements published in the last 2 years. In addition, a hand-search of the webpages of National Gastroenterology Society websites, the National Guideline Clearinghouse, the BMJ Clinical Evidence website, Google and Google Scholar was performed.

RESULTS

Fifteen guidelines were identified. Six guidelines were published in North America, four in Europe, four in Asia and one from the World Gastroenterology Organization. The majority of guidelines recommend screening average-risk individuals between ages 50 and 75 using colonoscopy (every 10 years), or flexible sigmoidoscopy (FS, every 5 years) or fecal occult blood test (FOBT, mainly the Fecal Immunochemical Test, annually or biennially). Disparities throughout the different guidelines are found relating to the use of colonoscopy, rank order between test, screening intervals and optimal age ranges for screening.

CONCLUSION

Average risk individuals between 50 and 75 years should undergo CRC screening. Recommendations for optimal surveillance intervals, preferred tests/test cascade as well as the optimal timing when to start and stop screening differ regionally and should be considered for clinical decision making. Furthermore, local resource availability and patient preferences are important to increase CRC screening uptake, as any screening is better than none.

Racial differences in symptom management experiences during breast cancer treatment

PURPOSE

Racial disparities in cancer treatment-related symptom burden are well documented and linked to worse treatment outcomes. Yet, little is known about racial differences in patients' treatment-related symptom management experiences. Such understanding can help identify modifiable drivers of symptom burden inequities. As part of the Cancer Health Accountability for Managing Pain and Symptoms (CHAMPS) study, we examined racial differences in symptom management experiences among Black and White breast cancer survivors (BCS).

METHODS

We conducted six focus groups (n = 3 Black BCS groups; n = 3 White BCS groups) with 22 stages I-IV BCS at two cancer centers. Focus groups were audio-recorded and transcribed verbatim. Based on key community-based participatory research principles, our community/academic/medical partner team facilitated focus groups and conducted qualitative analyses.

RESULTS

All BCS described positive symptom management experiences, including clinician attentiveness to symptom concerns and clinician recommendations for pre-emptively managing symptoms. Black BCS commonly reported having to advocate for themselves to get information about treatment-related symptoms, and indicated dissatisfaction regarding clinicians' failure to disclose potential treatment-related symptoms or provide medications to address symptoms. White BCS often described dissatisfaction regarding inadequate information on symptom origins and clinicians' failure to offer reassurance.

CONCLUSIONS

This study elucidates opportunities for future research aimed at improving equity for cancer treatment-related symptom management. For Black women, warnings about anticipated symptoms and treatment for ongoing symptoms were particular areas of concern. Routine symptom assessment for all women, as well as clinicians' management of symptoms for racially diverse cancer patients, need to be more thoroughly studied and addressed.

New Strategies to Improve Polypectomy During Colonoscopy

In the United States, colorectal cancer (CRC) is the second-leading cause of cancer-related deaths. The most effective strategy for prevention of CRC is to screen for and remove precancerous polyps. There are various ways to screen for CRC. In the United States, the most common method is colonoscopy. Polyps are classified primarily through pathology. Size is the primary risk factor for malignancy. In general, the bigger the polyp, the greater the risk for malignancy. There are 3 basic options for removal: standard polypectomy; advanced resection techniques, known as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD); and surgical removal. In the past 10 years, the use of surgical removal has significantly decreased. Noninvasive, nonmalignant polyps can be removed endoscopically. EMR and ESD are very effective and achieve similar clinical outcomes. Both procedures begin with a submucosal injection. The submucosal lift is one of the most significant advances that have been made in polypectomy. Traditionally, the approach to achieving a submucosal lift has relied on the use of a saline solution. Saline is inexpensive and widely available, but it dissipates quickly. Various viscous agents have been added to saline to maintain mucosal lifting throughout the procedure. Although most are effective, they are used off-label. The only solution approved by the US Food and Drug Administration for the submucosal lift procedure is Eleview. In a clinical trial, Eleview decreased the mean total injected volume and the mean total injected volume per lesion as compared with saline. Other advances in polypectomy techniques include the use of cold snare polypectomy and high-definition colonoscopes. The quality of the colonoscopy can also be improved if a physician knows and monitors his or her adenoma detection rate.

Polyp Resection and Removal Procedures: Insights From the 2017 Digestive Disease Week

Colorectal cancer (CRC) is an important public health issue not only because of its high incidence but also for its high mortality rate. When CRC is diagnosed at an early stage, the 5-year relative survival rate reaches 89.9%. However, only 39% of patients with CRC are diagnosed at this stage. Screening decreases both the incidence of CRC and the number of CRC-related deaths. There are several options available for screening, and colonoscopy is one of the most common methods utilized in the United States. Screening colonoscopy is associated with durable protection from CRC. However, it has become increasingly apparent in recent years that polyp detection and resection have not been completely effective in clinical practice. Because the protective benefit of colonoscopy is variable, quality benchmarks have been established to improve its clinical effectiveness. The adenoma detection rate (ADR) directly correlates with the incidence and mortality of postcolonoscopy (or interval) CRCs. It is now routine to remove large polyps (≥20 mm) using advanced techniques for endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Recent studies have helped identify which colorectal lesions are at higher risk of invasive cancer and would benefit from a complete en bloc resection. Such data may guide endoscopists in making a decision on whether to use ESD or EMR for removal of large lesions. An increased number of studies have reported on the efficacy and safety of cold snare resection, even for larger polyps. These data suggest that cold snare resection may be as effective, and perhaps safer, than hot snare resection for polyps up to 1 to 2 cm in size. However, data on the threshold for cold snare resection and the value of submucosal injectates are still lacking. Use of submucosal injection is generally preferred for larger polyps, particularly those located in the proximal colon, where the colonic wall is thinner.

XB130 enhances invasion and migration of human colorectal cancer cells by promoting epithelial‑mesenchymal transition

The expression of XB130 is associated with invasion and migration of many tumor cells, but its roles in human colorectal cancer (CRC) remains unknown. To investigate this, protein expression levels of XB130 in numerous human CRC cell lines were compared with a normal colorectal mucosa cell line by western blotting. Knockdown of XB130 using small interfering (si)RNA was performed to assess the effects on cell invasion and migration in a Transwell assay and a scratch test. Western blotting was also used to quantify the levels of proteins associated with epithelial‑mesenchymal transition (EMT), including E‑cadherin, vimentin, phosphorylated (p)‑protein kinase B (AKT), p‑forkhead homeobox type O 3a (FOXO3a) and zinc finger E‑box‑binding homeobox 1 (ZEB‑1). The relative expression of XB130 protein was significantly higher in CRC cells compared with control cells (P<0.01). Knockdown of XB130 using siRNA significantly decreased the invasive and migratory responses of CRC cells (P<0.01). In addition, levels of E‑cadherin were increased, while vimentin, p‑AKT, p‑FOXO3a and ZEB‑1 were decreased (P<0.01). In conclusion, the present study demonstrated that the expression of XB130 is elevated in CRC cells. Loss of XB130 was associated with decreased invasion and migration of CRC cells, possibly as a result of EMT inhibition. Thus, upregulation of XB130 may underlie some of the tumorigenic events observed in human CRCs. XB130 may be a promising target for CRC therapy in humans; further mechanistic studies exploring the function of XB130 in CRC cells are warranted.

Community-Based, Preclinical Patient Navigation for Colorectal Cancer Screening Among Older Black Men Recruited From Barbershops: The MISTER B Trial

OBJECTIVES

To test the effectiveness of a preclinical, telephone-based patient navigation intervention to encourage colorectal cancer (CRC) screening among older Black men.

METHODS

We conducted a 3-parallel-arm, randomized trial among 731 self-identified Black men recruited at barbershops between 2010 and 2013 in New York City. Participants had to be aged 50 years or older, not be up-to-date on CRC screening, have uncontrolled high blood pressure, and have a working telephone. We randomized participants to 1 of 3 groups: (1) patient navigation by a community health worker for CRC screening (PN), (2) motivational interviewing for blood pressure control by a trained counselor (MINT), or (3) both interventions (PLUS). We assessed CRC screening completion at 6-month follow-up.

RESULTS

Intent-to-treat analysis revealed that participants in the navigation interventions were significantly more likely than those in the MINT-only group to be screened for CRC during the 6-month study period (17.5% of participants in PN, 17.8% in PLUS, 8.4% in MINT; P < .01).

CONCLUSIONS

Telephone-based preclinical patient navigation has the potential to be effective for older Black men. Our results indicate the importance of community-based health interventions for improving health among minority men.

Colorectal Cancer Screening in Average Risk Patients

Colorectal cancer (CRC) contributes a major burden of cancer mortality in the United States. There are multiple effective screening approaches that can reduce CRC mortality. These approaches are supported by different levels of evidence, and each has its own advantages and disadvantages. Implementing a systematic approach to screening that addresses the multiple steps involved in the screening process is essential to improving population-level CRC screening. Offering patients stool-based screening is important for increasing screening uptake. However, programs that offer stool testing must support the population health infrastructure needed to promote adherence to repeat testing and follow-up of abnormal tests.

Colorectal Cancer Screening: Recommendations for Physicians and Patients From the U.S. Multi-Society Task Force on Colorectal Cancer

This document updates the colorectal cancer (CRC) screening recommendations of the U.S. Multi-Society Task Force of Colorectal Cancer (MSTF), which represents the American College of Gastroenterology, the American Gastroenterological Association, and The American Society for Gastrointestinal Endoscopy. CRC screening tests are ranked in 3 tiers based on performance features, costs, and practical considerations. The first-tier tests are colonoscopy every 10 years and annual fecal immunochemical test (FIT). Colonoscopy and FIT are recommended as the cornerstones of screening regardless of how screening is offered. Thus, in a sequential approach based on colonoscopy offered first, FIT should be offered to patients who decline colonoscopy. Colonoscopy and FIT are recommended as tests of choice when multiple options are presented as alternatives. A risk-stratified approach is also appropriate, with FIT screening in populations with an estimated low prevalence of advanced neoplasia and colonoscopy screening in high prevalence populations. The second-tier tests include CT colonography every 5 years, the FIT-fecal DNA test every 3 years, and flexible sigmoidoscopy every 5 to 10 years. These tests are appropriate screening tests, but each has disadvantages relative to the tier 1 tests. Because of limited evidence and current obstacles to use, capsule colonoscopy every 5 years is a third-tier test. We suggest that the Septin9 serum assay (Epigenomics, Seattle, Wash) not be used for screening. Screening should begin at age 50 years in average-risk persons, except in African Americans in whom limited evidence supports screening at 45 years. CRC incidence is rising in persons under age 50, and thorough diagnostic evaluation of young persons with suspected colorectal bleeding is recommended. Discontinuation of screening should be considered when persons up to date with screening, who have prior negative screening (particularly colonoscopy), reach age 75 or have <10 years of life expectancy. Persons without prior screening should be considered for screening up to age 85, depending on age and comorbidities. Persons with a family history of CRC or a documented advanced adenoma in a first-degree relative age <60 years or 2 first-degree relatives with these findings at any age are recommended to undergo screening by colonoscopy every 5 years, beginning 10 years before the age at diagnosis of the youngest affected relative or age 40, whichever is earlier. Persons with a single first-degree relative diagnosed at ≥60 years with CRC or an advanced adenoma can be offered average-risk screening options beginning at age 40 years.

Colorectal Cancer Screening: Recommendations for Physicians and Patients from the U.S. Multi-Society Task Force on Colorectal Cancer

This document updates the colorectal cancer (CRC) screening recommendations of the U.S. Multi-Society Task Force of Colorectal Cancer (MSTF), which represents the American College of Gastroenterology, the American Gastroenterological Association, and The American Society for Gastrointestinal Endoscopy. CRC screening tests are ranked in 3 tiers based on performance features, costs, and practical considerations. The first-tier tests are colonoscopy every 10 years and annual fecal immunochemical test (FIT). Colonoscopy and FIT are recommended as the cornerstones of screening regardless of how screening is offered. Thus, in a sequential approach based on colonoscopy offered first, FIT should be offered to patients who decline colonoscopy. Colonoscopy and FIT are recommended as tests of choice when multiple options are presented as alternatives. A risk-stratified approach is also appropriate, with FIT screening in populations with an estimated low prevalence of advanced neoplasia and colonoscopy screening in high prevalence populations. The second-tier tests include CT colonography every 5 years, the FIT-fecal DNA test every 3 years, and flexible sigmoidoscopy every 5 to 10 years. These tests are appropriate screening tests, but each has disadvantages relative to the tier 1 tests. Because of limited evidence and current obstacles to use, capsule colonoscopy every 5 years is a third-tier test. We suggest that the Septin9 serum assay (Epigenomics, Seattle, Wash) not be used for screening. Screening should begin at age 50 years in average-risk persons, except in African Americans in whom limited evidence supports screening at 45 years. CRC incidence is rising in persons under age 50, and thorough diagnostic evaluation of young persons with suspected colorectal bleeding is recommended. Discontinuation of screening should be considered when persons up to date with screening, who have prior negative screening (particularly colonoscopy), reach age 75 or have <10 years of life expectancy. Persons without prior screening should be considered for screening up to age 85, depending on age and comorbidities. Persons with a family history of CRC or a documented advanced adenoma in a first-degree relative age <60 years or 2 first-degree relatives with these findings at any age are recommended to undergo screening by colonoscopy every 5 years, beginning 10 years before the age at diagnosis of the youngest affected relative or age 40, whichever is earlier. Persons with a single first-degree relative diagnosed at ≥60 years with CRC or an advanced adenoma can be offered average-risk screening options beginning at age 40 years.

Clinical Features and Outcomes of Patients with Colorectal Cancers Harboring NRAS Mutations

Purpose:NRAS mutations are now routinely included in RAS testing prior to EGFR inhibitor therapy for metastatic colorectal cancer (mCRC). The clinical implications of NRAS mutation beyond lack of response to anti-EGFR therapy, however, are not known. We undertook this study to determine the clinical features and treatment outcomes of patients with NRAS-mutant mCRC.Experimental Design: We reviewed clinical characteristics, concurrent mutations, and outcomes for all mCRC cases with NRAS mutations undergoing standard genotyping at our institution from 2008 to 2015. Comparison groups consisted of RAS wild-type and KRAS-mutant mCRC consecutive cases genotyped from 2008 to 2012.Results: Three percent (87/2764) of mCRC patients had NRAS-mutant tumors (45% exon 2 and 55% exon 3), including three cases with concurrent NRAS and KRAS mutations. Left-sided primary site and African American self-reported race were associated with NRAS mutation (P < 0.01). Resection rate at 12 months was lower for NRAS-mutant mCRC than for RAS wild-type or KRAS-mutant mCRC. Median survival from time of first known metastasis was 33 months for NRAS-mutant, 47 months for KRAS-mutant, and 78 months for RAS wild-type cases (P < 0.001). Multivariate analysis assigned an HR for overall survival of 2.0 for NRAS mutation and 1.5 for KRAS mutation (P < 0.01).Conclusions:NRAS defines a molecular subset with distinct clinical characteristics from KRAS-mutant and wild-type mCRC. NRAS mutations are enriched in left-sided primary tumors and among African Americans. Mutations in NRAS are associated with poor survival and worse outcomes than either KRAS-mutant or wild-type mCRC. Clin Cancer Res; 23(16); 4753-60. ©2017 AACR.

Evaluating screening colonoscopy quality in an uninsured urban population following patient navigation

Patient navigation (PN) increases screening colonoscopy completion in minority and uninsured populations. However, colonoscopy quality is under-reported in the setting of PN and quality indicators have often failed to meet benchmark standards. This study investigated screening colonoscopy quality indicators after year-one of a PN initiative targeting the medically uninsured. This was a retrospective analysis of 296 outpatient screening colonoscopies. Patients were 45 to 75 years of age with no history of bowel cancer, inflammatory bowel disease, or colorectal surgery. The screening colonoscopy quality indicators: adenoma detection rate (ADR), cecal intubation rate (CIR), and bowel preparation quality were compared in 89 uninsured Federally Qualified Health Center (FQHC) patients who received PN and 207 University Hospital patients who received usual care. The FQHC PN and University Hospital cohorts were similar in female sex (69% vs. 70%; p = 0.861) and African American race (61% vs. 61%; p = 0.920). The FQHC PN cohort was younger (57 years vs. 60 years; p < 0.001). There was no difference in ADR (33% vs. 32%; p = 0.971) or CIR (96% vs. 95%; p = 0.900) comparing the FQHC PN and University Hospital cohorts. The FQHC PN patients had a greater likelihood of an optimal bowel preparation on multivariate logistic regression (odds ratio 4.17; 95% confidence interval 1.07 to 16.20). Uninsured FQHC patients who received PN were observed to have intra-procedure quality indicators that exceeded bench-mark standards for high-quality screening colonoscopy and were equivalent to those observed in an insured University Hospital patient population.

A randomized controlled trial of a multicomponent, targeted, low-literacy educational intervention compared with a nontargeted intervention to boost colorectal cancer screening with fecal immunochemical testing in community clinics

BACKGROUND

The objective of the current study was to improve colorectal cancer (CRC) screening uptake with the fecal immunochemical test (FIT). The current study investigated the differential impact of a multicomponent, targeted, low-literacy educational intervention compared with a standard, nontargeted educational intervention.

METHODS

Patients aged 50 to 75 years who were of average CRC risk and not up-to-date with CRC screening were recruited from either a federally qualified health center or a primary care community health clinic. Patients were randomized to the intervention condition (targeted photonovella booklet/DVD plus FIT kit) or comparison condition (standard Centers for Disease Control and Prevention brochure plus FIT kit). The main outcome was screening with FIT within 180 days of delivery of the intervention.

RESULTS

Of the 416 participants, 54% were female; the participants were racially and ethnically diverse (66% white, 10% Hispanic, and 28% African American), predominantly of low income, and insured (the majority had county health insurance). Overall, the FIT completion rate was 81%, with 78.1% of participants in the intervention versus 83.5% of those in the comparison condition completing FIT (P =  .17). In multivariate analysis, having health insurance was found to be the primary factor predicting a lack of FIT screening (adjusted odds ratio, 2.10; 95% confidence interval, 1.04-4.26 [P =  .04]).

CONCLUSIONS

The multicomponent, targeted, low-literacy materials were not found to be significantly different or more effective in increasing FIT uptake compared with the nontargeted materials. Provision of a FIT test plus education may provide a key impetus to improve the completion of CRC screening. The type of educational material (targeted vs nontargeted) may matter less. The findings of the current study provide a unique opportunity for clinics to adopt FIT and to choose the type of patient education materials based on clinic, provider, and patient preferences. Cancer 2017;123:1390-1400. © 2016 American Cancer Society.