Colorectal Cancer Disparity in African Americans: Risk Factors and Carcinogenic Mechanisms

Biomarker Profile of Colorectal Cancer: Current Findings and Future Perspective

OBJECTIVE

Breakthroughs in omics technology have led to a deeper understanding of the fundamental molecular changes that play a critical role in the development and progression of cancer. This review delves into the hidden molecular drivers of colorectal cancer (CRC), offering potential for clinical translation through novel biomarkers and personalized therapies.

METHODS

We summarizes recent studies utilizing various omics approaches, including genomics, transcriptomics, proteomics, epigenomics, metabolomics and data integration with computational algorithms, to investigate CRC.

RESULTS

Integrating multi-omics data in colorectal cancer research unlocks hidden biological insights, revealing new pathways and mechanisms. This powerful approach not only identifies potential biomarkers for personalized prognosis, diagnosis, and treatment, but also predicts patient response to specific therapies, while computational tools illuminate the landscape by deciphering complex datasets.

CONCLUSIONS

Future research should prioritize validating promising biomarkers and seamlessly translating them into clinical practice, ultimately propelling personalized CRC management to new heights.

Community Health workers United to Reduce Colorectal cancer and cardiovascular disease among people at Higher risk (CHURCH): study protocol for a randomized controlled trial

BACKGROUND

Colorectal cancer (CRC) is the second most lethal cancer in the United States (U.S.) with the highest incidence and mortality rates among African Americans (AAs) compared to other racial groups. Despite these disparities, AAs are the least likely to undergo CRC screening, have precancerous colorectal polyps removed, and have CRC detected at stages early enough for curative excision. In addition, compelling evidence links inflammatory dietary patterns to increased CRC and cardiovascular disease risk. Studies show that AA churches can successfully engage in health promotion activities including those related to cancer control. The current study seeks to leverage church-placed Community Health Workers (CHWs) to increase CRC screening and reduce CRC risk.

DESIGN AND METHODS

We aim to (1) increase guideline concordant CRC screening uptake using church-placed CHWs trained in screening with a validated instrument, Brief Intervention using Motivational Interviewing, and Referral to Treatment (SBIRT); and (2) reduce dietary risk factors (inflammatory dietary patterns) linked to CRC. The latter will be addressed by culturally adapting an existing, web-based lifestyle program called Alive!. Using a Hybrid Type 1 Implementation-Effectiveness cluster randomized design, we will randomize 22 AA churches into either the dual intervention arm (CHW-led SBIRT intervention plus Alive!) or a usual care arm comprised of CRC prevention educational pamphlets and a list of CRC screening sites. We will recruit 440 subjects and evaluate the effects of both arms on screening uptake (colonoscopy, fecal DNA) (primary outcome) and dietary inflammation score (secondary outcome) at 6-month follow-up, and Life Simple7 (LS7)-a cardiovascular disease (CVD) risk score-at 6 months and 1 year (secondary outcome). Finally, guided by a racism-conscious adaptation of the Consolidated Framework for Implementation Research (CFIR), we will conduct a mixed-methods process evaluation with key stakeholders to understand multi-level influences on CRC screening and CVD risk behaviors.

DISCUSSION

Church-placed CHWs are trusted influential connectors between communities and health systems. Studies have shown that these CHWs can successfully implement health prevention protocols in churches, including those related to cancer control, making them potentially important community mediators of CRC screening uptake and CRC/CVD risk reduction.

TRIAL REGISTRATION

NCT05174286; clinicaltrials.gov; August 31st, 2023.

Community Health workers United to Reduce Colorectal cancer and cardiovascular disease among people at Higher risk (CHURCH): study protocol for a randomized controlled trial

Background: Colorectal cancer (CRC) is the second most lethal cancer in the United States (U.S.) with the highest incidence and mortality rates among African Americans (AAs) compared to other racial groups. Despite these disparities, AAs are the least likely to undergo CRC screening, have precancerous colorectal polys removed, and have CRC detected at stages early enough for curative excision. In addition, compelling evidence links inflammatory dietary patterns to increased CRC and cardiovascular disease risk. Studies show that AA churches can successfully engage in health promotion activities including those related to cancer control. The current study seeks to leverage church-placed Community Health Workers (CHWs) to increase CRC screening and reduce CRC risk. Design and Methods: We aim to (1) increase guideline concordant CRC screening uptake using church-placed CHWs trained in screening with a validated instrument, Brief Intervention using Motivational Interviewing, and Referral to Treatment (SBIRT); and (2) reduce dietary risk factors (inflammatory dietary patterns) linked to CRC. The latter will be addressed by culturally adapting an existing, web-based lifestyle program called Alive!. Using a Hybrid Type 1 Implementation-Effectiveness cluster randomized design, we will randomize 22 AA churches into either the dual intervention arm (CHW-led SBIRT intervention plus Alive!) or a usual care arm comprised of CRC prevention educational pamphlets and a list of CRC screening sites. We will recruit 440 subjects and evaluate the effects of both arms on screening uptake (colonoscopy, fecal DNA) (primary outcome) and dietary inflammation score (secondary outcome) at 6-months follow up, and Life Simple7 (LS7) - a cardiovascular disease (CVD) risk score - at 6 months and 1-year (secondary outcome). Finally, guided by a racism-conscious adaptation of the Consolidated Framework for Implementation Research (CFIR), we will conduct a mixed- methods process evaluation with key stakeholders to understand multi-level influences on CRC screening and CVD risk behaviors. Discussion: Church-placed CHWs are trusted influential connectors between communities and health systems. Studies have shown that these CHWs can successfully implement health prevention protocols in churches, including those related to cancer control, making them potentially important community mediators of CRC screening uptake and CRC/CVD risk reduction. Trial registration: NCT05174286.

Racial/ethnic disparities in inpatient palliative care utilization and hospitalization outcomes among patients with colorectal cancer

PURPOSE

Research has shown that racial/ethnic disparities exist in outcomes for colorectal cancer (CRC) patients, but there are no studies assessing inpatient palliative care utilization and hospitalization outcomes in this population. We examined racial/ethnic disparities in palliative care utilization and hospitalization outcomes among CRC and early-onset CRC patients.

METHODS

Using National Inpatient Sample (NIS) data collected between 2016 and 2018, cross-sectional analyses were performed. Descriptive analyses were done, stratified by race/ethnicity. Multivariable logistic and linear regression models were used to examine racial/ethnic differences in palliative care utilization, inpatient mortality, chemotherapy/radiotherapy use, length of stay and total hospital charges among hospitalized patients with CRC and early-onset CRC.

RESULTS

Blacks had higher odds (AOR: 1.09; 95% CI: 1.03-1.16) of receiving palliative care consultation while Hispanics had lower odds (AOR: 0.90; 95% CI: 0.84-0.96) compared to Whites. Blacks had 1.1 times higher odds (95% CI: 1.01-1.18) of inpatient mortality relative to Whites while Hispanics had 16% (AOR: 0.84; 95% CI: 0.76-0.93) lower odds of inpatient mortality. Compared to Whites, Blacks (AOR: 1.99; 95% CI: 1.64-2.41), Hispanics (AOR: 2.49; 95% CI: 1.94-3.19) and colorectal cancer patients in the other category (AOR: 1.72; 95% CI: 1.35-2.18) were more likely to receive inpatient treatment with chemotherapy/radiotherapy. Furthermore, Black patients were 1.1 times (95% CI: 1.06-1.14) more likely to have a length of stay more than 5 days. Blacks (𝛃: $3,096.7; 95% CI: $1,207.0-$4,986.5) Hispanic (𝛃: $10,237.5; 95% CI: $7,558.2-$12,916.8) and other patients (𝛃: $6,332.0; 95% CI: $2,830.9-$9, 833.2) had higher hospital charges relative to their White counterparts. Among patients with early onset CRC, Blacks had higher palliative care use (AOR: 1.29; 95% CI: 1.10-1.51) and inpatient mortality (AOR: 1.38; 95% CI: 1.06-1.79) while Hispanics reported $5,589.7 (95% CI: $683.2-$10,496.2) higher total hospital charges and were more likely to receive inpatient chemotherapy/radiotherapy (AOR: 2.48; 95% CI: 1.70-3.63).

CONCLUSION

Further research is needed to explore specific cultural, socioeconomic, and political factors that explain these disparities and identify ways to narrow the gap. Meanwhile, the healthcare sector will need to assess what strategies might be helpful in addressing these disparities in outcomes in the context of other socioeconomic and cultural factors that may be affecting the patients.

Colorectal cancer survival disparities in the five regions of Georgia

BACKGROUND/OBJECTIVE

The objective of this study was to examine 5-year colorectal cancer survival rates. We also determined whether demographics, tumor characteristics, and treatment modality were associated with 5-year CRC survival in the Clayton, West Central, East Central, Southeast, and Northeast Georgia regions because the significant higher CRC mortality rates in these regions in comparison to the overall rates in the State of Georgia.

METHODS

We conducted a retrospective cohort analysis using data from the 1975-2016 Surveillance, Epidemiology, and End Results program aggregated CRC patients to these five regions. Five-year CRC survival was calculated and stratified by the five regions of Georgia, using the Kaplan-Meier method with log-rank test. Cox proportional hazard regression was used to examine the mentioned association in these five regions.

RESULTS

Among 11,023 CRC patients, 5-year CRC survival was lowest in Clayton (65.9%) compared to the West Central (69.0%), East Central (68.2%), Southeast (70.5%), and Northeast regions (69.5%) (p-value = 0.02). In multivariable analysis, greater risk of CRC death was found in the Clayton region compared to the West Central (HR, 1.12; 95%, 1.00-1.25) region when adjusting for demographics, tumor characteristics, and treatment modality. Among Clayton Georgians, age of 75+ years (HR, 2.13; 95%, 1.56-2.89), grade 3 & 4 tumors (HR, 2.22; 95%, 1.64-3.00), and distant stage (HR, 20.95; 95%, 15.99-27.45) were negatively associated with CRC survival.

CONCLUSION

We observed place-based differences in CRC survival with significantly lower survival rates in the Clayton region. Factors associated with higher risk of CRC death include older age at diagnosis, high-grade tumors, and distant stage CRC among Clayton Georgians. Our study provides important evidence to all relevant stakeholders in furthering the development of culturally tailored CRC screening interventions aimed at CRC early detection and improved outcomes.

Population-enriched innate immune variants may identify candidate gene targets at the intersection of cancer and cardio-metabolic disease

Both cancer and cardio-metabolic disease disparities exist among specific populations in the US. For example, African Americans experience the highest rates of breast and prostate cancer mortality and the highest incidence of obesity. Native and Hispanic Americans experience the highest rates of liver cancer mortality. At the same time, Pacific Islanders have the highest death rate attributed to type 2 diabetes (T2D), and Asian Americans experience the highest incidence of non-alcoholic fatty liver disease (NAFLD) and cancers induced by infectious agents. Notably, the pathologic progression of both cancer and cardio-metabolic diseases involves innate immunity and mechanisms of inflammation. Innate immunity in individuals is established through genetic inheritance and external stimuli to respond to environmental threats and stresses such as pathogen exposure. Further, individual genomes contain characteristic genetic markers associated with one or more geographic ancestries (ethnic groups), including protective innate immune genetic programming optimized for survival in their corresponding ancestral environment(s). This perspective explores evidence related to our working hypothesis that genetic variations in innate immune genes, particularly those that are commonly found but unevenly distributed between populations, are associated with disparities between populations in both cancer and cardio-metabolic diseases. Identifying conventional and unconventional innate immune genes that fit this profile may provide critical insights into the underlying mechanisms that connect these two families of complex diseases and offer novel targets for precision-based treatment of cancer and/or cardio-metabolic disease.

A case-control study of the association between the gut microbiota and colorectal cancer: exploring the roles of diet, stress, and race

BACKGROUND

The gut microbiota is associated with risk for colorectal cancer (CRC), a chronic disease for which racial disparities persist with Black Americans having a higher risk of CRC incidence and mortality compared to other groups. Given documented racial differences, the gut microbiota may offer some insight into previously unexplained racial disparities in CRC incidence and mortality. A case-control analysis comparing 11 women newly diagnosed with CRC with 22 cancer-free women matched on age, BMI, and race in a 1:2 ratio was conducted. Information about participants' diet and perceived stress levels were obtained via 24-h Dietary Recall and Perceived Stress Scale-10 survey, respectively. Participants provided stool samples from which microbial genomic DNA was extracted to reveal the abundance of 26 genera chosen a priori based on their previously observed relevance to CRC, anxiety symptoms, and diet.

RESULTS

Significantly lower alpha diversity was observed among cancer-free Black women compared to all other race-cancer status combinations. No group differences were observed when comparing beta diversity. Non-Hispanic White CRC cases tended to have higher relative abundance of Fusobacteria, Gemellaceae, and Peptostreptococcus compared to all other race-cancer combination groups. Perceived stress was inversely associated with alpha diversity and was associated with additional genera.

CONCLUSIONS

Our findings suggest that microbiome-CRC associations may differ by racial group. Additional large, racially diverse population-based studies are needed to determine if previously identified associations between characteristics of the gut microbiome and CRC are generalizable to Black women and other racial, ethnic, and gender groups.

National analysis of racial disparities in emergent surgery for colorectal cancer

Background

Racial disparities in access to preoperative evaluation for colorectal cancer remain unclear. Emergent admission may indicate lack of access to timely care. The present work aimed to evaluate the association of admission type with race among patients undergoing colorectal cancer surgery.

Methods

All adults undergoing resection for colorectal cancer in 2011-2020 National Inpatient Sample were identified. Multivariable regression models were developed to examine the association of admission type with race. Primary outcome was major adverse events (MAE), including mortality and complications. Secondary outcomes included costs and length of stay (LOS). Interaction terms between year, admission type, and race were used to analyze trends.

Results

Of 722,736 patients, 67.6 % had Elective and 32.4 % Emergent admission. Black (AOR 1.38 [95 % CI 1.33-1.44]), Hispanic (1.45 [1.38-1.53]), and Asian/Pacific Islander or Native American (1.25 [1.18-1.32]) race were associated with significantly increased odds of Emergent operation relative to White. Over the study period, non-White patients consistently comprised over 5 % greater proportion of the Emergent cohort compared to Elective. Furthermore, Emergent admission was associated with 3-fold increase in mortality and complications, 5-day increment in LOS, and $10,100 increase in costs. MAE rates among Emergent patients remained greater than Elective with a widening gap over time. Non-White patients experienced significantly increased MAE regardless of admission type.

Conclusion

Non-White race was associated with increased odds of emergent colorectal cancer resection. Given the persistent disparity over the past decade, systematic approaches to alleviate racial inequities in colorectal cancer screening and improve access to timely surgical treatment are warranted.

Variation in KRAS/NRAS/BRAF-Mutation Status by Age, Sex, and Race/Ethnicity Among a Large Cohort of Patients with Metastatic Colorectal Cancer (mCRC)

BACKGROUND

Racial/ethnic disparities in metastatic colorectal cancer (mCRC) survival are well documented as is the impact that tumor mutation of KRAS and BRAF has on prognosis. It has been suggested that frequency differences of KRAS- and BRAF-mutated tumors may partially explain this disparity. Demographic differences in mutation frequency are not well established nor whether mutation and microsatellite instability (MSI) differentially impact survival among groups.

METHODS

Using data for 11,117 patients diagnosed with de-novo mCRC from an electronic health record-derived database we estimated adjusted odds ratios (aOR) to characterize the association between demographics and MSI and KRAS/NRAS/BRAF-mutation status. Stratified Cox models were used to identify differences in overall survival (OS), adjusting for treatment and demographics.

RESULTS

Being female, compared to male, (aORKRAS:1.33 (1.23-1.44); aORBRAF:1.84 (1.56-2.16)), and non-Hispanic Black race (NHB), compared to non-Hispanic White (NHW) (aORKRAS:1.62 (1.42-1.85); aORBRAF: 0.55 (0.38-0.77)) were associated with KRAS- or BRAF-mutant tumors. MSI prevalence was similar across race/ethnicity but higher in women. BRAF-mutant tumors were associated with poorer prognosis overall, especially among non-white patients. Among patients who had KRAS/NRAS/BRAF-WT tumors we observed no difference in OS by race or MSI. Among patients with KRAS-mutant tumors, Hispanic patients had more favorable prognosis adjusted hazards ratio (aHR) = 0.76 (0.65-0.89)) than their NHW counterparts. Among those with BRAF-mutant tumors, NHB patients had poorer prognosis than NHW patients (aHR:1.78 (1.08-2.93)).

CONCLUSION

MSI and frequency of KRAS and BRAF mutations differed by demographics. Racial/ethnic disparities in OS differed by mutation. Future studies should explore biological and/or social determinants underlying these differences.

Availability of Primary Care Physicians and Racial Disparities in Colorectal Cancer-Related Mortality in the United States

INTRODUCTION

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States (US), however racial disparities in outcomes persist. We sought to assess the correlation of availability of primary care physicians (PCPs) and racial disparities in CRC-related mortality.

METHODS

We studied the correlation between age-adjusted incidence and mortality rates of CRC among all 50 states and the District of Columbia (D.C.) from the Center for Disease Control (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) with the number of actively practicing PCPs in all 50 states and D.C. from the Association of American Medical Colleges (AAMC) State Physician Workforce Data Report. Pearson's coefficient was used to study correlations and the two-sample t test was used for comparing state-level PCP/CRC ratios between the two groups. Statistical analysis was performed using VassarStats.

RESULTS

The mean AAMR per 100,000 population for CRC was significantly higher among AA versus White populations (t = 5.79, p < 0.001). Higher state-wide PCP per CRC case ratio correlated with lower state-wide CRCrelated mortality (r = -0.36, p = 0.011). The mean PCP per CRC case ratio was significantly lower among AA compared to White populations (t = -15.95, p < 0.0001). Higher PCP per CRC case ratio correlated with lower CRC-related mortality among both White (r = -0.64, p < 0.0001) and AA (r = -0.57, p = 0.0002) populations.

CONCLUSIONS

These findings suggest that racial disparities in CRC-related mortality may at least in part be related to lower availability of PCPs. Efforts focused on the development of strategies focused on improving access to primary care may help bridge racial disparities in CRC-related outcomes.

Epidemiology of Stage IV Colorectal Cancer: Trends in the Incidence, Prevalence, Age Distribution, and Impact on Life Span

Colorectal cancer is a common malignancy in men and women. Historically, stage IV colorectal cancer has 10 to 15% five-year survival. Developments in the management of colorectal metastatic disease have helped improve the overall survival of stage IV colorectal cancers from 12 to 30 months with some patients achieving disease-free survival.

Factors Associated With Racial and Ethnic Disparities in Locally Advanced Rectal Cancer Outcomes

Importance

Hispanic and non-Hispanic Black patients receiving neoadjuvant therapy and surgery for locally advanced rectal cancer (LARC) achieve less favorable clinical outcomes than non-Hispanic White patients, but the source of this disparity is incompletely understood.

Objective

To assess whether racial and ethnic disparities in treatment outcomes among patients with LARC could be accounted for by social determinants of health and demographic, clinical, and pathologic factors known to be associated with treatment response.

Design, Setting, and Participants

The National Cancer Database was interrogated to identify patients with T3 to T4 or N1 to N2 LARC treated with neoadjuvant therapy and surgery. Patients were diagnosed between January 1, 2004, and December 31, 2017. Data were culled from the National Cancer Database from July 1, 2022, through December 31, 2023.

Exposure

Neoadjuvant therapy for rectal cancer followed by surgical resection.

Main Outcomes and Measures

The primary outcome was the rate of pathologic complete response (pCR) following neoadjuvant therapy. Secondary outcomes were rate of tumor downstaging and achievement of pN0 status.

Results

A total of 34 500 patient records were reviewed; 21 679 of the patients (62.8%) were men and 12 821 (37.2%) were women. The mean (SD) age at diagnosis was 59.7 (12.0) years. In terms of race and ethnicity, 2217 patients (6.4%) were Hispanic, 2843 (8.2%) were non-Hispanic Black, and 29 440 (85.3%) were non-Hispanic White. Hispanic patients achieved tumor downstaging (48.9% vs 51.8%; P = .01) and pN0 status (66.8% vs 68.8%; P = .02) less often than non-Hispanic White patients. Non-Hispanic Black race, but not Hispanic ethnicity, was associated with less tumor downstaging (odds ratio [OR], 0.86 [95% CI, 0.78-0.94]), less frequent pN0 status (OR, 0.91 [95% CI, 0.83-0.99]), and less frequent pCR (OR, 0.81 [95% CI, 0.72-0.92]). Other factors associated with reduced rate of pCR included rural location (OR, 0.80 [95% CI, 0.69-0.93]), lack of or inadequate insurance (OR for Medicaid, 0.86 [95% CI, 0.76-0.98]; OR for no insurance, 0.65 [95% CI, 0.54-0.78]), and treatment in a low-volume center (OR for first quartile, 0.73 [95% CI, 0.62-0.87]; OR for second quartile, 0.79 [95% CI, 0.70-0.90]; OR for third quartile, 0.86 [95% CI, 0.78-0.94]). Clinical and pathologic variables associated with a decreased pCR included higher tumor grade (OR, 0.58 [95% CI, 0.49-0.70]), advanced tumor stage (OR for T3, 0.56 [95% CI, 0.42-0.76]; OR for T4, 0.30 [95% CI, 0.22-0.42]), and lymph node-positive disease (OR for N1, 0.83 [95% CI, 0.77-0.89]; OR for N2, 0.73 [95% CI, 0.65-0.82]).

Conclusions and Relevance

The findings of this cohort study suggest that disparate treatment outcomes for Hispanic and non-Hispanic Black patients are likely multifactorial in origin. Future investigation into additional social determinants of health and biological variables is warranted.

Incorporating Novel Technologies in Precision Oncology for Colorectal Cancer: Advancing Personalized Medicine

Colorectal cancer (CRC) is one of the most heterogeneous and deadly diseases, with a global incidence of 1.5 million cases per year. Genomics has revolutionized the clinical management of CRC by enabling comprehensive molecular profiling of cancer. However, a deeper understanding of the molecular factors is needed to identify new prognostic and predictive markers that can assist in designing more effective therapeutic regimens for the improved management of CRC. Recent breakthroughs in single-cell analysis have identified new cell subtypes that play a critical role in tumor progression and could serve as potential therapeutic targets. Spatial analysis of the transcriptome and proteome holds the key to unlocking pathogenic cellular interactions, while liquid biopsy profiling of molecular variables from serum holds great potential for monitoring therapy resistance. Furthermore, gene expression signatures from various pathways have emerged as promising prognostic indicators in colorectal cancer and have the potential to enhance the development of equitable medicine. The advancement of these technologies for identifying new markers, particularly in the domain of predictive and personalized medicine, has the potential to improve the management of patients with CRC. Further investigations utilizing similar methods could uncover molecular subtypes specific to emerging therapies, potentially strengthening the development of personalized medicine for CRC patients.

A Systems Biology Approach to Understand the Racial Disparities in Colorectal Cancer

Racial disparities between Black/African Americans (AA) and White patients in colorectal cancer are an ever-growing area of concern. Black/AA show the highest incidence and have the highest mortality among major U.S. racial groups. There is no definite cause other than possible sociodemographic, socioeconomic, education, nutrition, delivery of healthcare, screening, and cultural factors. A primary limitation in this field is the lack of and small sample size of Black/AA studies. Thus, this study aimed to investigate whether differences in gene expression contribute to this ongoing unanswered racial disparity issue. In this study, we examined transcriptomic data of Black/AA and White patient cohorts using a bioinformatic and systems biology approach. We performed a Kaplan-Meier overall survival analysis between both patient cohorts across critical colorectal cancer signal transduction networks (STN), to determine the differences in significant genes across each cohort. Other bioinformatic analyses performed included PROGENy (pathway responsive genes for activity inference), RNA sequencing differential expression using DESeq2, multivariable-adjusted regression, and other associated Kaplan-Meier analyses. These analyses identified novel prognostic genes independent from each cohort, 176 differentially expressed genes, and specific patient cohort STN survival associations. Despite the overarching limitation, the results revealed several novel differences in gene expression between the colorectal cancer Black/AA and White patient cohorts, which allows one to dive deeper into and understand the behavior on a systems level of what could be driving this racial difference across colorectal cancer. Concretely, this information can guide precision medicine approaches tailored specifically for colorectal cancer racial disparities.

SIGNIFICANCE

The purpose of this work is to investigate the racial disparities in colorectal cancer between Black/AA and White patient cohorts using a systems biology and bioinformatic approach. Our study investigates the underlying biology of each patient cohort. Concretely, the findings of this study include disparity-associated genes and pathways, which provide a tangible starting point to guide precision medicine approaches tailored specifically for colorectal cancer racial disparities.

Role of demographics in noninvasive testing for colorectal cancer screening: do targeted cut-off values improve detection?

BACKGROUND

Fecal immunochemical test (FIT) is a yearly alternative colorectal screening modality for average risk individuals unwilling or unable to undergo invasive colorectal cancer (CRC) screening due to cost and accessibility. This study aimed to determine whether FIT should be interpreted within the context of patient demographics and medical history.

METHODS

Patients >50 years old who had a FIT followed by colonoscopy within 1 year were analyzed based on age, race, BMI, social and medical comorbidities. False positive (FP) and false negative (FN) FIT results within each patient demographic and medical history variable were determined by comparing with the gold standard of colonoscopy using χ2 analysis.

RESULTS

One thousand twenty-five patients were reviewed. 21.8% of FIT results were positive. Factors which differed in positive FIT rates were age (P=0.003), smoking (P<0.001), alcohol (P=0.001), and hypertension (P<0.001). The difference in rates of FP and FN FIT outcomes among each variable underwent further subanalysis. The FP was 66.8% and the FN rate was 12.8%. Higher FN outcomes were noted in those above 70, males and smokers, though the result was only statistically significant for males (P=0.009). Females were observed to have higher FP rates (P=0.019).

CONCLUSIONS

Females had higher FP FIT rates compared to males, indicating that sex may influence FIT outcomes and should be accounted for when interpreting FIT results. This information can be utilized to identify populations at higher risk of FP or FN FIT results to target CRC screening. Additionally, recalculating the FP and FN rates for each variable may help determine new FIT targets.

Engaging the community on colorectal cancer screening: Additional factors identified by African Americans as potential barriers during focus groups

OBJECTIVE

African-Americans have the highest rate of colorectal cancer deaths. Adherence to colorectal cancer screening guidelines can improve outcomes. The objective of this study was to evaluate physician trust and barriers to screening utilizing a unique bi-directional learning focus group involving African-American adults and health care learners.

METHODS

A focus group of African-American adults from a community church and university health care learners was conducted to identify colon cancer screening barriers. Health care learners were medical students, resident physicians and gastroenterology fellows. Pre-focus group surveys, including the Wake Forest Physician Trust Scale (WFPTS) and a colon cancer screening knowledge survey, were administered. Audio recording of the focus group was transcribed with subsequent thematic analysis. A post-focus group survey evaluated the colorectal cancer screening barriers identified during the focus group. Analysis of pre- and post- focus group surveys was performed using Fisher Exact test with significance set at p<0.05.

RESULTS

The focus group consisted of 18 members (7 African-American community members, 11 non-African American health care learners). WFPTS revealed that 83% (86% community members, 82% health care learners; p = 1.0) strongly agree / agree that their physician would advocate for their health. 77% (86% community members, 73% health care learners; p = 1.0) strongly agree / agree that they trusted their physician. 100% recognized that colon cancer screening is recommended. The focus group identified lack of awareness (81%), colonoscopy preparation (81%), trust in physician (60%), lack of insurance coverage (56%), transportation (56%), colonoscopy wait time (50%), insufficient physician discussion (50%) and fear of procedure or cancer (35%) as screening barriers. Post-focus group surveys revealed that community members more frequently identified racial disparity in health care (p = 0.0474), physician respect toward patients (p = 0.0128) and insufficient physician discussion (p = 0.0006) as screening barriers.

CONCLUSIONS

Focus group discussion identified multiple barriers for colorectal cancer screening. Notably, differences in the perceptions of African-American community members and non-African-American health care learners about racial disparity in health care, physician respect toward patients and insufficient physician discussion were revealed. The integration of bi-directional focus group learning can be considered as a potential strategy to assist in the development of focused screening interventions.

Representation of Racial Minorities in the United States Colonoscopy Surveillance Interval Guidelines

BACKGROUND/AIMS

Clinical guidelines should ideally be formulated from data representative of the population they are applicable to; however, historically, studies have disproportionally enrolled non-Hispanic White (NHW) patients, leading to potential inequities in care for minority groups. Our study aims to evaluate the extent to which racial minorities were represented in the United States Colorectal Cancer Surveillance Guidelines.

METHODS

We reviewed US guidelines between 1997 and 2020 and all identified studies cited by recommendations for surveillance after a baseline colonoscopy with no polyps, adenomas, sessile serrated polyps, and hyperplastic polyps. We analyzed the proportion of studies reporting race, and among these studies, we calculated the racial distribution of patients and compared the proportion of Non-NHW patients between each subtype.

RESULTS

For all guidelines, we reviewed 75 studies encompassing 9,309,955 patients. Race was reported in 24% of studies and 14% of total patients. Non-NHW comprised 43% of patients in studies for normal colonoscopies, compared with 9% for adenomas, 22% for sessile serrated polyps, and 15% for hyperplastic polyps. For the 2020 guidelines, we reviewed 33 studies encompassing 5,930,722 patients. Race was reported in 15% of studies and 21% of total patients. Non-NHW comprised 43% of patients in studies for normal colonoscopies, compared with 9% for tubular adenomas. Race was not cited for any other 2020 guideline.

CONCLUSION

Racial minorities are significantly underrepresented in US Colorectal Cancer Surveillance Guidelines, which may contribute to disparities in care. Future studies should prioritize enrolling a diverse patient population to provide data that accurately reflects their population.

Overlooked and Damaging Impact of Structural Racism and Implicit Bias on US Health Care: Overarching Policy Implications

ABSTRACT

Marginalized populations, including racial and ethnic minorities, have historically faced significant barriers to accessing quality health care because of structural racism and implicit bias. A brief review and analysis of past and historic and current policies demonstrate that structural racism and implicit bias continue to underscore a health system characterized by unequal access and distribution of health care resources. Although advances in cancer care have led to decreased incidence and mortality, not all populations benefit. New policies must explicitly seek to eliminate disparities and drive equity for historically marginalized populations to improve access and outcomes.

Cost-Effectiveness of Liquid Biopsy for Colorectal Cancer Screening in Patients Who Are Unscreened

Importance

Despite recommendations for universal screening, adherence to colorectal cancer screening in the US is approximately 60%. Liquid biopsy tests are in development for cancer early detection, but it is unclear whether they are cost-effective for colorectal cancer screening.

Objective

To estimate the cost-effectiveness of liquid biopsy for colorectal cancer screening in the US.

Design, Setting, and Participants

In this economic evaluation, a Markov model was developed to compare no screening and 5 colorectal cancer screening strategies: colonoscopy, liquid biopsy, liquid biopsy following nonadherence to colonoscopy, stool DNA, and fecal immunochemical test. Adherence to first-line screening with colonoscopy, stool DNA, or fecal immunochemical test was assumed to be 60.6%, and adherence for liquid biopsy was assumed to be 100%. For colonoscopy, stool DNA, and fecal immunochemical test, patients who did not adhere to testing were not offered other screening. In colonoscopy-liquid biopsy hybrid, liquid biopsy was second-line screening for those who deferred colonoscopy. Scenario analyses were performed to include the possibility of polyp detection for liquid biopsy.

Exposures

No screening, colonoscopy, fecal immunochemical test, stool DNA, liquid biopsy, and colonoscopy-liquid biopsy hybrid screening.

Main Outcomes and Measures

Model outcomes included life expectancy, total cost, and incremental cost-effectiveness ratios. A strategy was considered cost-effective if it had an incremental cost-effectiveness ratio less than the US willingness-to-pay threshold of $100 000 per life-year gained.

Results

This study used a simulated cohort of patients aged 45 years with average risk of colorectal cancer. In the base case, colonoscopy was the preferred, or cost-effective, strategy with an incremental cost-effectiveness ratio of $28 071 per life-year gained. Colonoscopy-liquid biopsy hybrid had the greatest gain in life-years gained but had an incremental cost-effectiveness ratio of $377 538. Colonoscopy-liquid biopsy hybrid had a greater gain in life-years if liquid biopsy could detect polyps but remained too costly.

Conclusions and Relevance

In this economic evaluation of liquid biopsy for colorectal cancer screening, colonoscopy was a cost-effective strategy for colorectal cancer screening in the general population, and the inclusion of liquid biopsy as a first- or second-line screening strategy was not cost-effective at its current cost and screening performance. Liquid biopsy tests for colorectal cancer screening may become cost-effective if their cost is substantially lowered.

Overall Survival Differences in Young Black Colorectal Cancer Patients: a Report from the National Cancer Database

Objectives: Black patients have the highest overall incidence rate of early onset colorectal cancer, with many of these patients presenting with more aggressive disease at diagnosis, ultimately leading to decreased overall survival. We aimed to (1) evaluate how race and age affected overall survival in colorectal cancer patients, and (2) determine the different demographic and clinical covariables that may influence survival in younger individuals. Methods: The 2017 National Cancer Database (NCDB) was used to identify all patients that had colorectal cancer between 2004-2017. These patients were then divided into groups according to age (<45 and ≥45 years old) and race (white and black). Overall survival (OS) between white and black groups according to age was compared. Initial testing of survivor functions between groups revealed violations of the proportional hazards assumption. Accordingly, we used parametric maximum likelihood analyses fitting the survivor functions to Weibull distributions. Logistic regression analysis was used to determine univariate and multivariate relationships between the covariates and race for younger subjects. Propensity score matching analysis was also used to control for differences in the demographic or clinical variables between the young black versus white subgroups. Results: Out of 1.4 million potential cases initially identified, 207,823 unique cases were deemed eligible for evaluation based on study criteria. Black patients in the study population were more likely to be female, have medical comorbidities, and come from areas with lower average income and baseline education. OS was lower in older patients of both race categories when compared to the younger cohorts. Among patients older than 45 years, there were no significant differences in proportional hazard of death between black and white patients. However, among those younger than 45 years, younger black patients had significantly increased hazard of death. Regarding disease burden at diagnosis, pathologic characteristics and overall risk of death, there were no significant differences between black and white patients. Conclusions: Overall survival in young black patients with colorectal cancer is significantly reduced when compared to young white patients, even when controlling for demographic and pathologic factors. This suggests that the outcome disparities between black and white patients are complex, and the underlying factors are not well understood.

Impact of neoadjuvant chemotherapy for locally advanced colon cancer on postoperative complications

PURPOSE

Although not considered standard therapy, neoadjuvant chemotherapy (NAC) is an encouraging alternative for selected patients with locally advanced colon cancer (LAC). The aim of this study was to compare 30-day postoperative outcomes between patients undergoing upfront surgery and those undergoing NAC for LAC.

METHODS

Using the ACS-NSQIP data from 2016 to 2020, 11,498 patients with LAC were divided into those who underwent upfront colectomy (96.2%) and those who received NAC (3.8%). The primary outcome was a composite outcome encompassing 30-day major postoperative complications. Propensity score matched (PSM) analysis and multivariable logistic regression were performed.

RESULTS

After PSM analysis, there was no statistically significant difference in the development of a major complication. NAC was not significantly associated with the primary outcome. Risk factors for postoperative complications were T4 stage, older age, male sex, black race, smoking, dependent status, severe COPD, hypoalbuminemia, and preoperative transfusion. Laparoscopic and robotic surgery was protective.

CONCLUSION

NAC did not increase the odds of developing a major complication.

Prediagnostic 25-Hydroxyvitamin D in Association with Cancer-specific and All-cause Mortality among Low-income, Non-Hispanic Black Americans with Colorectal Cancer

BACKGROUND

Observational studies show high prediagnosis 25-hydroxyvitamin D is associated with lower mortality after colorectal cancer diagnosis. Results from clinical trials suggest vitamin D supplementation may improve outcomes among patients with colorectal cancer. Most studies included few Black Americans, who typically have lower 25-hydroxyvitamin D. We evaluated associations between serum 25-hydroxyvitamin D and mortality after colorectal cancer diagnosis among Black American cases.

METHODS

Data arose from 218 Black Americans from the Southern Community Cohort Study diagnosed with colorectal cancer during follow-up (age 40-79 at enrollment). Prediagnostic 25-hydroxyvitamin D was measured at enrollment and categorized as deficient (<12 ng/mL), insufficient (12-19.9 ng/mL), or sufficient (≥20 ng/mL). Mortality was determined from the National Death Index. Cox proportional hazards were used to estimate HRs and 95% confidence intervals (CI) for associations between 25-hydroxyvitamin D and mortality.

RESULTS

As a continuous exposure, higher 25-hydroxyvitamin D was associated with overall mortality [HR = 0.79 (0.65-0.96) per-SD increase, Ptrend = 0.02] and colorectal cancer-specific mortality [HR = 0.83 (0.64-1.08), Ptrend = 0.16]. For overall mortality, associations were strongest among females [HR = 0.65 (0.42-0.92)], current smokers [HR = 0.61 (0.38-0.98)], and obese participants [HR = 0.47 (0.29-0.77)]. Compared with those with deficiency, participants with sufficient 25-hydroxyvitamin D had lower overall mortality after multivariable adjustment [HR: 0.61 (0.37-1.01)].

CONCLUSIONS

Prediagnosis 25-hydroxyvitamin D is inversely associated with overall and colorectal cancer-specific mortality among Black Americans with colorectal cancer. Correcting vitamin D deficiency may improve survival of these patients, particularly for obese individuals and smokers.

IMPACT

Our results support including more Black Americans in trials of vitamin D supplementations to improve colorectal cancer outcomes.

Primary and Secondary Prevention Interventions to Reduce Risk Factors Associated with Colorectal Cancer in High-Risk Groups: a Systematic Literature Review

In the USA, colorectal cancer (CRC) is the 2nd leading cause of cancer-related deaths. Certain groups in the USA are at an increased risk of developing CRC, including those with a genetic risk and family history. The purpose of this project was to synthesize primary and secondary prevention interventions for individuals who are at high risk of CRC due to family history or genetic predisposition. This study systematically reviewed articles from PubMed, Google Scholar, and EBSCO using specific search terms to find relevant articles. Sixteen articles were identified for full-text review, which were categorized as non-drug interventions (n = 7) and drug interventions (n = 9). Non-drug interventions focused primarily on increasing screening in those with a first-degree relative (FDR) with CRC or those with Lynch syndrome (LS). Interventions that increased CRC screening often had a tailored component and were otherwise varied in study designs and intervention type. Drug interventions focused on the use of NSAIDs on patients with familial adenomatous polyposis (FAP). Studies showed very little racial and ethnic diversity. Findings suggest that tailored interventions are particularly effective in increasing CRC screening, and greater diversity of sample is needed with respect to race and ethnicity.

Associations between MICA and MICB Genetic Variants, Protein Levels, and Colorectal Cancer: Atherosclerosis Risk in Communities (ARIC)

BACKGROUND

The MHC class I chain-related protein A (MICA) and protein B (MICB) participate in tumor immunosurveillance and may be important in colorectal cancer, but have not been examined in colorectal cancer development.

METHODS

sMICA and sMICB blood levels were measured by SomaScan in Visit 2 (1990-92, baseline) and Visit 3 (1993-95) samples in cancer-free participants in the Atherosclerosis Risk in Communities Study. We selected rs1051792, rs1063635, rs2516448, rs3763288, rs1131896, rs2596542, and rs2395029 that were located in or in the vicinity of MICA or MICB and were associated with cancer or autoimmune diseases in published studies. SNPs were genotyped by the Affymetrix Genome-Wide Human SNP Array. We applied linear and Cox proportional hazards regressions to examine the associations of preselected SNPs with sMICA and sMICB levels and colorectal cancer risk (236 colorectal cancers, 8,609 participants) and of sMICA and sMICB levels with colorectal cancer risk (312 colorectal cancers, 10,834 participants). In genetic analyses, estimates adjusted for ancestry markers were meta-analyzed.

RESULTS

Rs1051792-A, rs1063635-A, rs2516448-C, rs3763288-A, rs2596542-T, and rs2395029-G were significantly associated with decreased sMICA levels. Rs2395029-G, in the vicinity of MICA and MICB, was also associated with increased sMICB levels. Rs2596542-T was significantly associated with decreased colorectal cancer risk. Lower sMICA levels were associated with lower colorectal cancer risk in males (HR = 0.68; 95% confidence interval, 0.49-0.96) but not in females (Pinteraction = 0.08).

CONCLUSIONS

Rs2596542-T associated with lower sMICA levels was associated with decreased colorectal cancer risk. Lower sMICA levels were associated with lower colorectal cancer risk in males.

IMPACT

These findings support an importance of immunosurveillance in colorectal cancer.

A Multi-Omics Overview of Colorectal Cancer to Address Mechanisms of Disease, Metastasis, Patient Disparities and Outcomes

Human colorectal cancer (CRC) is one of the most common malignancies in men and women across the globe, albeit CRC incidence and mortality shows a substantial racial and ethnic disparity, with the highest burden in African American patients. Even with effective screening tools such as colonoscopy and diagnostic detection assays, CRC remains a substantial health burden. In addition, primary tumors located in the proximal (right) or distal (left) sides of the colorectum have been shown to be unique tumor types that require unique treatment schema. Distal metastases in the liver and other organ systems are the major causes of mortality in CRC patients. Characterizing genomic, epigenomic, transcriptomic and proteomic (multi-omics) alterations has led to a better understanding of primary tumor biology, resulting in targeted therapeutic advancements. In this regard, molecular-based CRC subgroups have been developed that show correlations with patient outcomes. Molecular characterization of CRC metastases has highlighted similarities and differences between metastases and primary tumors; however, our understanding as to how to improve patient outcomes based on metastasis biology is lagging and remains a major obstacle to improving CRC patient outcomes. In this review, we will summarize the multi-omics features of primary CRC tumors and their metastases across racial and ethnic groups, the differences in proximal and distal tumor biology, molecular-based CRC subgroups, treatment strategies and challenges for improving patient outcomes.

Clinicopathological Characteristics and Mutational Landscape of APC, HOXB13, and KRAS among Rwandan Patients with Colorectal Cancer

Cancer research in Rwanda is estimated to be less than 1% of the total African cancer research output with limited research on colorectal cancer (CRC). Rwandan patients with CRC are young, with more females being affected than males, and most patients present with advanced disease. Considering the paucity of oncological genetic studies in this population, we investigated the mutational status of CRC tissues, focusing on the Adenomatous polyposis coli (APC), Kirsten rat sarcoma (KRAS), and Homeobox B13 (HOXB13) genes. Our aim was to determine whether there were any differences between Rwandan patients and other populations. To do so, we performed Sanger sequencing of the DNA extracted from formalin-fixed paraffin-embedded adenocarcinoma samples from 54 patients (mean age: 60 years). Most tumors were located in the rectum (83.3%), and 92.6% of the tumors were low-grade. Most patients (70.4%) reported never smoking, and 61.1% of patients had consumed alcohol. We identified 27 variants of APC, including 3 novel mutations (c.4310_4319delAAACACCTCC, c.4463_4470delinsA, and c.4506_4507delT). All three novel mutations are classified as deleterious by MutationTaster2021. We found four synonymous variants (c.330C>A, c.366C>T, c.513T>C, and c.735G>A) of HOXB13. For KRAS, we found six variants (Asp173, Gly13Asp, Gly12Ala, Gly12Asp, Gly12Val, and Gln61His), the last four of which are pathogenic. In conclusion, here we contribute new genetic variation data and provide clinicopathological information pertinent to CRC in Rwanda.

Microsatellite Instability with BRAF V600E Associated with Delayed Presentation but Poor Survival in Stage III Colorectal Cancer

Colorectal cancer (CRC) has tremendous molecular and genetic heterogeneity, making it a difficult cancer to treat. Two of the key prognostic indicators of CRC include microsatellite instability (MSI) and BRAF V600E mutation. Here, we performed a retrospective survival analysis on 145 stage II and III CRC patients treated at the University of Kansas Cancer Center between 2009 and 2020. Of the 145 patients, BRAF V600E was observed in 15% patients and MSI in 28% patients. Median survival was not reached for stage II. For stage III, patients with BRAF V600E showed poor overall survival, which worsened with concurrent presence of MSI [χ2=6.4, p=0.01]. Eighty-five percent of this group was found to have right-sided CRC. For stage III, overall survival (OS) was 27 months, 37 months, 87 months and not reached for MSI-H/BRAF V600E, MSS/BRAF V600E, MSS/BRAF WT and MSI-H/BRAF WT, respectively. Although associated with poor prognosis, presence of MSI in BRAF V600E patients was associated with delayed disease presentation (mean age 77) compared to those with stable microsatellite (mean age 63) [p=0.01]. Although median survival between the groups could not be assessed for stage II due to very few deaths and/or inadequate length of study, comparison of survival trend suggests that BRAF V600E, rather than MSI, is what drives prognosis in stage II CRC. Our findings suggest that prognostic value of MSI is more relevant for stage III than stage II CRC. Patients with MSI-H and BRAF V600E have advantage of late presentation, although at the cost of poor overall prognosis.

Colon cancer transcriptome

Over the last four decades, methodological innovations have continuously changed transcriptome profiling. It is now feasible to sequence and quantify the transcriptional outputs of individual cells or thousands of samples using RNA sequencing (RNA-seq). These transcriptomes serve as a connection between cellular behaviors and their underlying molecular mechanisms, such as mutations. This relationship, in the context of cancer, provides a chance to unravel tumor complexity and heterogeneity and uncover novel biomarkers or treatment options. Since colon cancer is one of the most frequent malignancies, its prognosis and diagnosis seem to be critical. The transcriptome technology is developing for an earlier and more accurate diagnosis of cancer which can provide better protectivity and prognostic utility to medical teams and patients. A transcriptome is a whole set of expressed coding and non-coding RNAs in an individual or cell population. The cancer transcriptome includes RNA-based changes. The combined genome and transcriptome of a patient may provide a comprehensive picture of their cancer, and this information is beginning to affect treatment decision-making in real-time. A full assessment of the transcriptome of colon (colorectal) cancer has been assessed in this review paper based on risk factors such as age, obesity, gender, alcohol use, race, and also different stages of cancer, as well as non-coding RNAs like circRNAs, miRNAs, lncRNAs, and siRNAs. Similarly, they have been examined independently in the transcriptome study of colon cancer.

Colorectal Cancer Risk Assessment and Precision Approaches to Screening: Brave New World or Worlds Apart?

Current colorectal cancer (CRC) screening recommendations take a "one-size-fits-all" approach using age as the major criterion to initiate screening. Precision screening that incorporates factors beyond age to risk stratify individuals could improve on current approaches and optimally use available resources with benefits for patients, providers, and health care systems. Prediction models could identify high-risk groups who would benefit from more intensive screening, while low-risk groups could be recommended less intensive screening incorporating noninvasive screening modalities. In addition to age, prediction models incorporate well-established risk factors such as genetics (eg, family CRC history, germline, and polygenic risk scores), lifestyle (eg, smoking, alcohol, diet, and physical inactivity), sex, and race and ethnicity among others. Although several risk prediction models have been validated, few have been systematically studied for risk-adapted population CRC screening. In order to envisage clinical implementation of precision screening in the future, it will be critical to develop reliable and accurate prediction models that apply to all individuals in a population; prospectively study risk-adapted CRC screening on the population level; garner acceptance from patients and providers; and assess feasibility, resources, cost, and cost-effectiveness of these new paradigms. This review evaluates the current state of risk prediction modeling and provides a roadmap for future implementation of precision CRC screening.

Systemic treatment for metastatic colorectal cancer

Significant progress has been achieved in the treatment of metastatic colorectal cancer (mCRC) patients during the last 20 years. There are currently numerous treatments available for the first-line treatment of mCRC. Sophisticated molecular technologies have been developed to reveal novel prognostic and predictive biomarkers for CRC. The development of next-generation sequencing and whole-exome sequencing, which are strong new tools for the discovery of predictive molecular biomarkers to facilitate the delivery of customized treatment, has resulted in tremendous breakthroughs in DNA sequencing technology in recent years. The appropriate adjuvant treatments for mCRC patients are determined by the tumor stage, presence of high-risk pathologic characteristics, microsatellite instability status, patient age, and performance status. Chemotherapy, targeted therapy, and immunotherapy are the main systemic treatments for patients with mCRC. Despite the fact that these novel treatment choices have increased overall survival for mCRC, survival remains optimal for individuals with non-metastatic disease. The molecular technologies currently being used to support our ability to practice personalized medicine; the practical aspects of applying molecular biomarkers to regular clinical practice; and the evolution of chemotherapy, targeted therapy, and immunotherapy strategies for the treatment of mCRC in the front-line setting are all reviewed here.

Systemic treatment for metastatic colorectal cancer

Significant progress has been achieved in the treatment of metastatic colorectal cancer (mCRC) patients during the last 20 years. There are currently numerous treatments available for the first-line treatment of mCRC. Sophisticated molecular technologies have been developed to reveal novel prognostic and predictive biomarkers for CRC. The development of next-generation sequencing and whole-exome sequencing, which are strong new tools for the discovery of predictive molecular biomarkers to facilitate the delivery of customized treatment, has resulted in tremendous breakthroughs in DNA sequencing technology in recent years. The appropriate adjuvant treatments for mCRC patients are determined by the tumor stage, presence of high-risk pathologic characteristics, microsatellite instability status, patient age, and performance status. Chemotherapy, targeted therapy, and immunotherapy are the main systemic treatments for patients with mCRC. Despite the fact that these novel treatment choices have increased overall survival for mCRC, survival remains optimal for individuals with non-metastatic disease. The molecular technologies currently being used to support our ability to practice personalized medicine; the practical aspects of applying molecular biomarkers to regular clinical practice; and the evolution of chemotherapy, targeted therapy, and immunotherapy strategies for the treatment of mCRC in the front-line setting are all reviewed here.

Ethnic Disparities in Ileal Pouch Anal Anastomosis Outcomes: An ACS-NSQIP Study

INTRODUCTION

Ileal pouch-anal anastomosis (IPAA) has become the gold standard operation performed for patients with ulcerative colitis (UC) who require colectomy for medically refractory disease or colitis-associated neoplasia. This study aims to evaluate whether differences in surgical outcomes following IPAA creation is associated with minority ethnicity using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical outcomes database.

METHODS

The ACS-NSQIP proctectomy-targeted data files (2016-2019) were reviewed to identify patients who underwent an IPAA creation (Current Procedural Terminology codes: 44157, 44158, 44211, and 45113). Demographic, comorbidity, perioperative characteristics, and postoperative outcomes, particularly total-morbidity, surgical site infection, and anastomotic leak, were compared for White, African-American, Hispanic, and Asian patients. Separate multivariable logistic regressions were calculated for each outcome of interest. Certain postoperative outcomes required collation to be analyzed due to low numbers, such as combining all surgical site infections (SSIs), anastomotic leak, and septic complications as "infection complications". For each regression, a P value of <0.05 was considered to be significant.

RESULTS

A total of 1462 patients were identified who underwent an IPAA creation. There were 1290 (88.2%) Caucasian, 66 (4.5%) African-American, 49 (3.4%) Hispanic, and 57 (3.9%) Asian patients. Minority race or ethnicity was not associated with higher odds of total morbidity, readmission, reoperation, the development of any SSI, anastomotic leak, or other septic complications as compared to White patients. African-American ethnicity was associated with higher odds of developing postoperative bleeding complications (odds ratio [OR] 2.45, 95% confidence interval [CI] 1.15-5.21; P = 0.020) and postoperative renal dysfunction (OR 4.32, CI 1.43-13.07; P = 0.010) as compared to White patients. Elevated body mass index (BMI) was associated with higher odds of developing an SSI (OR 1.03, CI 1.00-1.06; P = 0.045), or an "infection" complication (OR 1.04, CI 1.01-1.07; P = 0.012), but was protective against bleeding complications (OR 0.94, CI 0.9-0.98; P = 0.004). Smoking was associated with higher odds of developing an SSI, anastomotic leak, or septic complications in the combined "infection" regression analysis (OR 2.02, CI 1.25-3.26; P = 0.004). In the analysis of total-morbidity, both hypertension (OR 1.64, CI 1.11-2.42; P = 0.013) and an ASA Class score >3 (OR 1.36, CI 1.03-1.79; P = 0.029) were associated with increased odds of complications.

CONCLUSIONS

This analysis of the ACS-NSQIP national database data suggests that ethnicity is not associated with disparities in surgical outcomes following IPAA surgery. African-American ethnicity was however associated with higher odds of developing postoperative bleeding complications and renal dysfunction as compared to White patients. Elevated BMI and smoking history are associated with an increased risk of SSI, anastomotic leak and septic complications.

Design of the Building Research in CRC prevention (BRIDGE-CRC) trial: a 6-month, parallel group Mediterranean diet and weight loss randomized controlled lifestyle intervention targeting the bile acid-gut microbiome axis to reduce colorectal cancer risk among African American/Black adults with obesity

BACKGROUND

Among all racial/ethnic groups, people who identify as African American/Blacks have the second highest colorectal cancer (CRC) incidence in the USA. This disparity may exist because African American/Blacks, compared to other racial/ethnic groups, have a higher prevalence of risk factors for CRC, including obesity, low fiber consumption, and higher intakes of fat and animal protein. One unexplored, underlying mechanism of this relationship is the bile acid-gut microbiome axis. High saturated fat, low fiber diets, and obesity lead to increases in tumor promoting secondary bile acids. Diets high in fiber, such as a Mediterranean diet, and intentional weight loss may reduce CRC risk by modulating the bile acid-gut microbiome axis. The purpose of this study is to test the impact of a Mediterranean diet alone, weight loss alone, or both, compared to typical diet controls on the bile acid-gut microbiome axis and CRC risk factors among African American/Blacks with obesity. Because weight loss or a Mediterranean diet alone can reduce CRC risk, we hypothesize that weight loss plus a Mediterranean diet will reduce CRC risk the most.

METHODS

This randomized controlled lifestyle intervention will randomize 192 African American/Blacks with obesity, aged 45-75 years to one of four arms: Mediterranean diet, weight loss, weight loss plus Mediterranean diet, or typical diet controls, for 6 months (48 per arm). Data will be collected at baseline, mid-study, and study end. Primary outcomes include total circulating and fecal bile acids, taurine-conjugated bile acids, and deoxycholic acid. Secondary outcomes include body weight, body composition, dietary change, physical activity, metabolic risk, circulating cytokines, gut microbial community structure and composition, fecal short-chain fatty acids, and expression levels of genes from exfoliated intestinal cells linked to carcinogenesis.

DISCUSSION

This study will be the first randomized controlled trial to examine the effects of a Mediterranean diet, weight loss, or both on bile acid metabolism, the gut microbiome, and intestinal epithelial genes associated with carcinogenesis. This approach to CRC risk reduction may be especially important among African American/Blacks given their higher risk factor profile and increased CRC incidence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04753359 . Registered on 15 February 2021.

Survival improvement for patients with metastatic colorectal cancer over twenty years

Over the past two decades of successive clinical trials in metastatic colorectal cancer (CRC), the median overall survival of both control and experimental arms has steadily improved. However, the incremental change in survival for metastatic CRC patients not treated on trial has not yet been quantified. We performed a retrospective review of 1420 patients with de novo metastatic CRC who received their primary treatment at the University of Texas M.D. Anderson Cancer Center (UTMDACC) from 2004 through 2019. Median OS was roughly stable for patients diagnosed between 2004 and 2012 (22.6 months) but since has steadily improved for those diagnosed in 2013 to 2015 (28.8 months), and 2016 to 2019 (32.4 months). Likewise, 5-year survival rate has increased from 15.7% for patients diagnosed from 2004 to 2006 to 26% for those diagnosed from 2013 to 2015. Notably, survival improved for patients with BRAFV600E mutant as well as microsatellite unstable (MSI-H) tumors. Multivariate regression analysis identified surgical resection of liver metastasis (HR = 0.26, 95% CI, 0.19-0.37), use of immunotherapy (HR = 0.44, 95% CI, 0.29-0.67) and use of third line chemotherapy (regorafenib or trifluridine/tipiracil, HR = 0.74, 95% CI, 0.58-0.95), but not year of diagnosis (HR = 0.99, 95% CI, 0.98-1), as associated with better survival, suggesting that increased use of these therapies are the drivers of the observed improvement in survival.

The effect of medicare and screening guidelines on colorectal cancer outcomes

BACKGROUND

Colorectal cancer screening has been shown effective at reducing stage at presentation, but there is differential uptake of screening based on insurance status. We sought to determine the population-level effect of Medicare and screening guidelines on colorectal screening by race and region.

METHODS

Data on Black and white patients with colorectal cancer were obtained from the SEER database. Regression discontinuity was used to assess the causal effect of near-universal health insurance (represented by age 65) and United States Preventive Services Task Force guidelines (age 50) on the proportion of people presenting at advanced stage. This was stratified by race and region.

RESULTS

In the Southern United States, Black patients saw a significant decrease in advanced stage at presentation at age 65 (coefficient -0.12, p = 0.003), while white patients did not (coefficient -0.03, p = 0.09). At age 50, neither Black (coefficient 0.09, p = 0.10) nor white patients (coefficient -0.04, p = 0.1) saw a significant decrease in advanced stage. In the Western U.S., neither Black (coefficient 0.02, p = 0.72) or white patients (coefficient -0.02, p = 0.09) saw a significant decrease in advanced stage at age 65; however, both Black (coefficient -0.20, p = 0.008) and white patients (coefficient -0.05, p = 0.03) saw a significant decrease at age 50.

CONCLUSIONS

Our data highlight the significant impact that near-universal insurance has on reducing colorectal cancer stage at presentation in areas with poor baseline insurance coverage, particularly for Black patients. To reduce disparities in advanced stage at presentation for colorectal cancer, state-level insurance coverage should be addressed.

A case-control study of the association between the gut microbiota and colorectal cancer: exploring the roles of diet, stress, and race

Background

The gut microbiota is associated with risk for colorectal cancer (CRC), a chronic disease for which racial disparities persist with Black Americans having a higher risk of CRC incidence and mortality compared to other groups. Given documented racial differences, the gut microbiota may offer some insight into previously unexplained racial disparities in CRC incidence and mortality. A case-control analysis comparing 11 women newly diagnosed with CRC with 22 cancer-free women matched on age, BMI, and race in a 1:2 ratio was conducted. Information about participants' diet and perceived stress levels were obtained via 24-hour Dietary Recall and Perceived Stress Scale-10 survey, respectively. Participants provided stool samples from which microbial genomic DNA was extracted to reveal the abundance of 26 genera chosen a priori based on their previously observed relevance to CRC, anxiety symptoms, and diet.

Results

Significantly lower alpha diversity was observed among cancer-free Black women compared to all other race-cancer status combinations. No group differences were observed when comparing beta diversity. Non-Hispanic White CRC cases tended to have higher relative abundance of Fusobacteria, Gemellaceae, and Peptostreptococcus compared to all other race-cancer combination groups. Perceived stress was inversely associated with alpha diversity and was associated with additional genera.

Conclusions

Our findings suggest that microbiome-CRC associations may differ by racial group. Additional large, racially diverse population-based studies are needed to determine if previously identified associations between characteristics of the gut microbiome and CRC are generalizable to Black women and other racial, ethnic, and gender groups.

Examining colorectal cancer screening uptake and health provider recommendations among underserved middle aged and older African Americans

Background: The purpose of this study is to determine whether underserved middle-aged and older African Americans are receiving a colorectal cancer (CRC) screening test (sigmoidoscopy or colonoscopy) and if recommended by their provider. Additionally, we examined correlates of both provider recommendation and uptake of CRC screening. Methods: Seven hundred forty African American individuals, aged 55 and older, participated in this local community cross-sectional survey. We used a multivariate technique of logistic regression. Results: One out of three participants reported that they never received a sigmoidoscopy or colonoscopy for CRC screening. More than 31% indicted that their providers never suggested CRC testing. However, participants who indicated that their providers recommended sigmoidoscopy/colonoscopy were almost 49 times (odds ratio [OR]: 48.9, 95% confidence interval [CI]: 29.5-81.2) more likely to obtain it compared to their counterparts who were not advised to have these procedures. Our data suggest that African American men were significantly less likely than women to receive recommendations from their providers (OR: 0.70, 95% CI: 0.50-0.91). Furthermore, controlling for other variables, the following factors: 1) living arrangement (OR: 1.44, 95% CI: 1.02-2.04), 2) health maintenance organization (HMO) membership (OR: 1.84, 95% CI: 1.28-2.67), 3) number of providers (OR: 1.15, 95% CI: 1.01-1.32), 4) satisfaction with access to and quality of care (OR: 1.24, 95% CI: 1.03-1.51), 5) depressive symptoms (OR: 0.92, 95% CI: 0.86-0.98), and 6) gastrointestinal conditions (OR: 1.73, 95% CI: 1.16-2.58) were associated with obtaining a sigmoidoscopy or colonoscopy test. Conclusion: Our findings suggest that the absence of a provider recommendation is the primary barrier preventing underserved older African Americans from obtaining CRC screening. In addition, our data revealed significant association between obtaining CRC screening and some of the predisposing characteristics of participants, satisfaction with access to and quality of care, and physical and mental health. These findings are consistent with this notion that disparities in health care for African Americans can be traced back to four primary factors: patients, healthcare providers, the healthcare system, and society as a whole, and emphasize the need for establishing theory-driven, culturally-sensitive, and cost-effective CRC screening interventions that recognize and address the constraints to cancer screening experienced by this segment of population.

A Race-Specific, DNA Methylation Analysis of Aging in Normal Rectum: Implications for the Biology of Aging and Its Relationship to Rectal Cancer

Approximately 90% of colorectal cancer (CRC) develop over the age of 50, highlighting the important role of aging in CRC risk. African Americans (AAs) shoulder a greater CRC burden than European Americans (EA) and are more likely to develop CRC at a younger age. The effects of aging in AA and EA normal rectal tissue have yet to be defined. Here, we performed epigenome-wide DNA methylation analysis in the first, large-scale biracial cohort of normal rectum (n = 140 samples). We identified increased epigenetic age acceleration in EA than AA rectum (p = 3.91 × 10^-4) using linear regression. We also identified differentially methylated regions (DMRs) associated with chronological aging in AA and EA, separately using DMRcate. Next, a consensus set of regions associated with cancer was identified through DMR analysis of two rectal cancer cohorts. The vast majority of AA DMRs were present in our analysis of aging in rectum of EA subjects, though rates of epigenetic drift were significantly greater in AA (p = 1.94 × 10^-45). However, 3.66-fold more DMRs were associated with aging in rectum of EA subjects, many of which were also associated with rectal cancer. Our findings reveal a novel relationship between race, age, DNA methylation and rectal cancer risk that warrants further investigation.

Lower Utilization of Colorectal Cancer Screening Among Vegetarians, Adventist Health Study-2

This study aims to examine lifestyle predictors of the utilization of colorectal cancer screening. Using modified Poisson regression, we studied self-reported colorectal cancer screening utilization (colonoscopy or fecal occult blood test) with various dietary and lifestyle characteristics among 33,922 subjects aged 51 + years in the Adventist Health Study-2, a large population-based prospective cohort study. According to the multivariable-adjusted models, vegetarians were less likely to report screening: vegans, prevalence ratio (PR) = 0.80 (95% confidence interval 0.77-0.83); lacto-ovo-vegetarians (0.95 [0.93-0.97]); and semi-vegetarians (0.97 [0.94-0.99]) compared to non-vegetarians. Blacks were more likely than non-Blacks to be screened (1.04 [1.02-1.06]) and males were less likely (0.93 [0.92-0.95]) to utilize the screening tests. Older subjects were more likely to be screened, and unmarried and divorced/widowed subjects were less likely to screen. Education, personal income, and BMI were positively associated with screening, with p-value for trend < 0.001 for all three variables. A family history of colorectal cancer was associated with higher screening prevalence (1.15 [1.12-1.17]). Our stratified analyses on race and gender with dietary patterns showed non-Hispanic White vegans (PR = 0.77 [0.74-0.81]) and male vegans (PR = 0.76 [0.72-0.81]) were least likely compliant with colorectal cancer screening (p = 0.009 and p = 0.04, respectively). Vegans may believe that their personal risk for colorectal cancer is low due to their healthy lifestyle, resulting in lack of compliance to colorectal cancer screening. It remains to be seen whether vegans in AHS-2 also experience higher incidence of colorectal cancer or are diagnosed at a later stage.

Race, age, and sex differences on the influence of obesity on colorectal cancer sidedness and mortality: A national cross‐sectional study

BACKGROUND AND OBJECTIVES

Colorectal cancer (CRC) sidedness is recognized as a prognostic factor for survival; left-sided colorectal cancer is associated with better outcomes than right-sided colon cancer (RsCC). We aimed to evaluate the influence of obesity on CRC sidedness and determine how race, age, and sex affect mortality among overweight and obese individuals.

METHODS

A survey-weighted analysis was conducted using data obtained from the National Inpatient Sample between 2016 and 2019.

RESULTS

Of the 24 549 patients with a diagnosis of CRC and a reported body mass index (BMI), 13.6% were overweight and 49.9% were obese. The race distribution was predominantly non-Hispanic Whites (69.7%), followed by Black (15.6%), Hispanic (8.7%), and other race (6.1%). Overweight (BMI: 25-29.9) and obese (BMI: ≥30) individuals were more likely to have RsCC (adjusted OR [aOR] = 1.28; 95% CI: 1.17-1.39, p < 0.001 and aOR = 1.45; 95% CI: 1.37-1.54, p < 0.001, respectively). Obese Black individuals were more likely to have RsCC as compared to their White counterparts (aOR = 1.23; 95% CI: 1.09-1.38).

CONCLUSIONS

Obesity is associated with an increased risk of RsCC. In addition, racial disparities in CRC sidedness and outcomes are most pronounced among obese patients.

Regulatory Roles of Noncoding RNAs in the Progression of Gastrointestinal Cancers and Health Disparities

Annually, more than a million individuals are diagnosed with gastrointestinal (GI) cancers worldwide. With the advancements in radio- and chemotherapy and surgery, the survival rates for GI cancer patients have improved in recent years. However, the prognosis for advanced-stage GI cancers remains poor. Site-specific GI cancers share a few common risk factors; however, they are largely distinct in their etiologies and descriptive epidemiologic profiles. A large number of mutations or copy number changes associated with carcinogenesis are commonly found in noncoding DNA regions, which transcribe several noncoding RNAs (ncRNAs) that are implicated to regulate cancer initiation, metastasis, and drug resistance. In this review, we summarize the regulatory functions of ncRNAs in GI cancer development, progression, chemoresistance, and health disparities. We also highlight the potential roles of ncRNAs as therapeutic targets and biomarkers, mainly focusing on their ethnicity-/race-specific prognostic value, and discuss the prospects of genome-wide association studies (GWAS) to investigate the contribution of ncRNAs in GI tumorigenesis.

News Coverage of Colorectal Cancer on Google News: Descriptive Study

Background

Colorectal cancer (CRC) is one of the leading causes of cancer death in the United States. The incidence and prevalence of CRC have historically increased with age. Although rates of CRC in the United States have been decreasing over the past decades among those aged ≥65 years, there has been an uptick among those in younger age brackets. Google News is one of the biggest traffic drivers to top news sites. It aggregates and shares news highlights from multiple sources worldwide and organizes them by content type. Despite the widespread use of Google News, research is lacking on the type of CRC content represented in this news source. 

Objective

The purpose of this study was to analyze content related to CRC screening and prevention in Google News articles published during National Colorectal Cancer Awareness Month (March 2022).

Methods

Data collection for this cross-sectional study was conducted in March 2022—National Colorectal Cancer Awareness Month. Using the term colorectal cancer, 100 English-language Google News articles were extracted and coded for content. A combined approach—deductive and inductive coding—was utilized. Descriptive analyses were conducted, and frequency distributions were reported. Univariable analyses were performed to assess differences between articles that mentioned CRC screening and those that did not via chi-square tests.

Results

Of the 100 articles reviewed, nearly half (n=49, 49%) were created by health news organizations, and another 27% (n=27) were created by television news services. The predominant themes in the content included age at the onset of disease (n=59, 59%), mortality related to CRC (n=57, 57%), and the severity of disease (n=50, 50%). Only 18% (n=18) of articles discussed CRC disparities, 23% (n=23) mentioned that there are hereditary forms of the disease, 36% (n=36) spoke of colonoscopy to screen for the disease, and 37% (n=37) mentioned how the disease is treated. Although most articles mentioned CRC screening (n=61, 61%), it was striking that sex was only mentioned in 34% (21/61) of these articles, colonoscopy was mentioned in 46% (28/61), and diet was mentioned in 30% (18/61).

Conclusions

Heightening the public’s awareness of this disease is important, but it is critical that messages related to how preventable this cancer is, who is the most likely to develop CRC, and what can be done to detect it in the early stages when the disease is the most curable be the critical elements of dialogue, particularly during National Colorectal Cancer Awareness Month. There is a need to disseminate information about early-onset CRC and the importance of screening, especially among populations with low rates of uptake. Web-based news is potentially an underutilized communication mechanism for promoting CRC screenings as secondary prevention measures for high-risk groups.

Cryptosporidium and colorectal cancer: a review of epidemiology and possible association

Cryptosporidiosis is an important protozoan disease with serious public health implications. The contribution of Cryptosporidium to colorectal cancer is still vaguely studied, but little evidence from experimental and epidemiological studies has suggested a possible association. This review discusses the epidemiology of cryptosporidiosis and colorectal cancer and attempts to unravel the possible link between the two diseases using epidemiological, pathological, molecular, and immunological evidence. The review stressed the need to undertake more studies in this relatively neglected field.

How inclusive are cell lines in preclinical engineered cancer models?

Diverse factors contribute to significant and dire disparities in cancer risk and treatment outcomes. To address this, there was a call for inclusion of sex as a biological variable, which resulted in more instances of careful inclusion of sex in preclinical studies of cancer. Another variable in cancer treatment is genetic ancestry. Although this is considered explicitly in clinical research, it is considerably neglected in preclinical studies. Preclinical research can use several 3D in vitro model systems, such as spheroids/organoids, xenografts, or other bioengineered systems that combine biomaterials and cellular material. Ultimately, the cellular base for all of these in vitro model systems is derived from human cell lines or patient samples, to investigate mechanisms of cancer and screen novel therapeutics, all of which aim to maximize successful outcomes in clinical trials. This in itself offers an opportunity to potentiate effective treatments for many groups of people, when diverse variables like genetic ancestry are consciously included into study design. This Perspective highlights the need for conscious inclusion of genetic ancestry in preclinical cancer tissue engineering, especially when it pertains to determining therapeutic outcomes.

Summary: Genetic determinants, like ancestry, impact cancer risk and therapeutic outcomes. Hence, this is an important variable to consider at the very initial stages of biomedical research at the bench.

The Black Panther, Masculinity Barriers to Medical Care, and Colorectal Cancer Screening Intention Among Unscreened American Indian/Alaska Native, Black, and White Men

Objective

To determine if masculinity barriers to medical care and the death from colorectal cancer (CRC) of actor Chadwick Boseman (The Black Panther) influenced CRC early-detection screening intent among unscreened American Indian/Alaska Native (AIAN) and Non-Hispanic-Black (Black) men compared with Non-Hispanic-White (White) men.

Methods

Using a consumer-panel, we surveyed U.S. men aged 18-75 years (N = 895) using the 24-item Masculinity Barriers to Medical Care (MBMC) scale. We calculated the median score to create binary exposures to evaluate associations with CRC screening intent and conducted multivariable logistic regression to evaluate independent associations stratified by race/ethnicity.

Results

Overall, Black respondents were most likely to have a high MBMC score (55%) compared to White (44%) and AIAN (51%) men (p = 0.043). AIAN men were least likely to report CRC screening intent (51.1%) compared with Black (68%) and White men (64%) (p < 0.001). Black men who reported the recent death of Chadwick Boseman increased their awareness of CRC were more likely (78%) to report intention to screen for CRC compared to those who did not (56%) (p < 0.001). Black men who exhibited more masculinity-related barriers to care were more likely to intend to screen for CRC (OR: 1.76, 95% CI: 0.98-3.16) than their counterparts, as were Black men who reported no impact of Boseman's death on their CRC awareness (aOR: 2.96, 95% CI: 1.13-7.67). Conversely, among AIAN men, those who exhibited more masculinity-related barriers to care were less likely to have CRC screening intent (aOR: 0.47, 95% CI: 0.27-0.82) compared with their counterparts.

Conclusions

Masculinity barriers to medical care play a significant role in intention to screen for CRC. While Black men were most likely to state that The Black Panther's death increased their awareness of CRC, it did not appear to modify the role of masculine barriers in CRC screening intention as expected. Further research is warranted to better understand how masculine barriers combined with celebrity-driven health-promotion interventions influence the uptake of early-detection screening for CRC.

Impact

Our study provides formative data to develop behavioral interventions focused on improving CRC screening completion among diverse men.

Engaging the Community on Colorectal Cancer Screening Education: Focus Group Discussions Among African Americans

Colorectal cancer (CRC) is the third most diagnosed cancer in the USA, and African Americans experience disproportionate CRC diagnosis and mortality. Early detection could reduce CRC incidence and mortality, and reduce CRC health disparities, which may be due in part to lower screening adherence and later stage diagnosis among African Americans compared to whites. Culturally tailored interventions to increase access to and uptake of CRC stool-based tests are one effective strategy to increase benefits of screening among African Americans. The objectives of this study were to obtain feedback from African Americans on CRC educational materials being developed for a subsequent behavioral clinical trial and explore participants' knowledge, attitudes, and beliefs about CRC and CRC screening. Seven focus groups were conducted between February and November 2020. Participants were African Americans recruited through community contacts. Four focus groups were held in-person and three were conducted virtually due to Covid-19 restrictions. Participants ranked CRC educational text messages and provided feedback on a culturally tailored educational brochure. A focus group guide with scripted probes was used to elicit discussion and transcripts were analyzed using traditional content analysis. Forty-two African Americans participated. Four themes were identified from focus group discussions: (1) knowledge, attitudes, and beliefs on CRC and CRC screening; (2) reliable sources of cancer education information; (3) cultural factors affecting perspectives on health; and (4) community insights into cancer education. Participant input on the brochure was incorporated in content creation. Engaging African American community members to qualitatively examine cancer prevention has value in improving implementation strategy and planning for behavioral clinical trials.