Racial minorities are more likely than whites to report lack of provider recommendation for colon cancer screening

Evaluating the Reach of a Patient Navigation Program for Follow-up Colonoscopy in a Large Federally Qualified Health Center

Patient navigation (PN) has been shown to improve participation in cancer screening, including colorectal cancer screening, and is now a recommended practice by the Community Preventive Services Task Force. Despite the effectiveness of PN programs, little is known about the number of contacts needed to successfully reach patients or about the demographic and healthcare utilization factors associated with reach. PRECISE was an individual randomized study of PN versus usual care conducted as a partnership between two large health systems in the Pacific Northwest. The navigation program was a six-topic area telephonic program designed to support patients with an abnormal fecal test result to obtain a follow-up colonoscopy. We report the number of contact attempts needed to successfully reach navigated patients. We used logistic regression to report the demographic and healthcare utilization characteristics associated with patients allocated to PN who were successfully reached. We identified 1,200 patients with an abnormal fecal immunochemical test result, of whom 970 were randomized into the study (45.7% were female, 17.5% were Spanish-speaking, and the mean age was 60.8 years). Of the 479 patients allocated to the PN intervention, 382 (79.7%) were reached within 18 call attempts, and nearly all (n = 356; 93.2%) were reached within six contact attempts. Patient characteristics associated with reach were race, county of residence, and body mass index. Our findings can guide future efforts to optimize the reach of PN programs. Prevention Relevance: The findings from this large study can inform clinic-level implementation of future PN programs in Federally Qualified Health Centers to improve the reach of patients needing cancer screenings, optimize staff resources, and ultimately increase cancer screenings.

Disparities in Outcomes following Resection of Locally Advanced Rectal Cancer

Surgical margins following rectal cancer resection impact oncologic outcomes. We examined the relationship between margin status and race, ethnicity, region of care, and facility type. Patients undergoing resection of a stage II-III locally advanced rectal cancer (LARC) between 2004 and 2018 were identified through the National Cancer Database. Inverse probability of treatment weighting (IPTW) was performed, with margin positivity rate as the outcome of interest, and race/ethnicity and region of care as the predictors of interest. In total, 58,389 patients were included. After IPTW adjustment, non-Hispanic Black (NHB) patients were 12% (p = 0.029) more likely to have margin positivity than non-Hispanic White (NHW) patients. Patients in the northeast were 9% less likely to have margin positivity compared to those in the south. In the west, NHB patients were more likely to have positive margins than NHW patients. Care in academic/research centers was associated with lower likelihood of positive margins compared to community centers. Within academic/research centers, NHB patients were more likely to have positive margins than non-Hispanic Other patients. Our results suggest that disparity in surgical management of LARC in NHB patients exists across regions of the country and facility types. Further research aimed at identifying drivers of this disparity is warranted.

Environmental Levels of Volatile Organic Compounds, Race, and Socioeconomic Markers Correlate with Areas of High Colorectal Cancer Incidence

BACKGROUND

Ambient levels of volatile organic compounds (VOCs) released from nearby industrial plants have shown positive associations with increased colorectal cancer (CRC) rates. The objective of this study is to analyze the distribution of CRC in the context of socioeconomic status and its correlation with community environmental data.

METHODS

A retrospective study analyzed CRC patients from 2021 to 2023. The census tracts of the patients' residential addresses were obtained, and CRC rates were calculated for each census tract. Socioeconomic data was gathered on these communities. Environmental VOC measurements were obtained from the National Scale Air Toxics Assessment. All datapoints were compared to statewide levels.

RESULTS

Three census tracts in the county had higher CRC cases comparatively. These areas exhibited higher incidence rates and localized clusters of CRC cases, higher distribution of Black or African Americans, lower household incomes, lower home values, and lower educational attainment. VOC measurements in these census tracts had higher levels compared to county and state averages: specifically, 10.68% higher than county and 48.07% higher than state benzene levels (0.52 µg/m3 clusters vs 0.47µg/m3 county vs 0.35 µg/m3 state), 10.84% and 129.15% higher toluene (1.65 µg/m3 vs 1.49 vs 0.72 µg/m3), and 15.64% and 141.87% higher butadiene (0.048 µg/m3 vs 0.041 µg/m3 vs 0.020 µg/m3).

CONCLUSION

This study illustrates a positive correlation between higher ambient exposure to VOCs with increased CRC incidence. These findings underscore the potential interplay of environmental factors, socioeconomic determinants, and environmental injustice when considering strategies to address health disparities and CRC incidence.

Association of Historical Housing Discrimination and Colon Cancer Treatment and Outcomes in the United States

PURPOSE

In the 1930s, the federally sponsored Home Owners' Loan Corporation (HOLC) used racial composition in its assessment of areas worthy of receiving loans. Neighborhoods with large proportions of Black residents were mapped in red (ie, redlining) and flagged as hazardous for mortgage financing. Redlining created a platform for systemic disinvestment in these neighborhoods, leading to barriers in access to resources that persist today. We investigated the association between residing in areas with different HOLC ratings and receipt of quality cancer care and outcomes among individuals diagnosed with colon cancer-a leading cause of cancer deaths amenable to early detection and treatment.

METHODS

Individuals who resided in zip code tabulation areas in 196 cities with HOLC rating and were diagnosed with colon cancer from 2007 to 2017 were identified from the National Cancer Database and assigned a HOLC grade (A, best; B, still desirable; C, definitely declining; and D, hazardous and mapped in red). Multivariable logistic regression models investigated association of area-level HOLC grade and late stage at diagnosis and receipt of guideline-concordant care. The product-limit method evaluated differences in time to adjuvant chemotherapy. Multivariable Cox proportional hazard models investigated differences in overall survival (OS).

RESULTS

There were 149,917 patients newly diagnosed with colon cancer with a median age of 68 years. Compared with people living in HOLC A areas, people living in HOLC D areas were more likely to be diagnosed with late-stage disease (adjusted odds ratio, 1.06 [95% CI, 1.00 to 1.12]). In addition, people living in HOLC B, C, and D areas had 8%, 16%, and 24% higher odds of not receiving guideline-concordant care, including lower receipt of surgery, evaluation of ≥12 lymph nodes, and chemotherapy. People residing in HOLC B, C, or D areas also experienced delays in initiation of adjuvant chemotherapy after surgery. People residing in HOLC C (adjusted hazard ratio [aHR], 1.09 [95% CI, 1.05 to 1.13]) and D (aHR, 1.13 [95% CI, 1.09 to 1.18]) areas had worse OS, including 13% and 20% excess risk of death for individuals diagnosed with early- and 6% and 8% for late-stage disease for HOLC C and D, respectively.

CONCLUSION

Historical housing discrimination is associated with worse contemporary access to colon cancer care and outcomes.

Disparities in Emergency Department Waiting Times for Acute Gastrointestinal Bleeding: Results From the National Hospital Ambulatory Medical Care Survey, 2009-2018

OBJECTIVE

The primary aim of this study was to assess waiting time (WT) across different racial groups to determine whether racial disparities exist in patients presenting with gastrointestinal bleeding (GIB) to the United States emergency departments (EDs).

METHODS

Using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2009 to 2018, we compared WT of patients with GIB across different racial/ethnic groups, including nonhispanic white (NHW), African American (AA), Hispanic White (HW), and Nonhispanic other. Multinomial logistic regression was applied to adjust the outcomes for possible confounders. We also assessed the trend of the WT over the study interval and compared the WT between the first (2009) and last year (2018) of the study interval.

RESULTS

There were an estimated 7.8 million ED visits for GIB between 2009 and 2018. Mean WT ranged from 48 minutes in NHW to 68 minutes in AA. After adjusting for gender, age, geographic regions, payment type, type of GI bleeding, and triage status, multinomial logistic regression showed significantly higher waiting time for AA patients than NHW (OR 1.01, P =0.03). The overall trend showed a significant decrease in the mean WT ( P value<0.001). In 2009, AA waited 69 minutes longer than NHW ( P value<0.001), while in 2018, this gap was erased with no statistically significant difference ( P value=0.26).

CONCLUSION

Racial disparities among patients presenting with GIB are present in the United States EDs. African Americans waited longer for their first visits. Over time, ED wait time has decreased, leading to a decline in the observed racial disparity.

Colon Cancer Disparities in Stage at Presentation and Time to Surgery for Asian Americans, Native Hawaiians, and Pacific Islanders: A Study with Disaggregated Ethnic Groups

BACKGROUND

Vast differences in barriers to care exist among Asian American, Native Hawaiian, and Pacific Islander (AANHPI) groups and may manifest as disparities in stage at presentation and access to treatment. Thus, we characterized AANHPI patients with stage 0-IV colon cancer and examined differences in (1) stage at presentation and (2) time to surgery relative to white patients.

PATIENTS AND METHODS

We assessed all patients in the National Cancer Database (NCDB) with stage 0-IV colon cancer from 2004 to 2016 who identified as white, Chinese, Japanese, Filipino, Native Hawaiian, Korean, Vietnamese, Laotian, Hmong, Kampuchean, Thai, Asian Indian or Pakistani, and Pacific Islander. Multivariable ordinal logistic regression defined adjusted odds ratios (AORs), with 95% confidence intervals (CI), of (1) patients presenting with advanced stage colon cancer and (2) patients with stage 0-III colon cancer receiving surgery at ≥ 60 days versus 30-59 days versus < 30 days postdiagnosis, adjusting for sociodemographic/clinical factors.

RESULTS

Among 694,876 patients, Japanese [AOR 1.08 (95% CI 1.01-1.15), p < 0.05], Filipino [AOR 1.17 (95% CI 1.09-1.25), p < 0.001], Korean [AOR 1.09 (95% CI 1.01-1.18), p < 0.05], Laotian [AOR 1.51 (95% CI 1.17-1.95), p < 0.01], Kampuchean [AOR 1.33 (95% CI 1.04-1.70), p < 0.01], Thai [AOR 1.60 (95% CI 1.22-2.10), p = 0.001], and Pacific Islander [AOR 1.41 (95% CI 1.20-1.67), p < 0.001] patients were more likely to present with more advanced colon cancer compared with white patients. Chinese [AOR 1.27 (95% CI 1.17-1.38), p < 0.001], Japanese [AOR 1.23 (95% CI 1.10-1.37], p < 0.001], Filipino [AOR 1.36 (95% CI 1.22-1.52), p < 0.001], Korean [AOR 1.16 (95% CI 1.02-1.32), p < 0.05], and Vietnamese [AOR 1.55 (95% CI 1.36-1.77), p < 0.001] patients were more likely to experience greater time to surgery than white patients. Disparities persisted when comparing among AANHPI subgroups.

CONCLUSIONS

Our findings reveal key disparities in stage at presentation and time to surgery by race/ethnicity among AANHPI subgroups. Heterogeneity upon disaggregation underscores the importance of examining and addressing access barriers and clinical disparities.

Predictors of Colonoscopy Use Among Asian Indians in New York City, 2003 to 2016

BACKGROUND

Asian Americans have the lowest colorectal cancer screening uptake of any racial and ethnic group in the United States. Asian Indians are among the most under-screened Asian American subgroups, but there is limited data for this population. We sought to characterize predictors of colonoscopy use among Asian Indians in New York City.

METHODS

Using 2003 to 2016 data from the New York City Community Health Survey, we identified all Asian Indian participants aged 50 years or older. We examined the association between sociodemographic and medical factors and up-to-date colonoscopy use (defined as colonoscopy within the last 10 y) using logistic regression over 4 time periods: 2003 to 2008, 2009 to 2012, 2013 to 2014, 2015 to 2016.

RESULTS

On multivariable analysis, language, age, income, recent exercise, body mass index, and influenza vaccination were associated with colonoscopy uptake in 1 time period. Compared with participants who preferred English, those who preferred an Indian language were less likely to have been up-to-date in 2013 to 2014 (odds ratio 0.12, 95% CI 0.02-0.66). Individuals older than 65 years were more likely than those aged 50 to 64 years to have received a colonoscopy in 2009 to 2012 (odds ratio 3.91, 95% CI 1.49-10.24), although the risk estimates were also consistently positive in the other 3 time periods.

CONCLUSIONS

Among Asian Indians living in New York City, several demographic, socioeconomic, and health-related characteristics predict colonoscopy use. These findings highlight the importance of examining determinants of colonoscopy uptake in this understudied population to inform future public health interventions.

Inflammatory Bowel Disease-Associated Colorectal Cancer: Translational and Transformational Risks Posed by Exogenous Free Hemoglobin Alpha Chain, A By-Product of Extravasated Erythrocyte Macrophage Erythrophagocytosis

Colonic inflammatory bowel disease (IBD) encompasses ulcerative colitis (UC) and Crohn's colitis (CC). Patients with IBD are at increased risk for colitis-associated colorectal cancer (CACRC) compared to the general population. CACRC is preceded by IBD, characterized by highly heterogenous, pharmacologically incurable, pertinacious, worsening, and immune-mediated inflammatory pathologies of the colon and rectum. The molecular and immunological basis of CACRC is highly correlated with the duration and severity of inflammation, which is influenced by the exogenous free hemoglobin alpha chain (HbαC), a byproduct of infiltrating immune cells; extravasated erythrocytes; and macrophage erythrophagocytosis. The exogenous free HbαC prompts oxygen free radical-arbitrated DNA damage (DNAD) through increased cellular reactive oxygen species (ROS), which is exacerbated by decreased tissue antioxidant defenses. Mitigation of the Fenton Reaction via pharmaceutical therapy would attenuate ROS, promote apoptosis and DNAD repair, and subsequently prevent the incidence of CACRC. Three pharmaceutical options that attenuate hemoglobin toxicity include haptoglobin, deferoxamine, and flavonoids (vitamins C/E). Haptoglobin's clearance rate from plasma is inversely correlated with its size; the smaller the size, the faster the clearance. Thus, the administration of Hp1-1 may prove to be beneficial. Further, deferoxamine's hydrophilic structure limits its ability to cross cell membranes. Finally, the effectiveness of flavonoids, natural herb antioxidants, is associated with the high reactivity of hydroxyl substituents. Multiple analyses are currently underway to assess the clinical context of CACRC and outline the molecular basis of HbαC-induced ROS pathogenesis by exposing colonocytes and/or colonoids to HbαC. The molecular immunopathogenesis pathways of CACRC herein reviewed are broadly still not well understood. Therefore, this timely review outlines the molecular and immunological basis of disease pathogenesis and pharmaceutical intervention as a protective measure for CACRC.

Physician Perceptions on Cancer Screening for LGBTQ+ Patients

The LGBTQ+ community experiences cancer disparities due to increased risk factors and lower screening rates, attributable to health literacy gaps and systemic barriers. We sought to understand the experiences, perceptions, and knowledge base of healthcare providers regarding cancer screening for LGBTQ+ patients. A 20-item IRB-approved survey was distributed to physicians through professional organizations. The survey assessed experiences and education regarding the LGBTQ+ community and perceptions of patient concerns with different cancer screenings on a 5-point Likert scale. Complete responses were collected from 355 providers. Only 100 (28%) reported past LGBTQ+-related training and were more likely to be female (p = 0.020), have under ten years of practice (p = 0.014), or practice family/internal medicine (p < 0.001). Most (85%) recognized that LGBTQ+ subpopulations experience nuanced health issues, but only 46% confidently understood them, and 71% agreed their clinics would benefit from training. Family/internal medicine practitioners affirmed the clinical relevance of patients' sexual orientation (94%; 62% for medical/radiation oncology). Prior training affected belief in the importance of sexual orientation (p < 0.001), confidence in understanding LGBTQ+ health concerns (p < 0.001), and willingness to be listed as "LGBTQ+-friendly" (p = 0.005). Our study suggests that despite a paucity of formal training, most providers acknowledge that LGBTQ+ patients have unique health needs. Respondents had a lack of consensus regarding cancer screenings for lesbian and transgender patients, indicating the need for clearer screening standards for LGBTQ+ subpopulations and educational programs for providers.

Exploring the complexity and spectrum of racial/ethnic disparities in colon cancer management

BACKGROUND

Colorectal cancer is a leading cause of morbidity and mortality across U.S. racial/ethnic groups. Existing studies often focus on a particular race/ethnicity or single domain within the care continuum. Granular exploration of disparities among different racial/ethnic groups across the entire colon cancer care continuum is needed. We aimed to characterize differences in colon cancer outcomes by race/ethnicity across each stage of the care continuum.

METHODS

We used the 2010-2017 National Cancer Database to examine differences in outcomes by race/ethnicity across six domains: clinical stage at presentation; timing of surgery; access to minimally invasive surgery; post-operative outcomes; utilization of chemotherapy; and cumulative incidence of death. Analysis was via multivariable logistic or median regression, with select demographics, hospital factors, and treatment details as covariates.

RESULTS

326,003 patients (49.6% female, 24.0% non-White, including 12.7% Black, 6.1% Hispanic/Spanish, 1.3% East Asian, 0.9% Southeast Asian, 0.4% South Asian, 0.3% AIAE, and 0.2% NHOPI) met inclusion criteria. Relative to non-Hispanic White patients: Southeast Asian (OR 1.39, p < 0.01), Hispanic/Spanish (OR 1.11 p < 0.01), and Black (OR 1.09, p < 0.01) patients had increased odds of presenting with advanced clinical stage. Southeast Asian (OR 1.37, p < 0.01), East Asian (OR 1.27, p = 0.05), Hispanic/Spanish (OR 1.05 p = 0.02), and Black (OR 1.05, p < 0.01) patients had increased odds of advanced pathologic stage. Black patients had increased odds of experiencing a surgical delay (OR 1.33, p < 0.01); receiving non-robotic surgery (OR 1.12, p < 0.01); having post-surgical complications (OR 1.29, p < 0.01); initiating chemotherapy more than 90 days post-surgery (OR 1.24, p < 0.01); and omitting chemotherapy altogether (OR 1.12, p = 0.05). Black patients had significantly higher cumulative incidence of death at every pathologic stage relative to non-Hispanic White patients when adjusting for non-modifiable patient factors (p < 0.05, all stages), but these differences were no longer statistically significant when also adjusting for modifiable factors such as insurance status and income.

CONCLUSIONS

Non-White patients disproportionately experience advanced stage at presentation. Disparities for Black patients are seen across the entire colon cancer care continuum. Targeted interventions may be appropriate for some groups; however, major system-level transformation is needed to address disparities experienced by Black patients.

COVID-19 and inequities in colorectal and cervical cancer screening and diagnosis in Washington State

Introduction

Studies have shown that cancer screenings dropped dramatically following the onset of the coronavirus diseases 2019 (COVID‐19) pandemic. In this study, we examined differences in rates of cervical and colorectal cancer (CRC) screening and diagnosis indicators before and during the first year of the COVID‐19 pandemic.

Methodology

We used retrospective data from a large healthcare system in Washington State. Targeted screening data included completed cancer screenings for both CRC (colonoscopy) and cervical cancer (Papanicolaou test (Pap test)). We analyzed and compared the rate of uptake of colorectal (colonoscopies) and cervical cancer (Pap) screenings done pre‐COVID‐19 (April 1, 2019–March 31, 2020) and during the pandemic (April 1, 2020–March 31, 2021).

Results

A total of 26,081 (12.7%) patients underwent colonoscopies in the pre‐COVID‐19 period, compared to only 15,708 (7.4%) patients during the pandemic, showing a 39.8% decrease. A total of 238 patients were referred to medical oncology for CRC compared to only 155 patients during the first year of the pandemic, a reduction of 34%. In the pre‐COVID‐19 period, 22,395 (10.7%) women were administered PAP tests compared to 20,455 (9.6%) women during the pandemic, for a 7.4% reduction. period 1780 women were referred to colposcopy, compared to only 1680 patients during the pandemic, for a 4.3% reduction.

Conclusion

Interruption in screening and subsequent delay in diagnosis during the pandemic will likely lead to later‐stage diagnoses for both CRC and cervical cancer, which is known to result in decreased survival.

Impact

The results emphasize the need to prioritize cancer screening, particularly for those at higher risk.

Healthcare Disparities and Colorectal Cancer

Health care disparities are defined as health differences between groups that are avoidable, unnecessary, and unjust. Racial disparities in colorectal cancer mortality, particularly for Black patients, are well-described. Disparities in preventative measures, early detection, effective treatment, and posttreatment services contribute to these differences. Underlying these issues are patient, provider, health care system, and policy-level factors that lead to these disparities. Multilevel interventions designed to address each level of care can provide an effective means to mitigate these disparities.

Barriers and Facilitators to Colorectal Cancer Screening in African-American Men

BACKGROUND

African-Americans rank last among all racial groups for age-adjusted colorectal cancer mortality, 5-year survival rates, and rates of screening. Access to care does not fully explain racial disparities in rates of CRC and mortality. Sociocultural attitudes can predict probabilities of CRC screening.

AIMS

The objective of this study is to identify factors that influence colorectal cancer screening behavior in African-American men.

METHODS

Semi-structured interviews were conducted among 32 African-American men. Transcripts were analyzed using MAXQDA software. We then conducted a cross-sectional survey of 103 African-American men, using previously validated scales related to colorectal cancer screening and determinants. Data were analyzed with SPSS.

RESULTS

In the interview phase, beliefs relating to masculinity emerged as factors that hindered participation in screening. Overwhelmingly, participants felt that having an in-depth discussion about colorectal cancer with their provider was critical to enabling them to get screened. The survey phase demonstrated that most participants had poor colorectal cancer knowledge, as only 16% passed the knowledge test. Forty-eight percentage agreed that their provider did not recommend getting screened. Those who had been previously screened for colorectal cancer scored higher in total and on all subsets of the masculinity index than those who had not (p < .01). The most persuasive messages were those related to themes of masculinity.

CONCLUSION

This study provides a novel sociocultural perspective about colorectal cancer screening in African-American men. Our findings highlight the importance of family, masculinity, and community when promoting colorectal cancer screening to this population.

Filipinos' attitudes, barriers, and enablers on colorectal cancer screening: Insights from a qualitative research study

BACKGROUND

Filipinos have lower colorectal cancer (CRC) screening rates and worse outcomes versus non-Hispanic Whites. As Filipinos are understudied on how they perceive CRC screening, we conducted focus groups examining their attitudes, enablers, and barriers to screening.

METHODS

In August and September 2021, we recruited Filipinos aged 40-75 years to participate in an online focus group. Filipinos who received care at an academic medical center or were members of Filipino community organizations in Los Angeles, CA, were sent emails inviting them to participate. We used a semi-structured interview guide for the focus groups and audio recordings were transcribed and analyzed using an inductive coding approach. Codes were generated from the qualitative data, sorted, classified into themes and subthemes, and illustrated with verbatim quotes.

RESULTS

We conducted four online focus groups with 16 Filipinos. As for enablers for CRC screening, participants mentioned the importance having a doctor's recommendation. Participants reported the following barriers: potential out-of-pocket costs (the Philippines healthcare system is largely cash-based); fatalistic beliefs; reactive approach to health; lack of awareness in the community on CRC screening. Suggested solutions for improving CRC screening uptake in the community included: providing information on screening benefits, what to expect from each test (e.g., steps involved, accuracy), and financial considerations; participation by Filipino celebrities and doctors in media campaigns.

CONCLUSION

Our study highlights Filipinos' perceptions on CRC screening. These data can support investigators, health systems, public health agencies, and community organizations in developing culturally tailored, sustainable interventions to address CRC screening disparities among Filipinos.

Lessons Learned in Managing Patients with Colorectal Cancer During the COVID-19 Pandemic

OPINION STATEMENT

The COVID-19 pandemic forced us to rapidly and dramatically shift our medical priorities and decision making. With little literature or experience to rely on, the initial priority was to minimize patient exposure to the hospital and to others. It remains unclear whether cancer patients are at higher risk of infection or serious complications, or if it is our traditional therapies that place them to be at higher risk. By far, the greatest negative impact was on screening. Routine colonoscopies were considered elective, and as a result, delays in diagnosis will be felt for years to come. The most positive changes were the incorporation of tele-visits, increased use of oral therapies, alterations in treatment schedules of both chemotherapy and radiation, and an increased emphasis on neoadjuvant therapy. These too will be felt for years to come. The colorectal cancer medical community has responded collaboratively and effectively to maintain treatment and to optimize outcomes for our patients during the COVID-19 pandemic.

Effectiveness of Colorectal Cancer Screening Promotion Using E-Media Decision Aids: A Systematic Review and Meta-Analysis

Colorectal cancer (CRC)-screening reduces mortality, yet remains underutilized. The use of electronic media (e-media) decision aids improves saliency and fosters informed decision-making. This systematic review aimed to determine the effectiveness of CRC-screening promotion, using e-media decision aids in primary healthcare (PHC) settings. Three databases (MEDLINE, Web of Science, and the Cochrane Library) were searched for eligible studies. Studies that evaluated e-media decision aids compared to usual care or other conditions were selected. Quality was assessed by using Cochrane tools. Their effectiveness was measured by CRC-screening completion rates, and meta-analysis was conducted to calculate the pooled estimates. Ten studies involving 9393 patients were included in this review. Follow-up durations spanned 3–24 months. The two types of decision-aid interventions used were videos and interactive multimedia programs, with durations of 6–15 min. Data from nine feasible studies with low or some risk of bias were synthesized for meta-analysis. A random-effects model revealed that CRC-screening promotion using e-media decision aids were almost twice as likely to have screening completion than their comparisons (OR 1.62, 95% CI: 1.03–2.62, p < 0.05). CRC-screening promotion through e-media has great potential for increasing screening participation in PHC settings. Thus, its development should be prioritized, and it should be integrated into existing programs.

Changes in colorectal cancer knowledge and screening intention among Ohio African American and Appalachian participants: The screen to save initiative

African Americans and Appalachians experience greater incidence and mortality rates of colorectal cancer due to factors, such as reduced prevalence of screening. An educational session (the Screen to Save Initiative) was conducted to increase intent to screen for colorectal cancer among African Americans and Appalachians in Ohio. Using a community-based approach, from April to September 2017, 85 eligible participants were recruited in Franklin County and Appalachia Ohio. Participants completed a knowledge assessment on colorectal cancer before and after participating in either an educational PowerPoint session or a guided tour through an Inflatable Colon. Logistic regression models were used to determine what factors were associated with changes in colorectal cancer knowledge and intent to screen for colorectal cancer. The majority (71.79%) of participants gained knowledge about colorectal cancer after the intervention. Multivariate results showed that race (OR = 0.30; 95% CI: 0.11–0.80 for African Americans versus White participants) and intervention type (OR = 5.97; 95% CI: 1.94–18.43 for PowerPoint versus Inflatable Colon) were associated with a change in knowledge. The association between education and intent to screen was marginally statistically significant (OR = 0.42; 95% CI: 0.16–1.13 for college graduate versus not a college graduate). A change in colorectal cancer knowledge was not associated with intent to screen. Future educational interventions should be modified to increase intent to screen and screening for colorectal cancer. Further research with these modified interventions should aim to reduce disparities in CRC among underserved populations while listening to the voices of the communities.

Bias Issues in Colorectal Cancer Management: A Review

Based on census data, over one-third of the US population identifies as a racial or ethnic minority. This group of racial and ethnic minorities is more likely to develop cancer and die from it when compared with the general population of the USA. These disparities are most pronounced in the African American community. Despite overall CRC rates decreasing nationally and within certain racial and ethnic minorities in the USA, there continue to be disparities in incidence and mortality when compared with non-Hispanic Whites. The disparities in CRC incidence and mortality are related to systematic racism and bias inherent in healthcare systems and society. Disparities in CRC management will continue to exist until specific interventions are implemented in the context of each racial and ethnic group. This review's primary aim is to highlight the disparities in CRC among African Americans in the USA. For surgeons, understanding these disparities is formative to creating change and improving the quality of care, centering equity for all patients.

"Rescue" of Nonparticipants in Colorectal Cancer Screening: A Randomized Controlled Trial of Three Noninvasive Test Options

Few studies have directly targeted nonparticipants in colorectal cancer screening to identify effective engagement strategies. We undertook a randomized controlled trial that targeted nonparticipants in a previous trial of average-risk subjects which compared participation rates for mailed invitations offering a fecal test, a blood test or a choice of either. Nonparticipants (n = 899) were randomized to be offered a kit containing a fecal immunochemical test (FIT), directions on how to arrange a blood DNA test, or the option of doing either. Screening participation was assessed 12 weeks after the offer. To assess the cognitive and attitudinal variables related to participation and invitee choice, invitees were surveyed after 12 weeks, and associations were investigated using multinomial logistic regression. Participation rates were similar between groups (P = 0.88): 12.0% for FIT (35/292), 13.3% for the blood test (39/293), and 13.4% for choice (39/290). Within the choice group, participation was significantly higher with FIT (9.7%, 28/290) compared with the blood test (3.8%, 11/290, P = 0.005). The only variable significantly associated with participation was socioeconomic status when offered FIT, and age when offered choice but there was none when offered the blood test. Survey respondents indicated that convenience, time-saving, comfort, and familiarity were major influences on participation. There was no clear advantage between a fecal test, blood test, or choice of test although, when given a choice, the fecal test was preferred. Differences in variables associated with participation according to invitation strategy warrant consideration when deciding upon an invitation strategy for screening nonparticipants. PREVENTION RELEVANCE: This trial of screening for those at average risk for colorectal cancer targeted past fecal-test nonparticipants and compared participation rates for mailed invitations offering a fecal test, blood test, or choice of either. Although there was no clear advantage between strategies, factors associated with participation differed between each strategy.

Effects of culturally targeted message framing on colorectal cancer screening among African Americans

OBJECTIVE

This study examined how standard and culturally targeted versions of gain and loss-framed messaging affect African Americans' colorectal cancer (CRC) screening receptivity and behavior, as well as their anticipation of experiencing racism in undertaking CRC screening.

METHOD

Screening-deficient African Americans (N = 457) viewed an informational video about CRC risks, prevention, and screening and were randomized to receive a gain or loss-framed message about screening. Half of participants viewed an additional culturally targeted message about overcoming racial disparities in CRC by obtaining screening. Using the Theory of Planned Behavior, we measured general receptivity to CRC screening. We also measured arousal of anticipatory racism in response to messaging. Finally, we offered participants a no-cost fecal immunochemical testing kit (FIT Kit) and measured uptake and use.

RESULTS

Message framing interacted with culturally targeted messaging to affect CRC screening receptivity and behavior. Participants were no more receptive to CRC screening when standard loss-framing was used, but were more favorable if loss-framing was culturally targeted. Targeted loss-framing also reduced anticipatory racism, which partially mediated effects on screening receptivity. Finally, although participants least often accepted a FIT Kit with standard loss-framing, effects of messaging on FIT Kit uptake and use were not significant.

CONCLUSION

This study adds to growing recognition of important cultural nuance in effective use of message framing. Current finding also suggest that targeted and framed messaging could synergistically impact the extent to which African Americans engage in CRC screening, although specific impacts on FIT Kit screening are less certain. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Disparities in Cancer Care and the Asian American Population

Asian Americans are the only racial/ethnic group in the U.S. for whom cancer is the leading cause of death in men and women, unlike heart disease for all other groups. Asian Americans face a confluence of cancer risks, with high rates of cancers endemic to their countries of origin due to infectious and cultural reasons, as well as increasing rates of "Western" cancers that are due in part to assimilation to the American diet and lifestyle. Despite the clear mortality risk, Asian Americans are screened for cancers at lower rates than the majority of Americans. Solutions to eliminate the disparity in cancer care are complicated by language and cultural concerns of this very heterogeneous group. This review addresses the disparities in cancer screening, the historical causes, the potential contribution of racism, the importance of cultural perceptions of health care, and potential strategies to address a very complicated problem. Noting that the health care disparities faced by Asian Americans may be less conspicuous than the structural racism that has inflicted significant damage to the health of Black Americans over more than four centuries, this review is meant to raise awareness and to compel the medical establishment to recognize the urgent need to eliminate health disparities for all. IMPLICATIONS FOR PRACTICE: Cancer is the leading cause of death in Asian Americans, who face cancers endemic to their native countries, perhaps because of infectious and cultural factors, as well as those faced by all Americans, perhaps because of "Westernization" in terms of diet and lifestyle. Despite the mortality rates, Asian Americans have less cancer screening than other Americans. This review highlights the need to educate Asian Americans to improve cancer literacy and health care providers to understand the important cancer risks of the fastest-growing racial/ethnic group in the U.S. Eliminating disparities is critical to achieving an equitable society for all Americans.

Colorectal Cancer: In the Pursuit of Health Equity

Colorectal cancer mortality has decreased considerably following the adoption of national screening programs, yet, within at-risk subgroups, there continue to be measurable differences in clinical outcomes from variations in screening, receipt of chemotherapy, radiation or surgery, access to clinical trials, research participation, and survivorship. These disparities are well-described and some have worsened over time. Disparities identified have included race and ethnicity, age (specifically young adults), socioeconomic status, insurance access, geography, and environmental exposures. In the context of the COVID-19 pandemic, colorectal cancer care has necessarily shifted dramatically, with broad, immediate uptake of telemedicine, transition to oral medications when feasible, and considerations for sequence of treatment. However, it has additionally marginalized patients with colorectal cancer with historically disparate cancer-specific outcomes; among them, uninsured, low-income, immigrant, and ethnic-minority patients-all of whom are more likely to become infected, be hospitalized, and die of either COVID-19 or colorectal cancer. Herein, we outline measurable disparities, review implemented solutions, and define strategies toward ensuring that all have a fair and just opportunity to be as healthy as possible.

Factors associated with colorectal cancer screening in a peer-counseling intervention study in partnership with African American churches

Colorectal cancer (CRC) mortality is 47% higher in African American men and 34% higher in African American women compared to non-Hispanic white men and women. This analysis assessed factors associated with CRC screening among 163 African American participants of a peer-counseling intervention study (2016-2018). In a one-group pre/post-test pilot study, trained Community Health Advisors (CHAs) at 9 African American churches in Los Angeles (LA) promoted CRC screening via one-on-one counseling, print materials and telephone reminder calls. Participants completed telephone surveys 3-6 months after the intervention. We fit bivariate and multivariate mixed effects logistic regression models to assess correlates, including participants' demographic characteristics, access to care, cancer-related knowledge and attitudes and receipt of CHA counseling of (1) discussion of CRC screening with provider and (2) receipt of CRC screening during follow-up. After controlling for gender and education, receipt of CHA counseling (OR 3.77) was significantly associated with discussing CRC screening with a provider during follow-up but not with CRC screening. Instead, a routine check-up in the past 12 months (OR 4.47) and discussion of CRC screening with a provider (OR 3.07) were significantly associated with CRC screening during follow-up. Residence in South LA (OR 0.38) was significantly associated with lack of CRC screening. Findings confirm the important role of health care providers and suggest that residence in South LA constitutes an additional barrier to CRC screening. Further research and additional resources are needed to address disparities in the uptake of CRC screening among African Americans, especially in South LA.

Black and White Differences in Colorectal Cancer Screening and Screening Outcomes: A Narrative Review

Racial disparities in colorectal cancer incidence are widely documented. There are two potential mechanisms for these disparities: differences in access to screening, including screening follow-up, and differences in underlying risk of colorectal cancer. We reviewed the literature for evidence of these two mechanisms. We show that higher colorectal cancer incidence in blacks relative to whites emerged only after the dissemination of screening and describe evidence of racial disparities in screening rates. In contrast to the strong evidence for differences in colorectal cancer screening utilization, there is limited evidence for racial differences in adenoma prevalence. In general, black and white patients who are screened have similar adenoma prevalence, though there is some evidence that advanced adenomas and adenomas in the proximal colon are somewhat more likely in black than white patients. We conclude that higher rates of colorectal cancer incidence among black patients are primarily driven by lower rates of colorectal cancer screening. Our findings highlight the need to increase black patients' access to quality screening to reduce colorectal cancer incidence and mortality.

AGA White Paper: Roadmap for the Future of Colorectal Cancer Screening in the United States

The American Gastroenterological Association's Center for Gastrointestinal Innovation and Technology convened a consensus conference in December 2018, entitled, "Colorectal Cancer Screening and Surveillance: Role of Emerging Technology and Innovation to Improve Outcomes." The goal of the conference, which attracted more than 60 experts in screening and related disciplines, including the authors, was to envision a future in which colorectal cancer (CRC) screening and surveillance are optimized, and to identify barriers to achieving that future. This White Paper originates from that meeting and delineates the priorities and steps needed to improve CRC outcomes, with the goal of minimizing CRC morbidity and mortality. A one-size-fits-all approach to CRC screening has not and is unlikely to result in increased screening uptake or desired outcomes owing to barriers stemming from behavioral, cultural, and socioeconomic causes, especially when combined with inefficiencies in deployment of screening technologies. Overcoming these barriers will require the following: efficient utilization of multiple screening modalities to achieve increased uptake; continued development of noninvasive screening tests, with iterative reassessments of how best to integrate new technologies; and improved personal risk assessment to better risk-stratify patients for appropriate screening testing paradigms.

Cancer/health communication and breast/cervical cancer screening among Asian Americans and five Asian ethnic groups

Objectives: This paper is an examination of cancer/health communication factors (i.e. cancer/health information seeking, patient-provider communication (PPC), cancer screening information from providers) and screening for breast and cervical cancer among Asian Americans and five Asian ethnic groups (Chinese, Filipinos, Japanese, Koreans, Vietnamese) in comparison to Whites. Additionally, the relationship between cancer/health communication disparity and cancer screening gaps between Asian Americans and Whites was investigated. Design: Data comes from a nationally representative sample of 2011-2014 Health Information National Trends Surveys (HINTS). Results: Asian Americans and most Asian ethnic-groups reported significantly lower rates of cancer/health information seeking and lower evaluations for PPC as compared to Whites, though differences within Asian ethnic groups were observed (Koreans' greater cancer/health information seeking, Japanese' higher PPC evaluation). When the cancer/health communication factors were controlled, Asian Americans' odds of cancer screening were increased. Especially, Asian Americans' odds of adhering to the breast cancer screening guideline became nearly 1.4 times greater than Whites. Conclusion: This research demonstrates that health organizations, providers, and Asian American patients' collaborative efforts to increase the access to quality cancer information, to make culturally competent but straightforward screening recommendations, and to practice effective communication in medical encounters will contribute to diminishing cancer disparities among Asian Americans.

Impact of COVID-19 on colorectal cancer disparities and the way forward

In response to the coronavirus disease 2019 (COVID-19) pandemic, the U.S. Surgeon General advised all hospitals and ambulatory care centers to delay nonurgent medical procedures and surgeries. This recommendation, echoed by a multigastroenterology society guideline, led to the suspension of colonoscopies for colorectal cancer (CRC) screening and surveillance. Although this temporary suspension was necessary to contain COVID-19 infections, we as gastroenterologists, patient advocates, and CRC researchers have witnessed the downstream impact of COVID-19 and this recommendation on CRC screening, research, and advocacy. These effects are particularly noticeable in medically underserved communities where CRC morbidity and mortality are highest. COVID-19-related pauses in medical care, as well as shifts in resource allocation and workforce deployment, threaten decades worth of work to improve CRC disparities in medically underserved populations. In this perspective, we present the unique challenges COVID-19 poses to health equity in CRC prevention and provide potential solutions as we navigate these uncharted waters.

Colorectal cancer screening in hospitalized patients: results from the Nationwide Inpatient Sample

Colorectal cancer (CRC) is preventable with regular screening. This study aims to determine estimates and predictors of inpatient CRC screening during hospitalization in the USA. This nationwide population-based study utilized data from the National Inpatient Sample database from 2005 to 2014 to examine rates of CRC screening among hospitalized patients. There were 6470 inpatient CRC screening nationwide from 129 645 394 inpatient hospitalizations. Multivariable analysis showed that higher rates of inpatient CRC screening were associated with: females compared to males [odds ratio (OR): 0.87; 95% confidence interval (CI): 0.78-0.97]; 50-59 years age group compared to 70-79 years (OR: 0.76; 95% CI: 0.62-0.94) and more than 80 years (OR: 0.47; 95% CI: 0.35-0.64); Charlson Comorbidity Index score of 0 compared to scores of 1-2 (OR: 0.79; 95% CI: 0.64-0.98), 3-4 (OR: 0.61; 95% CI: 0.49-0.76), more than 5 (OR: 0.61; 95% CI: 0.47-0.79); rural hospitals rather than urban teaching hospital (OR: 0.50; 95% CI: 0.39-0.63) and urban nonteaching hospitals (OR: 0.64; 95% CI: 0.49-0.82); hospitals in the Midwest region (OR: 1.56; 95% CI: 1.14-2.12) compared to the Northeast region; recent years of 2011/2012 (OR: 1.89; 95% CI: 1.44-2.49) and 2013/2014 (OR: 2.70; 95% CI: 2.14-3.41) compared to the period 2005/2006. The CRC screening rate among hospitalized patients admitted in US hospitals is low. There were no association of differences in racial, household income or health insurance status with inpatient CRC screening. Noninvasive screening methods in hospitalized patients like stool-based fecal immunochemical test provide a unique method of increasing cancer screening rates.

Barriers Driving Racial Disparities in Colorectal Cancer Screening in African Americans

PURPOSE OF REVIEW

Colorectal cancer screening has been shown to decrease mortality from colorectal cancer. Screening disparities continue to exist among ethnic minorities, particularly for African Americans. We herein review the barriers of colorectal cancer screening in this population.

RECENT FINDINGS

At its foundation are patient barriers, which are further compounded by physician-related barriers and the idiosyncrasies of the healthcare system. Interventions to address the barriers include patient outreach, provider education, and healthcare legislation addressing financial barriers. Recent research has focused on factors predicting intentions to undergo colorectal cancer screening. Underlying all of the barriers is the systemic racism that affects and influences the healthcare system as much as all other institutions and contributes to inequities in the delivery of effective cancer prevention efforts. Perpetual disparities in CRC screening within the African American community are due to multifactorial barriers from the individual patient to provider and healthcare system and societal influences. An awareness of the behavioral and systemic factors that affect African Americans must underpin efforts to reach full equity in delivering CRC screening to this often medically underserved segment of our society.

The influence of patient-provider communication on cancer screenings differs among racial and ethnic groups

Our study aimed to estimate how associations between adults' perceptions of specific domains of PPC quality and their likelihood of receiving cancer screenings differed by race and ethnicity. We analyzed 2011-2015 Medical Expenditure Panel Survey (MEPS) data. Samples included 7337 women ages 50-74 (breast), 13,276 women ages 21-65 (cervical), and 9792 adults ages ≥50 years (colorectal). To examine individual domains of PPC quality (independent variables), adults reported how often providers: listened; showed respect; spent enough time; explained things; gave specific instructions; and demonstrated health literate practices (gave clear instructions and asked them to "teach-back" how they will follow instructions). Dependent variables were breast, cervical, and colorectal cancer screenings. Multivariable logistic regression was used to evaluate the odds of receiving cancer screenings using a composite measure of PPC quality and separate domains. Hispanic and non-Hispanic black adults who reported their providers always demonstrated PPC quality had higher odds of receiving colorectal cancer screenings compared to those whose providers did not. Adults' perceptions of whether or not their provider gave them specific instructions increased their odds of receiving breast (Hispanics OR = 1.65, 95% CI = 1.09, 2.51; non-Hispanic blacks OR = 1.54, 95% CI = 1.06, 2.24) and colorectal (non-Hispanic whites OR = 1.37, 95% CI = 1.13, 1.66; Hispanics OR = 1.29, 95% CI = 1.01, 1.66; non-Hispanic blacks OR = 1.92, 95% CI = 1.39, 2.65) cancer screenings. Non-Hispanic Asian women who reported their health care providers demonstrated "teach-back" had higher odds (OR = 2.25; 95% CI = 1.10, 4.62) of receiving cervical cancer screenings. Efforts to improve cancer screenings should focus on training providers to demonstrate health literate practices to improve cancer screenings.

Disparities in Utilization of Medical Specialists for Colonoscopy

Purpose: Colonoscopy is the preferred screening modality for colorectal cancer (CRC) prevention. The quality of the procedure varies although medical specialists such as gastroenterologists and colorectal surgeons tend to have better outcomes. We aimed to determine whether there are demographic and clinical differences between those who received a colonoscopy from a specialist versus those who received a colonoscopy from a nonspecialist.

Methods: Using the population-based South Carolina Outpatient Ambulatory Surgery Database, we looked retrospectively to obtain patient-level endoscopy records from 2010 to 2014. We used multilevel logistic regression to model whether patients saw a specialist for their colonoscopy. The primary variables were patient race and insurance type, and an interaction by rurality was tested.

Results: Of the 392,285 patients included in the analysis, 81% saw a specialist for their colonoscopy. County of residence explained 30% of the variability in the outcome. Non-Hispanic black (OR=0.65; confidence interval [95% CI]: 0.64–0.67) and Hispanic patients (OR=0.75; 95% CI: 0.67–0.84) were significantly less likely than non-Hispanic white patients to see a specialist. Compared with commercial/HMO insurance, all other types were less likely to see a specialist, and even more so for rural patients. The interaction of race by rurality was not significant.

Conclusions: Specialists play a key role in CRC screening and can affect later downstream outcomes. This study has shown that ethnic minorities and adults with public or other insurance, particularly in rural areas, are most likely not to see a specialist. These results are consistent with disparities in CRC incidence, mortality, and survival.

Predicting Colonoscopy Screening Behavior and Future Screening Intentions for African Americans Older than 50 Years

African Americans experience a disproportionate burden of morbidity and mortality from colorectal cancer, which may be due to low adherence to screening recommendations. Previous studies have found relationships between decision-making factors and screening behavior, but few have looked at both cognitive and affective factors or within a specifically African American sample. To better understand determinants that drive screening behavior, this study examines affective, cognitive, and social variables as predictors of colonoscopy in an age-eligible African American population. Participants completed surveys assessing affective associations with colonoscopy, perceived benefits and barriers, self-efficacy, knowledge, fear of colonoscopy, perceived risk, and colorectal cancer worry and fear. Regression analysis was used to model decision-making constructs as predictors of screening behavior/intentions. Affective, cognitive, and health care experience variables predicted colonoscopy completion and intentions. Provider-level factors and previous cancer screenings predicted prior screening only, but not intentions. Affective and cognitive components of perceived risk were associated with decreased likelihood of colonoscopy behavior, but increased likelihood of colonoscopy intentions. These findings suggest that colonoscopy decision making involves a complex array of both cognitive and affective determinants. This work extends our knowledge of colorectal cancer screening decision making by evaluating the effects of these multiple determinants on screening behavior in an African American sample. Future work exploring the interplay of affect and cognitions as influences on colonoscopy decision making and how health care experiences may moderate this effect is needed to develop effective intervention approaches and reduce screening disparities.

Knowledge and attitudes towards low dose computed tomography lung cancer screening and smoking among African Americans-a mixed method study

Background

The purpose of this study is to investigate knowledge, attitudes, and smoking cessation needs for African Americans who receive low dose computed tomography (LDCT) in an effort to reduce the health burden of lung cancer.

Methods

A mixed method study was conducted among African Americans who received LDCT. Data were gathered using a self-administered questionnaire and structured in-depth interview. Descriptive statistics were used to provide summary information on knowledge, attitude and smoking behaviors. Thematic analysis was used to analyze interview data. The sample size for both the quantitative and qualitative approach was fifteen.

Results

The results showed that 73% of participants were male, the mean age was 61.8 (SD =4.6) years old, and 66.7% of participants had an income less than $20,000. Eighty percent had an education level of high school or below and 73.3% were overweight or obese. Smoking history was long (mean years =39 SD =14.9), but the number of cigarettes smoked per day was low (mean =9.2 SD =7.3), and 64% of the patients had a low nicotine dependence. Assessment of knowledge and attitudes towards LDCT revealed that participants had a moderate/lower knowledge score (mean =4.3 SD =2.6), and most had a positive attitude. All participants planned to quit smoking, with 73% planning to quit within the next 6 months. Similar findings were also observed in the qualitative analysis.

Conclusions

African Americans who receive LDCT lung cancer screening in this study have a moderate/lower knowledge score and positive attitude towards LDCT. Most were not heavy smokers and had a lower nicotine dependence. Understanding the factors associated with smoking cessation among at-risk African American smokers will help reduce disparities in lung cancer burden, and is important to improve health for medically underserved minority populations.

Predictors of No-show Rate in the GI Endoscopy Suite at a Safety Net Academic Medical Center

BACKGROUND/OBJECTIVES

Noncompliance with physician and procedure appointments is associated with poor disease control and worse disease outcomes. This also impacts the quality of care, decreases efficiency, and affects revenue. Studies have shown that no-show rates are higher in clinics caring for underserved populations and may contribute to poorer health outcomes in this group.

METHODS

We performed a 17-month retrospective observational cohort study of patients scheduled for outpatient procedures in the Gastroenterology endoscopy suite at the University of Florida Health, Jacksonville. Multivariate logistic regression analysis was performed to evaluate associations between attendance and predictors of no-show.

RESULTS

In total, 6157 patients were scheduled to undergo different GI procedures during the study period. A total of 4388 (71%) patients completed their procedure, whereas 2349 (29%) failed to attend their appointment and were considered "no-show". There was a significant relationship between the visit attendance and race, insurance, gender, and marital status. Males had a higher no-show rate compared with females (30% vs. 28%; P<0.05). African Americans had the highest no-show rate (32%; P<0.05) amongst different races. Patients scheduled for surveillance colonoscopy (ie, history of polyps, IBD, Colon cancer) were more likely to show (78%) than those obtaining initial colorectal cancer screening (74%) or other indications (71%) (P<0.05).In the logistic regression model, patients with commercial insurance are more likely to show for their appointments than those with noncommercial insurance (eg, Medicare, Medicaid, City contract etc) [odds ratio (OR), 2.6; 95% confidence interval (CI), 2.2-3.0]. The odds of showing up are 1.7 times higher for married men compared with single men (OR, 1.7; 95% CI, 1.3-2.0). Similarly, married females are more likely to show up for appointment than single females (OR, 1.1; 95% CI, 0.9-1.3). We did not find significant association between the type of GI procedure (eg, colonoscopy vs. esophagogastroduodenoscopy vs. advanced endoscopic procedures) (P>0.05).

CONCLUSIONS

Predictors of no-shows for endoscopic gastrointestinal procedures included unpartnered or single patients, African American race and noncommercial insurance providers. Patients scheduled for surveillance colonoscopy had better adherence than initial screening. Further studies are required to better characterize these factors and improve adherence to the outpatient appointments based on the identified predictors.

Barriers and Facilitators to Colorectal Cancer Screening Within a Hispanic Population

INTRODUCTION

Colorectal cancer (CRC) is the third leading cancer cause of death among US Hispanics. CRC screening among the Hispanic population is lower compared with non-Hispanic Whites.

METHOD

The purpose of this qualitative, exploratory study was to better understand the barriers and facilitators of CRC screening and preference for stool-based testing collection methods among the predominantly Hispanic population of El Paso, Texas. Nine focus groups were conducted by a trained bilingual facilitator with a moderator guide informed by the literature. Transcripts of the focus groups were entered into qualitative analysis software and a thematic network was developed.

RESULTS

Fifty-six participants were recruited: average age was 68.5 years, 58.9% were female, 98.2% were Hispanic, 87.5% had an annual income of less than $20,000, 58.9% had 9th grade education or less, 12.5% had a discount program, and 5.4% had no insurance. Barriers to CRC screening included cost, fear, and embarrassment. Facilitators to screening included in-person health education and physician recommendation. Participants preferred the hygienic nature of a stool test collected with a brush and bottle.

CONCLUSION

Overall, there was a lack of knowledge regarding CRC and significant barriers to CRC screening. A community-based CRC screening program was subsequently developed from our findings.

Low Referral Rate for Genetic Testing in Racially and Ethnically Diverse Patients Despite Universal Colorectal Cancer Screening

BACKGROUND & AIMS

Guidelines recommend that all colorectal tumors be assessed for mismatch repair deficiency, which could increase identification of patients with Lynch syndrome. This is of particular importance for minority populations, in whom hereditary syndromes are under diagnosed. We compared rates and outcomes of testing all tumor samples (universal testing) collected from a racially and ethnically diverse population for features of Lynch syndrome.

METHODS

We performed a retrospective analysis of colorectal tumors tested from 2012 through 2016 at 4 academic centers. Tumor samples were collected from 767 patients with colorectal cancer (52% non-Hispanic white [NHW], 26% African American, and 17% Hispanic patients). We assessed rates of tumor testing, recommendations for genetic evaluation, rates of attending a genetic evaluation, and performance of germline testing overall and by race/ethnicity. We performed univariate and multivariate regression analyses.

RESULTS

Overall, 92% of colorectal tumors were analyzed for mismatch repair deficiency without significant differences among races/ethnicities. However, minority patients were significantly less likely to be referred for genetic evaluation (21.2% for NHW patients vs 16.9% for African American patients and 10.9% for Hispanic patients; P = .02). Rates of genetic testing were also lower among minority patients (10.7% for NHW patients vs 6.0% for AA patients and 3.1% for Hispanic patients; P < .01). On multivariate analysis, African American race, older age, and medical center were independently associated with lack of referral for genetic evaluation and genetic testing.

CONCLUSION

In a retrospective analysis, we found that despite similar rates of colorectal tumor analysis, minority patients are less likely to be recommended for genetic evaluation or to undergo germline testing for Lynch syndrome. Improvements in institutional practices in follow up after tumor testing could reduce barriers to diagnosis of Lynch diagnosis in minorities.

Colorectal Cancer Presentation and Survival in Young Individuals: A Retrospective Cohort Study

Emerging evidence suggests that the incidence of colorectal cancer is increasing among individuals under the age of 50 years. However, the pattern of disease presentation in young patients remains under investigation. This is a retrospective cohort study of patients diagnosed with colorectal cancer (CRC) between 2004 and 2015. Data was acquired from the Surveillance, Epidemiology, and End Results 18 program registries. A total of 269,398 patients who met the inclusion criteria were included in the final analysis. The primary outcomes were the likelihood of metastatic disease at diagnosis and survival. Of the 269,389 patients diagnosed with CRC, 11.8% of the patients were young (20 to 49 years), 45.6% were middle-aged (50 to 69 years), and 42.6% were elderly (70 years or older). Individuals in the middle-aged and elderly cohorts were significantly less likely to present with metastatic disease as compared to the young cohort (middle-aged adjusted odds ratio (aOR) = 0.73, 95% confidence interval (CI) = 0.70 to 0.75, elderly aOR = 0.49, 95% CI = 0.47 to 0.50). However, overall survival was longest in the young cohort. We conclude that young individuals with colorectal cancer have an increased risk of presenting with distant metastases as compared to the middle-aged and elderly, but, nevertheless, exhibit prolonged survival.

Colorectal Cancer Screening in Black Men: Recommendations for Best Practices

Screening for colorectal cancer has been demonstrated to reduce colorectal cancer mortality. Blacks have a higher mortality from this malignancy, particularly men, yet screening rates in this population are often found to be lower than in whites. A modest literature demonstrates effective interventions that can increase screening rates in blacks; however, results are not consistent and ongoing work is required. Most work has not addressed specific barriers to screening in black men. Given the lack of studies on black men only, this study evaluated the state of research in the black population using a PubMed search. The authors provide commentary that proposes increased (1) state and local government support for collaborative programs with healthcare organizations, including patient navigation; (2) augmented community-organizing efforts to generate more attention to the need for colorectal cancer screening in the black community, with a focus on black men; and (3) federal research funding to promote investigation into new interventions and evaluation of existing ones. Specific recommendations for black men include lowering the screening age to 45years, increasing access to health care, the use of patient navigators, and improved reporting and monitoring of colorectal cancer screening rates. SUPPLEMENT INFORMATION: This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Patterns and Trends in Cancer Screening in the United States

Introduction

We examined the prevalence of cancer screening reported in 2015 among US adults, adjusted for important sociodemographic and access-to-care variables. By using data from the National Health Interview Survey (NHIS) for 2000 through 2015, we examined trends in prevalence of cancer screening that adhered to US Preventive Services Task Force screening recommendations in order to monitor screening progress among traditionally underserved population subgroups.

Methods

We analyzed NHIS data from surveys from 2000 through 2015 to estimate prevalence and trends in use of recommended screening tests for breast, cervical, colorectal, and prostate cancers. We used logistic regression and report predictive margins for population subgroups adjusted for various socioeconomic and demographic variables.

Results

Colorectal cancer screening was the only test that increased during the study period. We found disparities in prevalence of test use among subgroups for all tests examined. Factors that reduced the use of screening tests included no contact with a doctor in the past year, no usual source of health care, and no insurance coverage.

Conclusion

Understanding use of cancer screening tests among different population subgroups is vital for planning public health interventions with potential to increase screening uptake and reduce disparities in cancer morbidity and mortality. Overarching goals of Healthy People 2020 are to “achieve health equity, eliminate disparities, and improve the health of all groups.” Adjusted findings for 2015, compared with previous years, show persistent screening disparities, particularly among the uninsured, and progress for colorectal cancer screening only.

Systematic review: methodological flaws in racial/ethnic reporting for gastroesophageal reflux disease

Health care disparities affecting the care of multiple disease groups are of growing concern internationally. Research guidelines, governmental institutions, and scientific journals have attempted to minimize disparities through policies regarding the collection and reporting of racial/ethnic data. One area where shortcomings remain is in gastroesophageal reflux disease (GERD). This systematic review, which adheres to the PRISMA statement, focuses on characterizing existing methodological weaknesses in research focusing on studies regarding the assessment, prevalence, treatment, and outcomes of GERD patients. Search terms included GERD and typical symptoms of GERD in ethnic groups or minorities. We reviewed 62 articles. The majority of studies did not report the race/ethnicity of all participants, and among those who did, very few followed accepted guidelines. While there were diverse participants, there was also diversity in the manner in which groups were labeled, making comparisons difficult. There appeared to be a disparity with respect to countries reporting race/ethnicity, with certain countries more likely to report this variable. Samples overwhelmingly consisted of the study country's majority population. The majority of studies justified the use of race/ethnicity as a study variable and investigated conceptually related factors such as socioeconomic status and environment. Yet, many studies wrote as if race/ethnicity reflected biological differences. Despite recommendations, it appears that GERD researchers around the world struggle with the appropriate and standard way to include, collect, report, and discuss race/ethnicity. Recommendations on ways to address these issues are included with the goal of preventing and identifying health care disparities.

The Association Between Primary Source of Healthcare Coverage and Colorectal Cancer Screening Among US Veterans

BACKGROUND

Colorectal cancer (CRC) is a deadly but largely preventable disease. Screening improves outcomes, but screening rates vary across healthcare coverage models. In the Veterans Health Administration (VA), screening rates are high; however, it is unknown how CRC screening rates compare for Veterans with other types of healthcare coverage.

AIMS

To determine whether Veterans with Veteran-status-related coverage (VA, military, TRICARE) have higher rates of CRC screening than Veterans with alternate sources of healthcare coverage.

METHODS

We conducted a cross-sectional analysis of Veterans 50-75 years from the 2014 Behavioral Risk Factor Surveillance System survey. We examined CRC screening rates and screening modalities. We performed multivariable logistic regression to identify the role of coverage type, demographics, and clinical factors on screening status.

RESULTS

The cohort included 22,138 Veterans. Of these, 76.7% reported up-to-date screening. Colonoscopy was the most common screening modality (83.7%). Screening rates were highest among Veterans with Veteran-status-related coverage (82.3%), as was stool-based screening (10.8%). The adjusted odds of up-to-date screening among Veterans with Veteran-status-related coverage were 83% higher than among Veterans with private coverage (adjusted OR = 1.83, 95% CI = 1.52-2.22). Additional predictors of screening included older age, black race, high income, access to medical care, frequent medical visits, and employed or married status.

CONCLUSIONS

CRC screening rates were highest among Veterans with Veteran-status-related coverage. High CRC screening rates among US Veterans may be related to system-level characteristics of VA and military care. Insight to these system-level characteristics may inform mechanisms to improve CRC screening in non-VA settings.

Lung cancer disparities and African-Americans

African-Americans, as historically disadvantaged minorities, have more advanced stages of cancer when diagnosed, lower survival rates, and lower rates of accessing timely care than do Caucasians. Lung cancer incidence and mortality, in particular, are high among African-Americans. The U.S. Preventive Services Task Force recently released an evidence-based lung cancer screening technology called low-dose computerized tomography. High-risk African-Americans might benefit greatly from such screening but not many are aware of this technology. Public health nurses can play a key role in increasing awareness of the technology among African-American communities and encouraging qualified African-Americans to obtain screening. This study discusses issues with lung cancer and smoking among African-Americans, a recently released evidence-based lung cancer screening technology, and implications for public health nurses to enhance uptake of the new screening technology among high-risk African-Americans.

Predictive overbooking and active recruitment increases uptake of endoscopy appointments among African American patients

BACKGROUND AND AIMS

Use of GI endoscopy is historically lower in nonwhite ethnic and racial groups compared with whites. These disparities are multifactorial but likely contribute to differences in GI clinical outcomes. We sought to improve endoscopy uptake overall and in minorities by predictive overbooking and active recruitment in a hospital-based GI clinic.

METHODS

From January to October 2014, we alternated between traditional booking for Veterans Affairs Healthcare Network patients with a physician recommendation for endoscopy and active recruitment of patients to fill projected open endoscopy appointment slots. On intervention weeks, patients attending a GI clinic were given the opportunity to "fast track" to an endoscopy appointment on short notice. During control weeks, patients were not actively recruited. We compared uptake of endoscopy appointments in both groups and performed logistic regression to determine predictors of participation in fast-track active recruitment.

RESULTS

During fast-track active recruitment for endoscopy, the clinic recruited an additional 111 patients for endoscopy over passive recruitment, including 46 African Americans (41.4%). In a logistic regression model controlling for demographic and clinical characteristics, African Americans were twice as likely (adjusted OR, 1.99; 95% CI, 1.26-3.17) than whites to participate in the fast-track option for recommended endoscopy.

CONCLUSIONS

Interventions to actively recruit patients for endoscopy increased the overall percentage of GI clinic patients undergoing endoscopy and disproportionately improved endoscopy appointment uptake in African Americans.

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.

Racial Disparities in Readmissions for Patients with Inflammatory Bowel Disease (IBD) After Colorectal Surgery

BACKGROUND

The incidence of inflammatory bowel disease (IBD) in minorities is increasing, and health outcome disparities are becoming more apparent. Our aim was to investigate the contribution of race to readmissions in IBD patients undergoing colorectal surgery.

DESIGN

The National Surgical Quality Improvement Program database from 2012 to 2013 was queried for all patients with IBD undergoing elective colorectal surgery. After stratifying by race, unadjusted univariate and bivariate comparisons were made. Primary outcome was all-cause 30-day readmission. Predictors of readmission were identified using multivariable logistic regression.

RESULTS

Of the 2523 patients with IBD who underwent elective colon surgery, 15.0 % were readmitted within 30 days of index operation. Black patients constituted 7.7 % of the entire cohort. Black patients were significantly different in smoking status (27 vs. 22 %) and Crohn's diagnosis (84 vs. 73 %) (p < 0.05). Black patients had significantly higher readmission rates (20 vs. 15 %) and longer length-of-stays (8 vs. 6 days) after surgery (p < 0.05). On multivariable analysis, black race remained a significant predictor for 30-day readmissions in patients with IBD (odds ratio 1.6, 95 % confidence interval 1.1-2.5).

CONCLUSIONS

Black patients with IBD have an increased risk for readmission after colorectal surgery. Efforts to reduce readmissions need to target not only well-studied risk factors such as postoperative complications, but also investigate non-NSQIP-measured elements such as social and behavioral determinants of health.