Colorectal cancer screening in African Americans: practice patterns in the United States. Are we doing enough?

Impact of race-specific screening guideline on the uptake of colorectal cancer screening among young African Americans

BACKGROUND

African Americans (AAs) have had lower colorectal cancer (CRC) screening rates, higher incidence rate, and earlier mean age at onset. The 2017 U.S. Multi-Society Task Force (MSTF) recommended initiating CRC screening at age 45 for AAs and age 50 for non-AAs.

OBJECTIVE

To investigate the impact of the 2017 MSTF's race-specific guidelines on CRC screening rate among young AAs.

DESIGN, SETTING, AND PARTICIPANTS

We used the 2015 and 2018 National Health Interview Survey to provide nationally representative estimates. The study sample included adults aged between 45 and 75 without a history of CRC, excluding screening recipients for diagnosis or surveillance purposes.

MAIN MEASURES

The outcome is a binary variable of CRC screening. Primary independent variables were age and race category (non-AAs aged 45-49, AAs 45-49, non-AAs 50-75, AAs 50-75), a binary variable indicating before or after the 2017 MSTF guideline (2015 vs. 2018), and their interaction terms. We employed a multivariable logistic model, adjusting for individual characteristics, and accounting for complex survey design.

KEY RESULTS

Among the total sample (n = 21,735), CRC screening rate increased from 54.6% in 2015 to 58.5% in 2018 (p < 0.01). By age and race, the screening rate exhibited an increase for all age and race groups except for young non-AAs. Compared to young non-AAs, the adjusted predicted probability (APP) of screening for young AAs was significantly higher by 0.10 (average marginal effect, 0.10; 95% confidence interval, 0.01-0.19) in 2018, while the difference was insignificant in 2015. Racial differences in screening among older adults were not significant in both years. The CRC screening rate was substantially lower among young AAs compared to older AAs (17.2% vs. 65.5% in 2018).

CONCLUSION

The race-specific recommendation is an effective policy tool to increase screening uptake and would contribute to reducing cancer disparities among racial/ethnic minorities.

Choice of injection time of conscious sedation and its impact on pain control in colonoscopy

Purpose

The aim of this study was to identify the effect of different injection times on pain during colonoscopy procedure.

Methods

In this retrospective study, the data of patients who underwent colonoscopy from June 2020 to September 2020 were assessed to investigate the effect of different injection time of sedative drugs (midazolam and dezocine). The primary endpoint was evaluating the pain intensity of the patients using visual analogue scale (VAS) immediately after colonoscopy .

Results

A total of 152 patients were eligible for this study. Of them, 76 received midazolam and dezocine injection 1 min prior to the colonoscopy procedure (the 1 Min group) and the other 76 patients received the injection 3 min prior to the procedure (the 3 Min group). The vital signs of all patients were stable except for one patient who was diagnosed with inflammatory bowel disease in the 3 Min group. A transient drop in blood pressure for this patient was observed during colonoscopy but returned to normal after general treatment. The two groups had similar rates of cecal intubation (84.21% vs. 90.97%, P = 0.22), addition of sedative drugs during procedure (2.63% vs. 5.26%, P = 0.68), and adequate bowel preparation (Boston Bowel Preparation Scale ≥6, 61.84% vs. 61.84%, P = 1.0). However, patients in the 3 Min group had significantly lower VAS than those in the 1 Min group [0 (0, 1) vs. 1 (0, 2), P = 0.041].

Conclusion

The timing of drug injection during conscious sedation may affect pain control during colonoscopy, with 3 min prior to the procedure showing lower VAS.

Assessment of Colorectal Cancer Screening Disparities in U.S. Men and Women Using a Demographically Representative Sample

Timely receipt of colorectal cancer (CRC) screening can reduce morbidity and mortality. This is the first known study to adopt Andersen's model of health services use to identify factors associated with CRC screening among US adults. The data from National Health Interview Survey from 2019 was utilized to conduct the analyses. Multivariable logistic regression was used to separately analyze data from 7,503 age-eligible women and 6,486 age-eligible men. We found similar CRC screening levels among men (57.7%) and women (57.6%). Factors associated with higher screening odds in women were older age, married/cohabitating with a partner, Black race, >bachelor's degree, having a usual source of care, and personal cancer history. Factors associated with lower odds for women were American Indian/Alaska Native race, living in the US for ≤10 years, ≤138% federal poverty level (FPL), uninsured or having Medicare, and in fair/poor health. For men, factors associated with higher screening odds were older age, homosexuality, married/cohabitating with a partner, Black race, >high school/general educational development education, having military insurance, having a usual source of care, and personal cancer history. Factors associated with lower odds for men were being a foreign-born US resident, living in the South or Midwest, ≤138% FPL, and being uninsured or having other insurance. Despite lower screening rates in the past, Black adults show a significantly higher likelihood of CRC screening than White adults; yet, screening disparities remain in certain other groups. CRC screening efforts should continue to target groups with lower screening rates to eliminate screening disparities.

Colorectal Cancer Screening Prevalence and Adherence for the Cancer Prevention Project of Philadelphia (CAP3) Participants Who Self-Identify as Black

Introduction

Colorectal cancer is the third leading cause of cancer-related deaths among Black men and women. While colorectal cancer screening (CRCS) reduces mortality, research assessing within race CRCS differences is lacking. This study assessed CRCS prevalence and adherence to national screening recommendations and the association of region of birth with CRCS adherence, within a diverse Black population.

Methods

Data from age-eligible adults, 50–75 years, (N = 357) participating in an ongoing, cross-sectional study, was used to measure CRCS prevalence and adherence and region of birth (e.g., Caribbean-, African-, US-born). Prevalence and adherence were based on contemporaneous US Preventive Services Task Force guidelines. Descriptive statistics were calculated and adjusted prevalence and adherence proportions were calculated by region of birth. Adjusted logistic regression models were performed to assess the association between region of birth and overall CRCS and modality-specific adherence.

Results

Respondents were 69.5% female, 43.3% married/living with partner, and 38.4% had <$25,000 annual income. Overall, 78.2% reported past CRCS; however, stool test had the lowest prevalence overall (34.6%). Caribbean (95.0%) and African immigrants (90.2%) had higher prevalence of overall CRCS compared to US-born Blacks (59.2%) (p-value <0.001). African immigrants were five times more likely to be adherent to overall CRCS compared to US-born Blacks (OR = 5.25, 95% CI 1.34–20.6). Immigrants had higher odds of being adherent to colonoscopy (Caribbean OR = 6.84, 95% CI 1.49–31.5; African OR = 7.14, 95% CI 1.27–40.3) compared to US-born Blacks.

Conclusions

While Caribbean and African immigrants have higher prevalence and adherence of CRCS when compared US-born Blacks, CRCS is still sub-optimal in the Black population. Efforts to increase CRCS, specifically stool testing, within the Black population are warranted, with targeted interventions geared towards US-born Blacks.

Self-reported reasons for colonoscopy among adults aged 45-49 versus 50 years and older from 2010-2018

BACKGROUND

In May of 2018, the American Cancer Society lowered the age of colorectal cancer (CRC) screening initiation from 50 to 45 years and in October 2020, United States Preventive Services Task Force published draft guidelines also lowering age of screening initiation to 45 years. Evaluating guideline adherence is needed; however, the majority of prior research on cancer screening do not distinguish whether colonoscopy was performed for true screening purposes or for post-symptomatic diagnosis.

METHODS

Using data from the National Health Interview Survey between 2010 to mid-2018, we assessed response to the question "What was the MAIN reason you had [last] colonoscopy?" stratified by age (45-49 versus 50+ years). Multivariable logistic regression defined adjusted odds ratios of receiving last colonoscopy for screening controlling for relevant demographic characteristics. To estimate the cost burden of colonoscopy, the proportion of respondents reporting paying out of pocket for their last colonoscopy was assessed.

RESULTS

Among 29,074 participants who had undergone a colonoscopy, 44.4 % of those aged 45-50 reported routine procedure as the reason for their most recent colonoscopy, as compared to 82.4 % in the 50+ age group (p < 0.001). Characteristics associated with undergoing colonoscopy as a routine procedure included Black race and male sex for both age cohorts (p < 0.01 for all). Notably, almost half (46.9 %) of participants younger than 50 years paid part of or the full cost of their colonoscopy, as compared to 30.7 % over the age of 50 (p < 0.001).

CONCLUSIONS

The majority of adults aged 45-49 self-report that last colonoscopy was not performed for screening, which is unsurprising given guidelines for screening for individuals under 50. As guidelines change, continued surveillance of colonoscopy patterns across age cohorts is needed, and studies should also incorporate reasons for testing.

Colorectal cancer screening in African Americans: are we following the guidelines?

PURPOSE

The age at onset, incidence, and mortality rate of colorectal cancer varies among racial groups being highest in African Americans. This increased risk led to the recommendation to begin screening at the age of 45 years. Whether the recommendation for screening of African Americans at an earlier age was implemented is unknown.

METHODS

We used data from the Cancer Control Supplement of National Health Interview Survey (NHIS) conducted in the years 2005, 2010, and 2015 to analyze demographic data and use of colorectal screening (colonoscopy, stool heme testing, sigmoidoscopy, computed tomographic colonography) among the US population between the ages of 45-49 years.

RESULTS

Data on colorectal screening was available from 6740 individuals; 16.5% were African Americans. Screening test use among African Americans in 2005, 2010, and 2015 was similar to use in Whites (i.e., 15.4% (95% CI 11.4-19.4), 28.4% (95% CI 19.3-30.4) and 20.2% (95% CI 14.8-25.5) vs. 16.9% (95% CI 15.1-18.6), 19.3% (95% CI 16.9-21.7), and 21.4% (95% CI 18.6-24.2) in 2005, 2010 and 2015, respectively. Observed screening test use rates may largely be accounted for by diagnostic exams.

CONCLUSION

The recommendation for earlier colorectal screening of African Americans has not yet resulted in increased test utilization. These results emphasize the need for multidisciplinary actions to inform and implement public health policy.

Improved Survival Outcome and Access to Cancer Screening from Hemorrhoid in Patients with Rectal Cancer

Background

The interventions for hemorrhoid increase access to rectal cancer screening and thus might reduce cancer death. We aimed to examine the impact of hemorrhoid on survival outcomes in rectal cancer.

Methods

We identified 510 patients with stage I to III rectal cancer from a prospectively collected database. Patients were divided into hemorrhoid and non-hemorrhoid group. The primary endpoints were disease-free survival (DFS) and overall survival (OS).

Results

Hemorrhoid group had significantly more stage I-II diseases in comparison to nonhemorrhoid group (71.1% vs. 55.9%, P = 0.049). The hemorrhoid group had significantly better DFS and OS compared to nonhemorrhoid group, the hazard ratios (HRs) of which were 0.39 (95% CI 0.17-0.88, P = 0.018) and 0.33 (95% CI 0.12-0.92, P = 0.034), respectively. Multivariate analysis revealed that hemorrhoid was independently associated with DFS [adjusted HR 0.43 (95% CI 0.17-0.95, P = 0.045)]. A nomogram for predicting DFS outcome was generated based on hemorrhoid history, with a concordance index of 0.71 (95% CI 0.66-0.75, P < 0.001).

Conclusions

There may exist a screening effect and survival benefit from hemorrhoid in rectal cancer, which supports the significance of rectal cancer screening in lowering its mortality.

Afro-Caribbeans Have a Lower Prevalence of Advanced Colon Neoplasia than African-Americans

BACKGROUND/AIMS

The black population in the USA is a heterogeneous group composed of smaller subgroups from different origins. The definition of black in many colorectal cancer (CRC) risk studies is vague, and differences in CRC risk comparing black subpopulations have not been evaluated. The aim of the study is to compare advanced colorectal neoplasia (ACN) between two subgroups of black populations: African-American (AA) and Afro-Caribbean (AC). A secondary aim was to determine whether there are differences in prevalence of adenomas.

METHODS

This was a retrospective study of 3797 AA and AC patients undergoing first time screening colonoscopy in two different institutions in the USA.

RESULTS

Overall adenoma prevalence was 29.3% for the entire population with 29.5% in AAs and 29.0% in AC with no statistically significant difference between the study groups (AOR: 1.02; 95% CI 0.88-1.18, P = 0.751). However, ACN was significantly higher in the AA group (11.8%) compared to AC (9.0%) (AOR: 1.30, 95% CI 1.02-1.66, P = 0.034). It was observed that AAs had ACN at a higher BMI than AC. After adjusting for BMI/ethnicity interactions, the difference in ACN between both groups became more significant (AOR: 1.93, 95% CI 1.16-3.23, P = 0.012).

CONCLUSIONS

AAs have a higher risk of ACN than AC. Current recommendations to start screening in average-risk AAs at an earlier age may not apply to other black subgroups.

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.

How spatial accessibility to colonoscopy affects diagnostic adherences and adverse intestinal outcomes among the patients with positive preliminary screening findings

Background

Colonoscopy is an important procedure for early colorectal cancer (CRC) detection, however, patients with positive preliminary screening results in China may not seek for colonoscopy to confirm the diagnosis. We evaluated the spatial accessibility of colonoscopy among the residents with positive preliminary screening results in Guangzhou, China, and investigated how colonoscopy accessibility was associated with the population adherence and adverse intestinal outcomes.

Methods

This study was based on the Guangzhou community‐based CRC screening program. Spatial accessibility was measured using three metrics including travel time from home to nearest colonoscopy hospital, physician‐to‐population ratio (PPR) and accessibility indicator estimated with enhanced two‐step floating catchment area method (E2SFCA). We used Cox regression and logistic regression to assess the association of colonoscopy accessibility with population adherence and adverse intestinal outcomes, respectively.

Results

A total of 34 606 people were identified with positive preliminary screening findings. Central areas were reported with higher E2SFCA scores, higher PPR and less travel time. The model adjusting for potential individual level confounders found that PPR > 50 (Hazard Ratio (HR) = 1.88, 95% Confidence Interval (CI): 1.79‐1.97) and higher scores of E2SFCA (HR = 3.78, 95% CI: 2.07‐6.92) were associated with increased adherence, although estimates were not significant in the model adjusting for both individual and district‐level confounders. For adverse intestinal outcomes, the final multilevel logistic model suggested a lower risk of intestinal lesions among the residents in areas with PPR > 50 (Odds Ratio (OR) = 0.49, 95% CI: 0.24‐0.99) and higher scores of E2SFCA (OR = 0.20, 95% CI: 0.05‐0.82).

Conclusion

Significant inequality of colonoscopy accessibility was observed across Guangzhou. The increased incidence of intestinal lesions was associated with spatial inequalities of medical resources. Policies against the spatial inequality in medical resources should be developed.

Predictors of overall and test-specific colorectal Cancer screening adherence

This study investigated predictors of overall and test-specific colorectal cancer screening (CRCS). Stool blood test (SBT) and/or colonoscopy screening were offered to primary care patients in two randomized controlled trials which assessed the impact of behavioral interventions on screening. Data were obtained through surveys and electronic medical records. Among 1942 participants, 646 (33%) screened. Exposure to interventions was associated with higher overall CRCS by twofold to threefold; older age, African American race, being married, and having a higher screening decision stage were also associated with higher overall CRCS (odds ratios = 1.30, 1.31, 1.34, and 5.59, respectively). Intervention, older age, female gender, and being married were associated with higher SBT adherence, while preference for colonoscopy was associated with lower SBT adherence. Intervention and higher decision stage were associated with higher colonoscopy adherence, while preference for SBT was associated with lower colonoscopy adherence. Among older individuals, African Americans had higher overall CRCS than whites, but this was not true among younger individuals (interaction p = .041). The higher screening adherence of African Americans over whites was due to stronger screening with a non-preferred test, i.e., higher SBT adherence only among individuals who preferred colonoscopy and higher colonoscopy adherence only among individuals who preferred SBT. Intervention exposure, sociodemographic background, and screening decision stage predicted overall CRCS adherence. Gender and test preference also affected test-specific screening adherence. Interactions involving race and test preference suggest that it is important to provide both colonoscopy and SBT screening options to patients, particularly African Americans.

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

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

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.

Screening for colorectal cancer in Tianhe, Guangzhou: results of combining fecal immunochemical tests and risk factors for selecting patients requiring colonoscopy

Objective

To explore the performance of a protocol combining fecal immunochemical test (FIT) and a high-risk factor questionnaire (HRFQ) for selecting patients requiring colonoscopy as part of a population-based colorectal cancer (CRC) screening program in China.

Methods

From 2015 to 2016, we conducted a CRC screening program for all residents aged 45 years or older in Tianhe District, Guangzhou City, China. Participants underwent an FIT and received an HRFQ as part of primary screening. Those with positive FIT and/or HRFQ results were considered to be at high risk and were recommended to undergo colonoscopy.

Results

A total of 10 074 subjects were recruited and enrolled in the screening program. In the enrolled population, 17.5% had positive FIT results and 19.4% had positive HRFQ results. Of those recommended to undergo diagnostic colonoscopy, 773 did so. The screening method’s overall positive predictive value (PPV) was 4.9% for non-adenomatous polyps, 11.4% for low-risk adenomas (LRAs), 15.9% for high-risk adenomas (HRAs) and 1.6% for CRC. The PPVs of positive FIT results for non-adenomatous polyps, LRAs, HRAs and CRC were 5.2%, 15.9%, 22.5% and 2.5%, respectively. The PPVs of positive HRFQ results for non-adenomatous polyps, LRA, HRA and CRC were 4.1%, 10.2%, 14.3% and 1.4%, respectively. The PPVs associated with combined positive FIT and HRFQ results for non-adenomatous polyps, LRAs, HRAs and CRC were 4.5%, 16.4%, 23.7% and 2.8%, respectively.

Conclusion

Our results suggest that this two-step CRC screening strategy, involving a combination of FIT and HRFQ followed by colonoscopy, is useful to identify early-stage CRC. The high detection rates and PPVs for CRC and adenomas encourage this strategy’s use in ongoing screening programs.

Latina and Black/African American Women's Perspectives on Cancer Screening and Cancer Screening Reminders

INTRODUCTION

Racial and ethnic disparities continue to exist in cancer screening rates, especially among US Latina and Black/African American populations. We conducted six focus groups among 41 women from these communities in order to better understand their preferences about cancer screening reminders and the motivators and deterrents they face in obtaining recommended breast, cervical, and colon cancer screening.

METHODS

Using self-reported patient race/ethnicity from electronic medical records of a large, integrated health care system in Seattle, we recruited women ages 30-60 to participate in one of five 2-hour focus groups. Using verbatim transcripts from these discussions, we conducted a qualitative analysis to identify common themes.

RESULTS

The focus group participants were primarily strong endorsers and utilizers of recommended breast, cervical, and colon cancer screening services. Insurance and belief in preventive care were the most common motivators that they cited in obtaining cancer screening. However, they still reported multiple barriers to getting recommended cancer screening for themselves and community members, including lack of time, conflicting information about screening intervals, distrust in the health care system, and a lack of understanding of the benefits of preventive care.

CONCLUSIONS

Efforts to improve understanding about the benefits of cancer screening, clarify cancer screening guideline recommendations, increase cultural competency among health care professionals, and expand the times and locations where cancer screening is available are all options that may improve cancer screening rates among Latinas and Black/African American women.