Colorectal cancer disparities: Issues, controversies and solutions

Low neighborhood socioeconomic status is associated with poor outcomes in young adults with colorectal cancer

BACKGROUND

The incidence of early-onset colorectal cancer has increased markedly over the past decade. Although established for older adults, there are limited data on socioeconomic and racial disparities in screening, treatment, and outcomes in this distinct group.

METHODS

Adults with primary colorectal cancer diagnosed at age <50 were identified from the Surveillance, Epidemiology, and End Results database. The exposure of interest was neighborhood socioeconomic status based on the Yost Index, a census-tract level composite score of neighborhood economic health. Univariate analysis was performed with χ2 analyses. Logistic regression models were created to evaluate the association of neighborhood socioeconomic status (Yost Index quintile) with metastasis at presentation and surgical intervention. Kaplan-Meier and Cox proportional hazards models were created.

RESULTS

In total, 45,660 early-onset colorectal cancer patients were identified; 16.8% (7,679) were in the lowest quintile of neighborhood socioeconomic status. Patients with the lowest neighborhood socioeconomic status were 1.13 times (95% confidence interval 1.06-1.21) more likely to present with metastases and had lower survival (hazard ratio 1.45, 95% confidence interval 1.37-1.53) compared to those with the highest neighborhood socioeconomic status. Non-Hispanic Black patients were more likely to present with metastatic disease (odds ratio 1.11, 95% confidence interval 1.05-1.19), less likely to undergo surgery for localized or regional disease (odds ratio 0.48, 95% confidence interval 0.43-0.53), and had lower survival (hazard ratio 1.21, 95% confidence interval 1.15-1.27) than non-Hispanic White patients.

CONCLUSION

Socioeconomic and racial disparities in early-onset colorectal cancer span diagnosis, treatment, and survival. As the disease burden of early-age onset colorectal cancer increases, interventions to boost early diagnosis and access to surgery are necessary to improve survival among minorities and patients with low neighborhood socioeconomic status.

Community collaboration to advance racial/ethnic equity in colorectal Cancer screening: Protocol for a multilevel intervention to improve screening and follow-up in community Health centers

INTRODUCTION

Colorectal cancer (CRC) screening utilization is low among low-income, uninsured, and minority populations that receive care in community health centers (CHCs). There is a need for evidence-based interventions to increase screening and follow-up care in these settings.

METHODS

A multilevel, multi-component pragmatic cluster randomized controlled trial is being conducted at 8 CHCs in two metropolitan areas (Boston and Los Angeles), with two arms: (1) Mailed FIT outreach with text reminders, and (2) Mailed FIT-DNA with patient support. We also include an additional CHC in Rapid City (South Dakota) that follows a parallel protocol for FIT-DNA but is not randomized due to lack of a comparison group. Eligible individuals in participating clinics are primary care patients ages 45-75, at average-risk for CRC, and overdue for CRC screening. Participants with abnormal screening results are offered navigation for follow-up colonoscopy and CRC risk assessment.

RESULTS

The primary outcome is the completion rate of CRC screening at 90 days. Secondary outcomes include the screening completion rate at 180 days and the rate of colonoscopy completion within 6 months among participants with an abnormal result. Additional goals are to enhance our understanding of facilitators and barriers to CRC risk assessment in CHC settings.

CONCLUSIONS

This study assesses the effectiveness of two multilevel interventions to increase screening participation and follow-up after abnormal screening in under-resourced clinical settings, informing future efforts to address CRC disparities.

TRIAL REGISTRATION

NCT05714644.

Association Between Racial and Socioeconomic Disparities and Hospital Performance in Treatment and Outcomes for Patients with Colon Cancer

BACKGROUND

Disparities in colon cancer care and outcomes by race/ethnicity, socioeconomic status (SES), and insurance are well recognized; however, the extent to which inequalities are driven by patient factors versus variation in hospital performance remains unclear. We sought to compare disparities in care delivery and outcomes at low- and high-performing hospitals.

METHODS

We identified patients with stage I-III colon adenocarcinoma from the 2012-2017 National Cancer Database. Adequate lymphadenectomy and timely adjuvant chemotherapy administration defined hospital performance. Multilevel regression models evaluated disparities by race/ethnicity, SES, and insurance at the lowest- and highest-performance quartile hospitals.

RESULTS

Of 92,573 patients from 704 hospitals, 45,982 (49.7%) were treated at 404 low-performing hospitals and 46,591 (50.3%) were treated at 300 high-performing hospitals. Low-performing hospitals treated more non-Hispanic (NH) Black, Hispanic, low SES, and Medicaid patients (all p < 0.01). Among low-performing hospitals, patients with low versus high SES (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.82-0.92), and Medicare (OR 0.90, 95% CI 0.85-0.96) and Medicaid (OR 0.88, 95% CI 0.80-0.96) versus private insurance, had decreased odds of receiving high-quality care. At high-performing hospitals, NH Black versus NH White patients (OR 0.83, 95% CI 0.72-0.95) had decreased odds of receiving high-quality care. Low SES, Medicare, Medicaid, and uninsured patients had worse overall survival at low- and high-performing hospitals (all p < 0.01).

CONCLUSION

Disparities in receipt of high-quality colon cancer care occurred by SES and insurance at low-performing hospitals, and by race at high-performing hospitals. However, survival disparities by SES and insurance exist irrespective of hospital performance. Future steps include improving low-performing hospitals and identifying mechanisms affecting survival disparities.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors Affecting the Rate of Colonoscopy Among African Americans Aged Over 45 Years

African Americans continue to have a low rate of colonoscopy screening despite the U.S. Preventive Services Taskforce's (USPSTF) recommendations and its proven benefits. Colonoscopy has proven to be an effective screening and therapeutic procedure. Understanding the root cause of the problem is a crucial step toward achieving the desired colonoscopy rate among this population. This paper evaluates factors that contribute to the underutilization of colonoscopy. The paper also analyzes strategies that could be maximized to increase colonoscopy rates, minimize colorectal cancer inequalities, and promote optimal colorectal health among African Americans.

Integrating equity frameworks into surgical quality improvement and health administrative databases: A narrative review

Ensuring safe, timely, and effective surgery is critical for high-quality healthcare and is the goal of surgical quality monitoring systems. At the heart of these systems are health administrative databases which house patient clinico-demographic information, healthcare processes and outcomes. Through analysis of monitoring systems outputs, we can identify gaps within healthcare delivery, patient experience, and surgical outcomes. However, gaps in our healthcare can only be measured by the variables we collect. Equity stratifiers are sociodemographic descriptors that can identify patient populations who experience differences in health and healthcare that may be considered unjust or unfair. They include age, education, gender, geographic location, income, Indigenous identity, racialized group, and sex at birth. These equity stratifiers represent measurable components of the social determinants of health housed within health administrative databases and allow for standardized analysis and reporting of health inequity. However, not all databases collect these stratifiers - making granular analysis of patient subgroups who may experience health inequity impossible to measure. Moreover, in databases that do collect this information, a wide range in the classification systems used makes for comparisons across jurisdictions challenging. The focus of this narrative review will be to apply the principles of the equity stratifier framework to examine what measures are collected in surgical quality improvement databases, cancer monitoring systems and provincial/state health administrative databases in the United States of America and Canada. The goal of this narrative review is to 1) inform researchers, surgeons, and policymakers of the current landscape of social variables collected within common health administrative databases. 2) Outline the pros and cons of the current collection system. 3) Issue a call to action for policymakers to incorporate health equity frameworks into the collection and reporting of data.

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.

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

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

Colorectal cancer in the 45-to-50 age group in the United States: a National Cancer Database (NCDB) analysis

BACKGROUND

Amid increasing awareness of early-onset colorectal cancer (CRC), guidelines in the United States (US) recently lowered the recommended routine CRC screening age from 50 to 45 in average-risk individuals. There are little data on the number of patients in this age group diagnosed with CRC prior to these changes. Our objective was to audit the historic CRC case trends and impact of CRC in the 45-to-50-year-old category prior to new screening recommendations.

METHODS

Colorectal adenocarcinoma cases in 45-to-50-year-old patients were queried from the NCDB (2004-2017). Cases were stratified by sex, race, and site. The disability-adjusted lost years (DALY) and lost earnings were estimated. The average annual percentage changes (AAPC) of CRC incidence were estimated using jointpoint analysis. The main outcome measures were DALY and lost earnings. Secondary outcome measures were the 2004-2017 AAPC and the cumulative incidence of potential CRC cases in the 45-to-50 cohort through 2030 without guideline changes.

RESULTS

67,442 CRC patients in the 45-to-50 demographic were identified. The CRC burden resulted 899,905 DALY and $17 billion in lost earnings. The 2004-2017 AAPC was 1.6%, with an estimated 13-year increase of 25%. There were sex-, race-, and anatomic site-specific discrepancies with estimated 13-year increases of 30% for males, 110% for American Indian/ Alaska Natives/ Asian American/ Pacific Islander races, and 31% for rectal cancer by 2030.

CONCLUSION

CRC has been steadily increasing in the 45-to-50 age group, with tremendous disability and cost ensuing. There is great potential benefit from lowering the recommended routine CRC screening age to 45. Targeted intervention could ensure the most vulnerable segments benefit from the new guidelines, in both reducing the incidence and improving survivorship in CRC patients.

Cancer-Associated Microbiota: From Mechanisms of Disease Causation to Microbiota-Centric Anti-Cancer Approaches

Helicobacter pylori infection is the only well-established bacterial cause of cancer. However, due to the integral role of tissue-resident commensals in maintaining tissue-specific immunometabolic homeostasis, accumulated evidence suggests that an imbalance of tissue-resident microbiota that are otherwise considered as commensals, can also promote various types of cancers. Therefore, the present review discusses compelling evidence linking tissue-resident microbiota (especially gut bacteria) with cancer initiation and progression. Experimental evidence supporting the cancer-causing role of gut commensal through the modulation of host-specific processes (e.g., bile acid metabolism, hormonal effects) or by direct DNA damage and toxicity has been discussed. The opportunistic role of commensal through pathoadaptive mutation and overcoming colonization resistance is discussed, and how chronic inflammation triggered by microbiota could be an intermediate in cancer-causing infections has been discussed. Finally, we discuss microbiota-centric strategies, including fecal microbiota transplantation, proven to be beneficial in preventing and treating cancers. Collectively, this review provides a comprehensive understanding of the role of tissue-resident microbiota, their cancer-promoting potentials, and how beneficial bacteria can be used against cancers.

The association of health insurance and race with treatment and survival in patients with metastatic colorectal cancer

Background

Black patients and underinsured patients with colorectal cancer (CRC) present with more advanced disease and experience worse outcomes. The study aim was to evaluate the interaction of health insurance status and race with treatment and survival in metastatic CRC.

Materials and methods

Patients diagnosed with metastatic CRC within NCDB from 2006–2016 were included. Primary outcomes included receipt of chemotherapy and 3-year all-cause mortality. Multivariable logistic regression and Cox-regression (MVR) including a two-way interaction term of race and insurance were performed to evaluate the differential association of race and insurance with receipt of chemotherapy and mortality, respectively.

Results

128,031 patients were identified; 70.6% White, 14.4% Black, 5.7% Hispanic, and 9.3% Other race. Chemotherapy use was higher among White compared to Black patients. 3-year mortality rate was higher for Blacks and lower for Hispanics, in comparison with White patients. By MVR, Black patients were less likely to receive chemotherapy. When stratified by insurance status, Black patients with private and Medicare insurance were less likely to receive chemotherapy than White patients. All-cause mortality was higher in Black patients and lower in Hispanic patients, and these differences persisted after controlling for insurance and receipt of chemotherapy.

Conclusion

Black patients and uninsured or under-insured patients with metastatic CRC are less likely to receive chemotherapy and have increased mortality. The effect of health insurance among Blacks and Whites differs, however, and improving insurance alone does not appear to fully mitigate racial disparities in treatment and outcomes.

Propensity Score Matching Analysis of the Effect of Payer Status on the Survival of Colon Cancer Patients

Background and objective

Colon cancer is one of the most common types of cancer globally. The factors that could affect colon cancer survival include age, stage, treatment, and other socioeconomic aspects. Payer status has been shown to be a significant predictor of cancer patient survival in retrospective studies. However, due to the limitations of retrospective studies, patient baseline characteristics between payer statuses are not comparable. Few studies have addressed the effect of payer status on the overall survival (OS) of patients using propensity score matching (PSM). In light of this, we conducted a study to examine the effect of payer status on the survival of colon cancer patients based on PSM.

Materials and methods 

About 66,493 stage II/III colon cancer patients aged 40-90 years and diagnosed between 2004 and 2015 were analyzed from a de-identified National Cancer Database (NCDB) file. All patients had undergone surgery, and patients who had received radiation therapy, hormone therapy, immunotherapy, palliative care, or therapies other than chemotherapy were excluded. Only private or Medicaid payer status was included. The propensity score was calculated by computing the probability of patients being in the Medicaid group using logistic regression. The PSMATCH procedure in the SAS software (SAS Inc., Gary, NC) was used to perform PSM on patients with Medicaid and private insurance. The greedy nearest neighbor matching method was used to match one Medicaid to one privately insured patient with a caliper of 0.2. At the same time, an exact match was done for gender, age group, race, and stage at diagnosis. Multivariate Cox regression was then used to estimate the effect of payer status on survival before and after PSM.

Results

Among the 66,493 patients, 90.3% were privately insured and 9.7% had Medicaid. In univariate analysis, payer status was found to be a significant predictor of OS. Prior to PSM, the median overall survival (MOS) for patients with private insurance was 12.75 years, while those with Medicaid had a MOS of 9.02 years. After PSM, 6,167 paired patients were matched, and patients with private insurance had a MOS of >12.82 years and Medicaid patients had a MOS of 8.88 years. After PSM, patients with Medicaid had a 50% increased risk of death, and payer status proved to be a statistically significant predictor of OS of colon cancer.

Conclusion

Based on our findings, as per the PSM method, payer status can be a significant predictor of survival among colon cancer patients. Also, chemotherapy, race, age, and other socioeconomic factors were also found to be significant predictors of OS. Further research should be conducted to investigate other covariates not studied here and the mediation effect of payer on the survival of cancer patients.

Racial and ethnic disparities in colorectal cancer incidence and mortality

The occurrence of colorectal cancer (CRC) shows a large disparity among recognized races and ethnicities in the U.S., with Black Americans demonstrating the highest incidence and mortality from this disease. Contributors for the observed CRC disparity appear to be multifactorial and consequential that may be initiated by structured societal issues (e.g., low socioeconomic status and lack of adequate health insurance) that facilitate abnormal environmental factors (through use of tobacco and alcohol, and poor diet composition that modifies one's metabolism, microbiome and local immune microenvironment) and trigger cancer-specific immune and genetic changes (e.g., localized inflammation and somatic driver gene mutations). Mitigating the disparity by prevention through CRC screening has been demonstrated; this has not been adequately shown once CRC has developed. Acquiring additional knowledge into the science behind the observed disparity will inform approaches towards abating both the incidence and mortality of CRC between U.S. racial and ethnic groups.

Better survival of right-sided than left-sided stage II colon cancer: a propensity scores matching analysis based on SEER database

BACKGROUND/AIMS

Most studies have found that right-sided colon cancer (RCC) has worse prognosis than left-sided colon cancer (LCC), especially in stage III, but the reported prognosis of stage II colon cancer is variable. This study aimed to evaluate the impact of tumor location on survival outcomes in stage II colon cancer.

MATERIALS AND METHODS

Patients with stage II colon cancer were identified in the Surveillance, Epidemiology, and End Results database from 2004 to 2009. The effect of tumor location on overall survival and cancer-specific survival was analyzed using Cox proportional hazards regression models and propensity score matching.

RESULTS

Of 16,519 patients, 69.6% had RCC and30.4% had LCC. In unadjusted analyses, RCC had a 13% increased overall mortality risk (hazards ratio [HR], 1.13; 95% confidence interval [CI], 1.07-1.19; p<0.001) but an18% reduction in cancer-specific mortality risk compared with LCC (HR, 0.82; 95% CI, 0.76-0.89; p<0.001). After propensity scores matching analyses, RCC had a 21% reduced overall mortality risk (HR, 0.79; 95% CI, 0.72-0.87; p<0.001) and a 49% reduction in cancer-specific mortality risk compared with LCC (HR, 0.51; 95% CI, 0.44-0.60; p<0.001).

CONCLUSION

When adjusted for multiple clinicopathological features, stage II RCC showed better prognosis than stage II LCC.

Association of Race/Ethnicity With Overall Survival Among Patients With Colorectal Liver Metastasis

This cohort study assesses the association of race/ethnicity with overall survival among patients with colorectal liver metastasis overall and among those undergoing liver resection.

Specificity of metabolic colorectal cancer biomarkers in serum through effect size

INTRODUCTION

Colorectal cancer is one of the most diagnosed cancers, leading to numerous deaths. In addition to existing screening methods, metabolic profiling could help both to diagnose and to understand the various states of the disease.

OBJECTIVES

Find specific candidate biomarkers (CB) in serum of patients with colorectal cancer (CRC), in comparison to the situation after remission (R-CRC), evaluated on distinct patients.

METHODS

All serum samples were analyzed using comprehensive two-dimensional gas chromatography (GC × GC) coupled to high resolution time of flight mass spectrometry (TOF-MS) through an optimized and validated untargeted analytical method regulated by a quality control (QC) system. First, we used a specific multi-approaches data (pre)processing workflow to highlight, annotate and assess the performances of the most altered metabolites between CRC patients (n = 18) and healthy control samples (HC, n = 19) specifically matched for age and gender, two of the most influential confounding factors. On the contrary, due to the difficulty to control for all clinical and demographic traits when sampling small cohorts, the samples from patients in remission (n = 17) were not matched. Because of the consequent risk of bias, the usual null hypothesis significance tests (NHST) could not be applied reliably. Therefore, we compared the R-CRC samples to another specifically matched group of healthy controls (R-HC, n = 17), and used this comparison to indirectly address the difference between patients with colorectal cancer and patients in remission through a measure called effect size (ES) whose methodological aspects were investigated.

RESULTS

24 candidate biomarkers were found significantly altered and able to discriminate the CRC and HC samples efficiently (Receiver Operating Characteristic (ROC) area under the curve (AUC) of 0.86, sensitivity and specificity of 0.72 and 0.78). 10 of those were found to have signals close to healthy levels in the R-CRC samples and were therefore specific to colorectal cancer. In the point-biserial case studied here, r-like (strength of association) and d-like (standardized mean difference) ES were directly convertible and only linear and rank-based ES were different. We therefore used and recommend Hedges' g, Spearman's rho and Kendall's tau, along with an unstandardized ES. The confidence intervals, that quantify the uncertainty of the measure, were well represented through scatterplots and distribution curves.

CONCLUSION

The candidate biomarkers found, along with their specificity, could help for the detection of colorectal cancer, the diagnosis of remission, and for the understanding of its pathophysiology, after proper validation on independent cohorts. The effect size, here applied on a MS global profiling data set, is an ideal complement to NHST and a useful tool to compare and combine distinct cohorts, within a study as well as between studies (meta-analysis).

Disparities in Colorectal Cancer Screening in the United States Before and After Implementation of the Affordable Care Act

BACKGROUND & AIMS

Colorectal cancer (CRC) is major cause of cancer-related mortality in the United States. Screening, however, is suboptimal and there are disparities in outcomes. After health policy changes and national efforts to increase rates of screening and address inequities, we aimed to examine progress towards eliminating racial and ethnic disparities in CRC screening.

METHODS

We conducted a repeated cross-sectional analysis of average-risk adults (age 50-75 years) included in the behavioral risk factors surveillance system survey. The main outcome was CRC screening status. We determined screening rates overall and by race and ethnicity (1 variable) for each survey year from 2008 through 2016 and used Joinpoint analyses to determine significant trends in rates over time by race and ethnicity. We also examined screening modalities used overall and by race and ethnicity.

RESULTS

We analyzed data from 1,089,433 respondents. Screening uptake was 61.1% in 2008 and 67.6% in 2016 (P < .001); it was highest among whites and lowest among Hispanics. Only whites, Hispanics, and Asians had significantly higher screening rates in each study year (P < .001). Despite increasing rates among Hispanics, the screening rate disparity between whites and Hispanics was 17% at the end of the study period. Screening rates in blacks did not change with time and were 4.0% lower than the rate in whites in 2016. Other racial and ethnic groups had varying levels of improvement with time. Colonoscopy was the most common modality each year.

CONCLUSIONS

In a cross-sectional analysis of average-risk adults, we found that although rates of CRC screening have increased overall since 2008, they have increased disproportionately in each racial and ethnic group, and disparities in screening uptake persist.

Updated Assessment of Colorectal Cancer Incidence in the U.S. by Age, Sex, and Race/Ethnicity

BACKGROUND

Whether recent updates to colon cancer screening guidelines benefit men and women or all race/ethnic groups equally is not clear.

AIMS

The aim of this study is to evaluate age-, sex-, and race/ethnicity-specific trends in CRC incidence and disease burden among adults.

METHODS

Using 2000-2014 surveillance, epidemiology, and end results database, annual CRC incidence (per 100,000 persons/year) among U.S. adults was categorized by age (using 10-year age intervals) and stratified by sex and race/ethnicity. Comparison of incidence between groups utilized the z-statistic with p < 0.05 indicating statistical significance.

RESULTS

Overall, CRC incidence was the highest among patients aged ≥ 80 years (330.8 per 100,000 persons/year), which was significantly higher in men versus women (377.2 vs. 304.3 per 100,000 persons/year, p < 0.001). CRC incidence in younger individuals was 22.8 per 100,000 persons/year (age 40-49) and 6.8 per 100,000 persons/year (age 30-39). CRC incidence was significantly higher in African Americans compared to non-Hispanic whites. From 2000 to 2014, CRC incidence declined in all age groups over age 60, remained stable in age 50-59, and demonstrated proportional increases in among age 20-49 years. While CRC incidence in all race/ethnic groups aged ≥ 60 years declined, Hispanics aged 50-59 increased 21.9%, but remained stable in other race/ethnic groups. Race/ethnicity-specific disparities in CRC incidence in patients aged 20-49 were also observed.

CONCLUSIONS

While CRC incidence has declined among U.S. adults aged ≥ 60, increasing incidence among patients aged < 50 is concerning. Identifying risk factors among "average-risk" patients is needed to better implement targeted screening of individuals not currently meeting CRC screening criteria.

The impact of APC polymorphisms on the transition from polyps to colorectal cancer (CRC)

OBJECTIVE

The purpose of this study was to investigate the function of APC polymorphisms (D1822V and E1317Q) on the transition from polyps to colorectal cancer (CRC).

METHODS

259 patients with polyps were included in the study. APC polymorphisms were genotyped via polymerase chain reaction (PCR) and subsequent sequencing. χ² test was performed to analyze the relationship of APC polymorphisms or CRC occurrence with clinical features. COX regression was used to find out risk factors for CRC. Hazard ratio (HR) and 95% confidence interval (CI) represented the risk of CRC.

RESULTS

Clinical information on sex, regular physical activity, smoking history, alcohol use and polyps types was recorded. Neither D1822V nor E1317Q polymorphism was associated with these factors. In following analysis, we found significant difference in the frequency of males between CRC and non-CRC patients (87.4% vs. 58.7%, P < 0.001). Distinct difference in the distribution of D1822V polymorphism was also observed between CRC and non-CRC patients (P = 0.001). In COX analysis, sex was identified as a risk factor for transition from polyps to CRC (HR = 2.442, 95%CI = 1.281-4.654). D1822V polymorphism tended to inhibit the transition process (HR = 0.286, 95%CI = 0.170-0.480). However, E1317Q seemed to have no significant effect on this process (HR = 1.042, 95%CI = 0.676-1.606).

CONCLUSION

In a word, APC D1822V polymorphism has strong effect on the transition from polyps to CRC.

Increasing uptake of evidence-based screening services though a community health worker-delivered multimodality program: study protocol for a randomized pragmatic trial

BACKGROUND

Underserved ethnic minority populations experience significant disparities in HIV, hepatitis C virus (HCV), colorectal cancer (CRC), and cervical cancer incidence and mortality. Much of the excess burden of these diseases among underserved communities is due to lack of preventive care, including screening. Barriers to disease screening include low awareness, lack of access to care and health insurance, and cultural beliefs regarding disease prevention. Our current trial aims to examine community health worker (CHW)-delivered, home-based multi-modality screening for HIV, HCV, CRC, and cervical cancer simultaneously.

DESIGN

We are conducting a randomized pragmatic trial among 900 Haitian, Hispanic, and African-American participants from diverse underserved communities in South Florida. People between the ages of 50 and 65 who have not had appropriate HIV, HCV, CRC, and cervical cancer screening per United States Preventive Services Task Force (USPSTF) recommendations are eligible for the study. Participants are recruited by CHWs and complete a structured interview to assess multilevel determinants of disease risk. Participants are then randomized to receive HIV, HCV, CRC, and cervical cancer screening via navigation to care by a CHW (Group 1) or via CHW-delivered home-based screening (Group 2). The primary outcome is completion of screening for each of these diseases within 6 months post-enrollment.

DISCUSSION

Our trial is among the first to examine the effectiveness of a CHW-delivered, multimodality, home-based disease-screening approach. If found to be effective, this approach may represent a cost-effective strategy for disease screening within underserved and underscreened minority groups.

TRIAL REGISTRATION

Clinical Trials.gov # NCT02970136, registered November 21, 2016.

Racial Comparisons in Timeliness of Colon Cancer Treatment in an Equal-Access Health System

BACKGROUND

Non-Hispanic black (NHB) adults with cancer may have longer time-to-treatment than non-Hispanic whites (NHW) in the United States. Unequal access to medical care may partially account for this racial disparity. This study aimed to investigate whether there were racial differences in time-to-treatment and in treatment delays for patients diagnosed with colon cancer in the equal-access Military Health System (MHS).

METHODS

Patients age 18-79 years diagnosed with colon adenocarcinoma between January 1, 1998, and December 31, 2014, were identified in the Department of Defense Central Cancer Registry and the MHS Data Repository-linked databases. Median time-to-treatment (surgery and chemotherapy) and 95% confidence intervals were compared between NHBs and NHWs in multivariable quantile regression models. Odds ratios and 95% confidence intervals of receiving delayed treatment defined by guidelines for NHBs relative to NHWs were estimated using multivariable logistic regression.

RESULTS

Patients (n = 3067) had a mean age at diagnosis of 58.4 (12.2) years and the racial distribution was 76.7% NHW and 23.3% NHB. Median adjusted time-to-treatment was similar for NHB compared to NHW patients. The likelihood of receiving delayed treatment was similar between NHB and NHW patients.

CONCLUSIONS

In the MHS, there was no evidence of treatment delays for NHBs compared to NHWs, suggesting the role of equal access to medical care and insurance coverage in reducing racial disparities in colon cancer treatment.

Outcomes Among Minority Patients With Metastatic Colorectal Cancer in a Safety-net Health Care System

BACKGROUND

Metastatic colorectal cancer (CRC) outcomes continue to improve, but they vary significantly by race and ethnicity. We hypothesize that these disparities arise from unequal access to care.

MATERIALS AND METHODS

The Harris Health System (HHS) is an integrated health delivery network that provides medical care to the underserved, predominantly minority population of Harris County, Texas. As the largest HHS facility and an affiliate of Baylor College of Medicine's Dan L. Duncan Comprehensive Cancer Center, Ben Taub Hospital (BTH) delivers cancer care through multidisciplinary subspecialty that prioritize access to care, adherence to evidence-based clinical pathways, integration of supportive services, and mitigation of financial toxicity. We performed a retrospective analysis of minority patients diagnosed with and treated for metastatic CRC at BTH between January 2010 and December 2012. Kaplan-Meier survival curves were compared with survival curves from randomized control trials reported during that time period.

RESULTS

We identified 103 patients; 40% were black, 49% were Hispanic, and 12% were Asian or Middle Eastern. Thirty-five percent reported a language other than English as their preferred language. Seventy-four percent of patients with documented coverage status were uninsured. Eighty-four percent of patients received standard chemotherapy with a clinician-reported response rate of 63%. Overall survival for BTH patients undergoing chemotherapy was superior to that of subjects enrolled in the CRYSTAL (Cetuximab Combined with Irinotecan in First-Line Therapy for Metastatic Colorectal Cancer) trial (median, 24.0 vs. 19.9 months; P = .014).

CONCLUSION

HHS provides a health delivery infrastructure through which minority patients with socioeconomic challenges experience clinical outcomes comparable with highly selected patients enrolled in randomized control trials. Efforts to resolve CRC disparities should focus on improving access of at-risk populations to high-quality comprehensive cancer care.

Mortality-to-incidence ratios by US Congressional District: Implications for epidemiologic, dissemination and implementation research, and public health policy

The mortality-to-incidence ratio (MIR) can be computed from readily accessible, public-use data on cancer incidence and mortality, and a high MIR value is an indicator of poor survival relative to incidence. Newly available data on congressional district-specific cancer incidence and mortality from the U.S. Cancer Statistics (USCS) database from 2011 to 2015 were used to compute MIR values for overall (all types combined), breast, cervix, colorectal, esophagus, lung, oral, pancreas, and prostate cancer. Congressional districts in the South and Midwest, including MS, AL, and KY, had higher (worse) MIR values for all cancer types combined than for the U.S. as a whole. For all cancers combined, there was a positive correlation between each district's percent of rural residents and the MIR (r = 0.47; p < .001). The MIR for all cancer types combined was lower in districts within states that expanded Medicaid vs. those states that did not expand Medicaid (0.36 vs. 0.38; p < .001). A positive correlation was seen between the proportion of non-Hispanic Black residents and MIR (r = 0.15; p < .01 for all cancers). Lower MIRs were observed in districts in New England and in states that expanded Medicaid. However, there also were some interesting departures from this rule (e.g., Wyoming, South Dakota, parts of Wisconsin and Florida). Rural congressional districts have generally higher MIRs than more urban districts. There is some concern that poorer, more rural states that did not expand Medicaid may experience greater disparities in MIRs relative to Medicaid expansion states in the future.

Race, the microbiome and colorectal cancer

In the past decade, more cancer researchers have begun to understand the significance of cancer prevention, which has prompted a shift in the increasing body of scientific literature. An area of fascination and great potential is the human microbiome. Recent studies suggest that the gut microbiota has significant roles in an individual's ability to avoid cancer, with considerable focus on the gut microbiome and colorectal cancer. That in mind, racial disparities with regard to colorectal cancer treatment and prevention are generally understudied despite higher incidence and mortality rates among Non-Hispanic Blacks compared to other racial and ethnic groups in the United States. A comprehension of ethnic differences with relation to colorectal cancer, dietary habits and the microbiome is a meritorious area of investigation. This review highlights literature that identifies and bridges the gap in understanding the role of the human microbiome in racial disparities across colorectal cancer. Herein, we explore the differences in the gut microbiota, common short chain fatty acids produced in abundance by microbes, and their association with racial differences in cancer acquisition.

Race, Poverty, and Mental Health Drive Colorectal Cancer Screening Disparities in the Veterans Health Administration

INTRODUCTION

Colorectal cancer (CRC) is a common but largely preventable malignancy. Screening is recommended for all adults aged 50-75 years; however, screening rates are low nationally and vary by patient factors and across health care systems. It is currently unknown whether there are inequities in CRC screening rates by patient sociodemographic and/or clinical factors in the Veterans Health Administration (VA) where the majority of patients are CRC screening-eligible age and CRC is the third most commonly diagnosed cancer.

METHODS

We performed a retrospective cohort study using VA national clinical performance and quality data to determine the overall CRC screening rate, rates by patient sociodemographic and clinical factors, and predictors of screening adjusting for patient and system factors. We also determined whether disparities in screening exist in VA.

RESULTS

The overall CRC screening rate in VA was 81.5%. Screening rates were lowest among American Indians/Alaska Natives [75.3%; adjusted odds ratio (aOR)=0.77, 95% confidence interval (CI)=0.65-0.90], those with serious mental illness (75.8%; aOR=0.65, 95% CI=0.61-0.69), those with substance abuse (76.9%; aOR=0.76, 95% CI=0.72-0.80), and those in the lowest socioeconomic status quintile (79.5%; aOR=1.10-1.31 for quintiles 2-5 vs. lowest quintile 1). Increasing age, Hispanic ethnicity, black race, Asian race, and high comorbidity were significant predictors of screening uptake.

CONCLUSIONS

Many racial/ethnic disparities in CRC screening documented in non-VA settings do not exist in VA. Nonetheless, overall high VA CRC screening rates have not reached American Indians/Alaska Natives, low socioeconomic status groups, and those with mental illness and substance abuse. These groups might benefit from additional targeted efforts to increase screening uptake.

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

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

Optimizing Patient Selection for Laparoscopic and Open Colorectal Cancer Resections: A National Surgical Quality Improvement Program–Matched Analysis

The aim of this study was to identify patients undergoing colorectal cancer (CRC) resection who might benefit specifically from either an open or laparoscopic approach. From the NSQIP database (2012–2013), patients who underwent laparoscopic colectomy (LC) or open colectomy (OC) for CRC were identified. The two groups were matched and compared in terms of any, medical, and surgical complications. A wide range of patient characteristics were collected and analyzed. Interaction analysis was performed in a multivariable regression model to identify risk factors that may make LC or OC more beneficial in certain subgroups of patients. Overall, OC (n = 6593) was associated with a significantly higher risk of any [odds ratio (OR) 2.03, 95% confidence interval (CI) 1.87–2.20], surgical (OR 1.98, 95% CI 1.82–2.16), and medical (OR 1.71, 95% CI 1.51–1.94) complications than LC (n = 6593). No subgroup of patients benefited from an open approach. Patients with obesity (BMI > 30) (P = 0.03) and older age (>65 years) (P = 0.01) benefited more than average from a laparoscopic approach. For obese patients, LC was associated with less overall complications (OC vs LC: OR 1.92 obese vs 1.21 nonobese patients). For elderly patients, LC was more preferable regarding the risk of medical complications (OC vs LC OR of 1.91 vs 1.34 for younger patients). No subgroup of CRC patients benefited specifically more from an open colorectal resection. This supports that the laparoscopic technique should be performed whenever feasible. For the obese and elderly patients, the benefits of the laparoscopic approach were more pronounced.

To Screen or Not to Screen Adults 45-49 Years of Age: That is the Question

Should we adopt the recently published American Cancer Society (ACS) recommendations to screen adults at 45 years of age? The main reasons for adopting the recommendation include the increase of colorectal cancer (CRC) in the young, especially late-stage tumors. Screening at 45 years is also supported by predictive modeling, which the ACS employed using updated and improved models as compared to those previously used by the United States Preventive Services Task Force. Reasons against adopting include concerns with the models as well as diversion of scarce screening resources away from high-risk populations. Readers are provided with opposing viewpoints regarding the ACS recommendation.

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.

Medical Mistrust and Colorectal Cancer Screening Among African Americans

Despite well-documented benefits of colorectal cancer (CRC) screening, African Americans are less likely to be screened and have higher CRC incidence and mortality than Whites. Emerging evidence suggests medical mistrust may influence CRC screening disparities among African Americans. The goal of this systematic review was to summarize evidence investigating associations between medical mistrust and CRC screening among African Americans, and variations in these associations by gender, CRC screening type, and level of mistrust. MEDLINE, CINAHL, Web of Science, PsycINFO, Google Scholar, Cochrane Database, and EMBASE were searched for English-language articles published from January 2000 to November 2016. 27 articles were included for this review (15 quantitative, 11 qualitative and 1 mixed methods study). The majority of quantitative studies linked higher mistrust scores with lower rates of CRC screening among African Americans. Most studies examined mistrust at the physician level, but few quantitative studies analyzed mistrust at an organizational level (i.e. healthcare systems, insurance, etc.). Quantitative differences in mistrust and CRC screening by gender were mixed, but qualitative studies highlighted fear of experimentation and intrusiveness of screening methods as unique themes among African American men. Limitations include heterogeneity in mistrust and CRC measures, and possible publication bias. Future studies should address methodological challenges found in this review, such as limited use of validated and reliable mistrust measures, examination of CRC screening outcomes beyond beliefs and intent, and a more thorough analysis of gender roles in the cancer screening process.

Vitamin D Regulation of the Uridine Phosphorylase 1 Gene and Uridine-Induced DNA Damage in Colon in African Americans and European Americans

BACKGROUND & AIMS

African Americans have the greatest colorectal cancer (CRC) burden in the United States; interethnic differences in protective effects of vitamin D might contribute to disparities. 1α,25(OH)₂D₃ vitamin D (the active form of vitamin D) induces transcription of the uridine phosphorylase gene (UPP1) in colon tissues of European Americans but to a lesser extent in colon tissues of African Americans. UPP1-knockout mice have increased intestinal concentrations of uridine and Deoxyuridine triphosphate (dUTP), have increased uridine-induced DNA damage, and develop colon tumors. We studied 1α,25(OH)₂D₃ regulation of UPP1 and uridine-induced DNA damage in the colon and differences in these processes between African and European Americans.

METHODS

We quantified expression and activity of UPP1 in response to 1α,25(OH)₂D₃ in young adult mouse colonic cells, human CRC cells (LS174T), and organoids (derived from rectosigmoid biopsy samples of healthy individuals undergoing colonoscopies) using quantitative polymerase chain reaction, immunoblot, and immunocytochemistry assays. Binding of the vitamin D receptor to UPP1 was tested by chromatin immunoprecipitation. Uridine-induced DNA damage was measured by fragment-length analysis in repair enzyme assays. Allele-specific 1α,25(OH)₂D₃ responses were tested using luciferase assays.

RESULTS

Vitamin D increased levels of UPP1 mRNA, protein, and enzymatic activity and increased vitamin D receptor binding to the UPP1 promoter in young adult mouse colonic cells, LS174T cells, and organoids. 1α,25(OH)₂D₃ significantly reduced levels of uridine and uridine-induced DNA damage in these cells, which required UPP1 expression. Organoids derived from colon tissues of African Americans expressed lower levels of UPP1 after exposure to 1α,25(OH)₂D₃ and had increased uridine-induced DNA damage compared with organoids derived from tissues of European Americans. Luciferase assays with the T allele of single nucleotide polymorphism rs28605337 near UPP1, which is found more frequently in African Americans than European Americans, expressed lower levels of UPP1 after exposure to 1α,25(OH)₂D₃ than assays without this variant.

CONCLUSIONS

We found vitamin D to increase expression of UPP1, leading to reduce uridine-induced DNA damage, in colon cells and organoids. A polymorphism in UPP1 found more frequently in African Americans than European Americans reduced UPP1 expression upon cell exposure to 1α,25(OH)₂D₃. Differences in expression of UPP1 in response to vitamin D could contribute to the increased risk of CRC in African Americans.

First data from a population based cancer registry in Ethiopia

BACKGROUND

The Addis Ababa City Cancer Registry, established in September 2011, is the only population-based cancer registry in Ethiopia, covering a catchment population of just over three million habitants. Herein, we report incidence data based on the first two years of registration, 2012-2013.

METHODS

Newly-diagnosed cancer cases in the capital city were actively collected from 22 hospitals, clinics, and diagnostic facilities.

RESULTS

During 2012-2013, a total of 4139 newly diagnosed cases were recorded, with the majority (67%) occurring in females. Cancers of the breast (31.5%) and cervix (14.1%) were the two most common cancers among females, while colorectal cancers (10.6%) and non-Hodgkin lymphomas (10.2%) were the most common cancers among males. The average annual age-standardized rate for all sites 2012-13 were 136.2 (per 100,000) and 70.7 in females and males, respectively. Female age-standardized rates were 40.6 for breast cancer and 21.5 for cervix, while equivalent rates in males were 7.6 per 100,000 for colorectal cancer and 6.8 per 100,000 for non-Hodgkin lymphoma.

CONCLUSION

In general, these incidence patterns were similar to those reported in neighboring countries, which suggests that the majority of cancer cases occurring in Addis Ababa are captured within this starting phase of the registry. However, our finding of colorectal cancer as the most commonly-diagnosed cancer in males is novel and requires further investigation.

A systematic review of clinic and community intervention to increase fecal testing for colorectal cancer in rural and low-income populations in the United States - How, what and when?

BACKGROUND

Interventions to improve fecal testing for colorectal cancer (CRC) exist, but are not yet routine practice. We conducted this systematic review to determine how implementation strategies and contextual factors influenced the uptake of interventions to increase Fecal Immunochemical Tests (FIT) and Fecal Occult Blood Testing (FOBT) for CRC in rural and low-income populations in the United States.

METHODS

We searched Medline and the Cochrane Library from January 1998 through July 2016, and Scopus and clinicaltrials.gov through March 2015, for original articles of interventions to increase fecal testing for CRC. Two reviewers independently screened abstracts, reviewed full-text articles, extracted data and performed quality assessments. A qualitative synthesis described the relationship between changes in fecal testing rates for CRC, intervention components, implementation strategies, and contextual factors. A technical expert panel of primary care professionals, health system leaders, and academicians guided this work.

RESULTS

Of 4218 citations initially identified, 27 unique studies reported in 29 publications met inclusion criteria. Studies were conducted in primary care (n = 20, 74.1%), community (n = 5, 18.5%), or both (n = 2, 7.4%) settings. All studies (n = 27, 100.0%) described multicomponent interventions. In clinic based studies, components that occurred most frequently among the highly effective/effective study arms were provision of kits by direct mail, use of a pre-addressed stamped envelope, client reminders, and provider ordered in-clinic distribution. Interventions were delivered by clinic staff/community members (n = 10, 37.0%), research staff (n = 6, 22.2%), both (n = 10, 37.0%), or it was unclear (n = 1, 3.7%). Over half of the studies lacked information on training or monitoring intervention fidelity (n = 15, 55.6%).

CONCLUSIONS

Studies to improve FIT/FOBT in rural and low-income populations utilized multicomponent interventions. The provision of kits through the mail, use of pre-addressed stamped envelopes, client reminders and in-clinic distribution appeared most frequently in the highly effective/effective clinic-based study arms. Few studies described contextual factors or implementation strategies. More robust application of guidelines to support reporting on methods to select, adapt and implement interventions can help end users determine not just which interventions work to improve CRC screening, but which interventions would work best in their setting given specific patient populations, clinical settings, and community characteristics.

TRIAL REGISTRATION

In accordance with PRISMA guidelines, our systematic review protocol was registered with PROSPERO, the international prospective register of systematic reviews, on April 16, 2015 (registration number CRD42015019557 ).

Racial Disparity in Gastrointestinal Cancer Risk

Cancer from the gastrointestinal tract and its associated excretory organs will occur in more than 300,000 Americans in 2017, with colorectal cancer responsible for >40% of that burden; there will be more than 150,000 deaths from this group of cancers in the same time period. Disparities among subgroups related to the incidence and mortality of these cancers exist. The epidemiology and risk factors associated with each cancer bear out differences for racial groups in the United States. Esophageal adenocarcinoma is more frequent in non-Hispanic whites, whereas esophageal squamous cell carcinoma with risk factors of tobacco and alcohol is more frequent among blacks. Liver cancer has been most frequent among Asian/Pacific Islanders, chiefly due to hepatitis B vertical transmission, but other racial groups show increasing rates due to hepatitis C and emergence of cirrhosis from non-alcoholic fatty liver disease. Gastric cancer incidence remains highest among Asian/Pacific Islanders likely due to gene-environment interaction. In addition to esophageal squamous cell carcinoma, cancers of the small bowel, pancreas, and colorectum show the highest rates among blacks, where the explanations for the disparity are not as obvious and are likely multifactorial, including socioeconomic and health care access, treatment, and prevention (vaccination and screening) differences, dietary and composition of the gut microbiome, as well as biologic and genetic influences. Cognizance of these disparities in gastrointestinal cancer risk, as well as approaches that apply precision medicine methods to populations with the increased risk, may reduce the observed disparities for digestive cancers.

Racial differences in colorectal cancer survival at a safety net hospital

BACKGROUND

While racial disparity in colorectal cancer survival have previously been studied, whether this disparity exists in patients with metastatic colorectal cancer receiving care at safety net hospitals (and therefore of similar socioeconomic status) is poorly understood.

METHODS

We examined racial differences in survival in a cohort of patients with stage IV colorectal cancer treated at the largest safety net hospital in the New England region, which serves a population with a majority (65%) of non-Caucasian patients. Data was extracted from the hospital's electronic medical record. Survival differences among different racial and ethnic groups were examined graphically using Kaplan-Meier analysis. A univariate cox proportional hazards model and a multivariable adjusted model were generated.

RESULTS

Black patients had significantly lower overall survival compared to White patients, with median overall survival of 1.9 years and 2.5 years respectively. In a multivariate analysis, Black race posed a significant hazard (HR 1.70, CI 1.01-2.90, p=0.0467) for death. Though response to therapy emerged as a strong predictor of survival (HR=0.4, CI=0.2-0.7, p=0.0021), it was comparable between Blacks and Whites.

CONCLUSIONS

Despite presumed equal access to healthcare and socioeconomic status within a safety-net hospital system, our results reinforce findings from previous studies showing lower colorectal cancer survival in Black patients, and also point to the importance of investigating other factors such as genetic and pathologic differences.

Decreasing Black-White Disparities in Colorectal Cancer Incidence and Stage at Presentation in the United States

Background: There are long-standing black-white disparities in colorectal cancer incidence and outcomes in the United States. Incidence and stage at diagnosis reflect the impact of national efforts directed at colorectal cancer prevention and control. We aimed to evaluate trends in black-white disparities in both indicators over four decades to inform the future direction of prevention and control efforts.Methods: We used Surveillance, Epidemiology, & End Results (SEER) data to identify whites and blacks with histologically confirmed colorectal cancer from January 1, 1975 through December 31, 2012. We calculated the age-adjusted incidence and the proportion of cases presenting in late stage by race and year. We then calculated the annual percentage change (APC) and average APC for each indicator by race, examined changes in indicators over time, and calculated the incidence disparity for each year.Results: There were 440,144 colorectal cancer cases from 1975 to 2012. The overall incidence decreased by 1.35% and 0.46% per year for whites and blacks, respectively. Although the disparity in incidence declined from 2004 to 2012 (APC = -3.88%; P = 0.01), incidence remained higher in blacks in 2012. Late-stage disease declined by 0.27% and 0.45% per year in whites and blacks, respectively. The proportion of late-stage cases became statistically similar in whites and blacks in 2010 (56.60% vs. 56.96%; P = 0.17).Conclusions: Black-white disparities in colorectal cancer incidence and stage at presentation have decreased over time.Impact: Our findings reflect the positive impact of efforts to improve colorectal cancer disparities and emphasize the need for interventions to further reduce the incidence gap. Cancer Epidemiol Biomarkers Prev; 26(5); 762-8. ©2016 AACR.

Toward the Elimination of Colorectal Cancer Disparities Among African Americans

BACKGROUND

In the USA, race and socioeconomic status are well-known factors associated with colorectal cancer incidence and mortality rates. These are higher among blacks than whites and other racial/ethnic groups.

METHODS

In this article, we review opportunities to address disparities in colorectal cancer incidence, mortality, and survivorship among African Americans.

RESULTS

First, we summarize the primary prevention of colorectal cancer and recent advances in the early detection of the disease and disparities in screening. Then, we consider black-white disparities in colorectal cancer treatment and survival including factors that may contribute to such disparities and the important roles played by cultural competency, patient trust in one's physician, and health literacy in addressing colorectal cancer disparities, including the need for studies involving the use of colorectal cancer patient navigators who are culturally competent.

CONCLUSION

To reduce these disparities, intervention efforts should focus on providing high-quality screening and treatment for colorectal cancer and on educating African Americans about the value of diet, weight control, screening, and treatment. Organized approaches for delivering colorectal cancer screening should be accompanied by programs and policies that provide access to diagnostic follow-up and treatment for underserved populations.

Colorectal Cancer in African Americans: An Update

This review is an update to the American College of Gastroenterology (ACG) Committee on Minority Affairs and Cultural Diversity's paper on colorectal cancer (CRC) in African Americans published in 2005. Over the past 10 years, the incidence and mortality rates of CRC in the United States has steadily declined. However, reductions have been strikingly much slower among African Americans who continue to have the highest rate of mortality and lowest survival when compared with all other racial groups. The reasons for the health disparities are multifactorial and encompass physician and patient barriers. Patient factors that contribute to disparities include poor knowledge of benefits of CRC screening, limited access to health care, insurance status along with fear and anxiety. Physician factors include lack of knowledge of screening guidelines along with disparate recommendations for screening. Earlier screening has been recommended as an effective strategy to decrease observed disparities; currently the ACG and American Society of Gastrointestinal Endoscopists recommend CRC screening in African Americans to begin at age 45. Despite the decline in CRC deaths in all racial and ethnic groups, there still exists a significant burden of CRC in African Americans, thus other strategies including educational outreach for health care providers and patients and the utilization of patient navigation systems emphasizing the importance of screening are necessary. These strategies have been piloted in both local communities and Statewide resulting in notable significant decreases in observed disparities.

Methylation of MGMT and ADAMTS14 in normal colon mucosa: biomarkers of a field defect for cancerization preferentially targeting elder African-Americans

Somatic hypermethylation of the O⁶-methylguanine-DNA methyltransferase gene (MGMT) was previously associated with G > A transition mutations in KRAS and TP53 in colorectal cancer (CRC). We tested the association of MGMT methylation with G > A mutations in KRAS and TP53 in 261 CRCs. Sixteen cases, with and without MGMT hypermethylation, were further analyzed by exome sequencing. No significant association of MGMT methylation with G > A mutations in KRAS, TP53 or in the whole exome was found (p > 0.5 in all comparisons). The result was validated by in silico comparison with 302 CRCs from The Cancer Genome Atlas (TCGA) consortium dataset. Transcriptional silencing associated with hypermethylation and stratified into monoallelic and biallelic. We also found a significant clustering (p = 0.001) of aberrant hypermethylation of MGMT and the matrix metalloproteinase gene ADAMTS14 in normal colonic mucosa of CRC patients. This suggested the existence of an epigenetic field defect for cancerization disrupting the methylation patterns of several loci, including MGMT or ADAMTS14, that may lead to predictive biomarkers for CRC. Methylation of these loci in normal mucosa was more frequent in elder (p = 0.001) patients, and particularly in African Americans (p = 1 × 10⁻⁵), thus providing a possible mechanistic link between somatic epigenetic alterations and CRC racial disparities in North America.

Colorectal cancer survival in Jamaica

Objective

To determine the intermediate and long-term survival of patients diagnosed with colorectal cancer (CRC) and to determine factors that affect survival.

Method

Patients were identified from a prospectively maintained colonoscopy database. All patients who underwent colonoscopy during the period January 2008 to December 2012 and had histologically confirmed invasive carcinoma were included. These patients were contacted at the end of 2013 to determine their survival status. In addition to demographics, variables analyzed included presenting complaint and tumor site and stage at presentation.

Results

Of 1757 patients being subjected to colonoscopy, 118 had endoscopic and histologic documentation of invasive CRC. Of these the survival status of 102 was determined as of December 2013 and they formed the basis of our study. The mean age of the group was 62 years with approximately 20% of the group being age 50 years or younger. Females (54%) slightly outnumbered males. Anemia or overt rectal bleeding was a dominant indication (44%) and 65% of the tumours were left sided. There were 58 (57%) deaths and the median overall survival time was two years post diagnosis. Log rank tests for equality of survivorship looking at age, gender, tumor site and presentation revealed that only presenting complaint was a predictor of survivorship (p < 0.001). Patients presenting with bleeding or anemia have the best survival.

Conclusions

Long-term survival from colorectal cancer remains poor with only about 33% of patients being alive five years after their diagnosis.

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This manuscript documents the poor intermediate and long-term survival from colorectal cancer in Jamaica.

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Mean survival was 24 months and only 33% of patients were alive five years after their diagnosis.

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Patients presenting with anemia or bleeding had a better outcome.

Race and colorectal cancer screening compliance among persons with a family history of cancer

AIM: To determine compliance to colorectal cancer (CRC) screening guidelines among persons with a family history of any type of cancer and investigate racial differences in screening compliance.

METHODS: We used the 2007 Health Information National Trends Survey and identified 1094 (27.4%) respondents (weighted population size = 21959672) without a family history of cancer and 3138 (72.6%) respondents (weighted population size = 58201479) with a family history of cancer who were 50 years and older. We defined compliance with CRC screening as the use of fecal occult blood testing within 1 year, sigmoidoscopy within 5 years, or colonoscopy within 10 years. We compared compliance with CRC screening among those with and without a family member with a history of cancer.

RESULTS: Overall, those with a family member with cancer were more likely to be compliant with CRC screening (64.9% vs 55.1%; OR = 1.45; 95%CI: 1.20-1.74). The absolute increase in screening rates associated with family history of cancer was 8.2% among whites. Hispanics had lowest screening rates among those without family history of cancer 41.9% but had highest absolute increase (14.7%) in CRC screening rate when they have a family member with cancer. Blacks had the lowest absolute increase in CRC screening (5.3%) when a family member has a known history of cancer. However, the noted increase in screening rates among blacks and Hispanics when they have a family member with cancer were not higher than whites without a family history of cancer: (54.5% vs 58.7%; OR = 1.16; 95%CI: 0.72-1.88) for blacks and (56.7% vs 58.7%; OR = 1.25; 95%CI: 0.72-2.18) for Hispanics.

CONCLUSION: While adults with a family history of any cancer were more likely to be compliant with CRC screening guidelines irrespective of race/ethnicity, blacks and Hispanics with a family history of cancer were less likely to be compliant than whites without a family history. Increased burden from CRC among blacks may be related to poor uptake of screening among high-risk groups.

Racial and Ethnic Disparities in Colonoscopic Examination of Individuals With a Family History of Colorectal Cancer

BACKGROUND & AIMS

Guidelines recommend that persons with a high-risk family history of colorectal cancer (CRC) undergo colonoscopy examinations every 5 years, starting when they are 40 years old. We investigated factors associated with colonoscopy screening of individuals with a family history of CRC, focusing on race and ethnicity.

METHODS

In a retrospective study, we analyzed data from the 2009 California Health Interview Survey on persons 40-80 years old with a first-degree relative (mother, father, sibling, or child) with CRC who had visited a physician within the past 5 years. Our study included an unweighted and population-weighted sample of 2539 and 870,214 individuals with a family history of CRC, respectively. We performed a survey-weighted logistic regression analysis to adjust for relevant demographic and socioeconomic variables and used estimates to calculate relative risks and 95% confidence intervals (CIs) for colonoscopy examination within the past 5 years.

RESULTS

In the weighted sample, 60.0% of subjects received a colonoscopy within the past 5 years. A physician recommendation for CRC screening increased the odds that an individual would undergo colonoscopy examination (relative risk, 1.89; 95% CI, 1.61-2.24). Latinos were 31% less likely to receive colonoscopies than whites (95% CI, 7%-55%). Among individuals 40-49 years old, blacks were 71% less likely to have had a colonoscopy than whites (95% CI, 13%-96%).

CONCLUSION

On the basis of an analysis of data from the California Health Interview Survey, less than two-thirds of individuals with a family history of CRC reported receiving guideline-recommended colonoscopy examinations within the past 5 years. We observed racial and ethnic disparities in colonoscopy screening of this high-risk group; Latinos and blacks were less likely to have had a colonoscopy than whites.