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Distance, Region, and Insurance Coverage Associated With Increased Risk of Advanced Colon Cancer

Early-stage colon cancer is treatable and has a very promising survival rate. However, less than 40% of new colon cancer diagnoses are early-stage disease. Now, a new study has identified an association of distance, region, and insurance coverage with advanced colon cancer at initial diagnosis. Utilizing the Nation Cancer Database, patients 18 years or older diagnosed with colon cancer as a primary diagnosis between 2010 and 2017 were compared in terms of distance to their medical facility, region of residence, and insurance coverage. 

The study found that patients at an increased risk of advanced pathologic disease:

  • Traveled a greater distance to their medical facility
  • Lived in the Northeast, Mountain, or Central regions of the United States
  • Only had Medicaid or did not have insurance coverage

 

Sahar Alam is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

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Study Finds Risk-Stratified Colorectal Cancer Screening Is Feasible and Cost-Effective

Colorectal cancer (CRC) is the third most common cancer diagnosis and the second most common cause of cancer death globally. The American Cancer Society estimates that there will be 106,180 new colon cancer cases and 44,850 new rectal cancer cases in the United States in 2022. Early detection and consistent screening reduce CRC incidence and mortality. A recent randomized controlled trial that analyzed the feasibility, adherence, yield, and related costs of various screening modalities found that a risk-adapted approach is feasible and cost-favorable for population-based screening. 

Current guidelines recommend standardized screening plans for specific age groups, with colonoscopy recommended every 10 years and a fecal immunochemical test (FIT) between 1-3 years. Implementation of risk-stratified screening can potentially allow for more frequent screening and earlier detection of CRC at a population level. This would especially be beneficial for individuals who are at higher risk of CRC. Additionally, risk-stratified screening can help health practitioners detect and introduce plans for CRC treatment at earlier stages.

The National Health Service Breast Screening Programme (NHSBSP) recently investigated the potential benefits, costs, and effectiveness of risk-stratified breast cancer screening with BC-Predict, a platform that collects self-reported risk factor information for breast cancer, analyzes the self-reported information, and invites high-risk or moderate-risk women to a conversation about prevention and early detection options. BC-Predict was found to have the potential to reduce breast cancer mortality due to early screening. It also reduced screening in women who are at lower risk, minimizing the number of false positive test results in lower-risk women. The results from this analysis are pertinent to risk-stratified screening for CRC and support the implementation of a risk-adapted approach in CRC screening.

What Did the Study Find?

More than 19,000 participants in the TARGET-C trial conducted in six cities in China were placed into one of the screening arms in a 1:2:2 ratio: 

  • One-time colonoscopy (n=3,883)
  • Annual fecal immunochemical test (FIT) (n=7,793)
  • Annual risk-adapted screening (n=7,697).

The detection rate of advanced colorectal neoplasia, CRC, and advanced precancerous lesions were the main outcomes that were monitored. The follow-up to trace the rate of advanced colorectal neoplasia for all participants was conducted over a 3-year study period. 

Over three screening rounds, the participation rates for colonoscopy, FIT, and risk-adapted screening arms were 42.4%, 99.3%, and 89.2%, respectively. The costs to the for detecting one advanced neoplasm, presented as both Chinese Yuan (CNY) and US dollar, using a package payment format were:

  • CNY6,928 ($1,004) for one-time colonoscopy
  • CNY5,821 ($844) for annual fecal immunochemical test (FIT)
  • CNY6,694 ($970) for annual risk-adapted screening.

These findings underscore the value of a risk-adapted approach for CRC screening for feasibility and cost-effectiveness, as well as for allowing for more frequent screening and earlier detection of CRC for individuals with a high or moderate risk for CRC.

 

Sahar Alam is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

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New NCCN Guidelines Recommend Genetic Testing for All CRC Patients

Colorectal cancer (CRC) is the third most diagnosed cancer and over 5 million people worldwide currently live with CRC. According to the American Cancer Society, the lifetime risk of developing CRC is 1 in 23 for men and 1 in 25 for women, and recent research indicates an increased incidence of CRC among individuals younger than 50 years of age.

Recent research has revealed that a significant number of CRC patients with heritable genetic mutations remain undiagnosed under past genetic testing guidelines, which limited testing to specific age groups and forms of cancer. Now, the National Comprehensive Cancer Network (NCCN) has announced new guidelines that recommend germline multigene panel testing for all individuals with CRC ages <50, as well as consideration for germline multigene panel testing for those with evidence of mismatch repair deficiency in their tumor or a family history of CRC. 

Robert Nussbaum, M.D., co-authored a letter to the NCCN to formally request universal germline testing for CRC patients to be added to the guidelines. He states, “As the medical community’s understanding of genetic links to cancer evolves, genetic testing guidelines must evolve with it.” Increased accessibility to multipanel genetic testing can extend the representation of medically underserved populations and reduce the exacerbation of existing disparities. Expanding guidelines for genetic testing for CRC can also help family members determine their risk for CRC, increase surveillance for early detection, discover curative treatments, and promote awareness of CRC for those at increased risk. 

Universal Versus Guideline-Directed Targeted Testing for Hereditary Cancer 

Genetic factors play a significant role in the risk of developing many forms of cancer. Identification of germline predisposition can notably determine and direct a more effective plan of care, treatment, risk-reducing interventions, cancer screening, and germline testing. A multicenter cohort study among 2,984 cancer patients compared universal genetic testing with guideline-directed targeted genetic testing based on clinical guidelines to examine the prevalence of pathogenic germline variants (PGVs) in cancer patients. One in eight patients had a pathogenic germline variant, but 48% of those cases would not have been identified with a guideline-based approach. This underscores the limitations of clinical and guideline-based risk assessment for genetic testing. The multigene panel was more efficient at identifying heritable variants compared to guideline-directed targeted genetic testing. 

Importantly, identifying PGVs in cancer patients can encourage their relatives to take earlier action for risk assessment and cancer prevention. However, financial barriers and lack of insurance coverage can limit patient participation in genetic screening. This study points to the effectiveness of multigene panel testing and its implications for cancer prevention and treatment.

 

Sahar Alam is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

 

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Dr. Shahnaz Sultan: Pre-Endoscopy COVID-19 Testing Led to Disparities

The Colon Cancer Foundation had the opportunity to speak with Dr. Shahnaz Sultan, MD, MHSC, AGAF, about her research team’s findings that pandemic-related pre-procedure COVID-19 testing caused higher rates of endoscopy cancellations among patients from marginalized populations. A Professor of Medicine in the Division of Gastroenterology, Hepatology, and Nutrition and the Program Director for the Gastroenterology Fellowship Training Program at the University of Minnesota, Dr. Sultan’s research interests are focused on reducing colorectal cancer morbidity and mortality by improving adherence and quality of colonoscopy.

Q: What is the main takeaway you want people to understand from your research?

One of the most important things we want to emphasize is that colorectal cancer [CRC] is a very preventable cancer and there is a lot of high-quality evidence that shows that screening for CRC actually leads to a reduction in associated mortality. We really need to think about CRC screening along a continuum—whether you are doing stool-based testing or you’re getting a colonoscopy, it’s a multi-step process, and at every step, we need to be cognizant about reducing barriers and helping patients complete their CRC screening tests. Adding another step that patients have to complete prior to colonoscopy, such as pre-procedure SARS-CoV2 testing, in addition to completing their bowel prep, following dietary guidelines, finding transportation, and coming in to get a colonoscopy, really makes it that much more challenging. Pre-procedure testing serves as one more step and one more possible barrier in terms of getting people up-to-date with their screening. 

Q: As you were conducting your research, were there any findings that surprised you?

Our objective here was to understand the impact of pre-procedure COVID-19 testing—we wanted to see the magnitude of the impact and who was specifically affected by this additional requirement. When we looked at the canceled outpatient endoscopy procedures in our cohort from March 2021 to September 2021, we were surprised that the overall cancellation rate was so high in terms of getting people to complete their colonoscopy. Among the 574 cancellations, a little under 10% were due to pre-procedure COVID-19 testing requirements, and a good proportion of the remainder, about 51%, were patient-initiated cancellations. There were a lot of additional factors that were potentially holding people back from CRC screening. Additionally, we were surprised that pre-procedure testing was disproportionately affecting certain populations. Persons who self-identified as Black, American Indian, Alaskan Native, or Hispanic were more likely to have testing-related cancellations. 

Dr. Shahnaz Sultan

Q: Of the patients who canceled their colonoscopy, do we know if they went for an alternate form of testing for colorectal cancer, such as stool-based testing?

That’s an interesting question! We do not have that health data within our health system, but you bring up a good point. During the pandemic, a lot of other health systems were shifting gears from colonoscopy to stool-based testing and using programmatic efforts to directly reach out to patients to make sure they were getting some form of CRC screening. 

Q: Healthcare challenges, such as the COVID-19 pandemic, have demonstrated to significantly disrupt CRC screening procedures and participation, especially for medically underserved communities. What steps can be taken or what policies can be implemented in the future to support CRC screening participation and prevent significant disruptions to CRC screening?                                              

There is a lot of ongoing research to understand different barriers we can address or different interventions we can take to improve screening at the population level. We really need a multifaceted or multi-pronged approach to screening. We really need to think about interventions that not only focus on patients, but we also need to target providers, health systems, and community leaders, and think about national and federal policy decisions. I think there are a lot of opportunities to decrease barriers at different levels in terms of getting people to be more up-to-date with screening at a population level.

In terms of policy, one of the things that we have been able to fix recently is this loophole that existed in the past where if a test was done for screening purposes, but polyps were removed, then it was no longer counted as a screening test, and that incurred copayments and additional burdens on patients. I think that has been a real coup for us in the gastroenterology community and overall in terms of helping to support the care of our patients. Also, I think there are a lot of opportunities at the national level to support programmatic efforts to improve screening for populations that are underinsured or don’t have access to care, and I think we need to do more outreach and find ways to include health educators and patient navigators. We need to make sure we are educating patients about the importance of screening and helping address financial or logistical barriers that might serve as additional challenges for patients to overcome.

Continued on Page 2.

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Studies at ASCO Point to Biomarker-Directed Treatment for Colorectal Cancer

CCCF Research

At the 2022 American Society of Clinical Oncology (ASCO) Annual Meeting, several research studies were presented that shared a targeted approach to colorectal cancer (CRC) treatment that can ensure efficacy and reduction of side effects. The infographic below highlights those studies and their key findings.

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ASCO: Studies Identify Associations and Disparities in Colorectal Cancer Care

There is little known about the connection between various factors (such as environmental quality index, unmet needs, cancer survivorship, etc.) and the outcomes of patients affected by colorectal cancer (CRC). Studying the trends and associations around the onset and progression of CRC is integral to educating people on risk reduction. Additionally, using a disparity lens can aid decision-making processes and allow providers to target high-risk populations who may be in need of greater assistance and care. 

Several such studies were presented at the 2022 annual meeting of the American Society of Clinical Oncology. For example, Suleyman Yasin Goksu and team studied the association of young-onset CRC with the national level Environmental Quality Index (EQI). Their greatest finding? YOCRC can be linked to lower environmental quality. Additionally, Megan E. Delisle and team identified the association between unmet needs (in the physical, emotional, and practical sense) and survivors’ utilization of emergency services in the first three years following treatment. They found that a greater amount of unmet needs could be linked to higher utilization of emergency services–which is an issue that can be resolved through preventative measures. Both these studies reach important conclusions regarding how we draw patterns from disease. 

Here are some other studies from ASCO that dived into disparities and early-age onset CRC (EAO-CRC) outcomes:

  1. Disparity of treatment-related adverse events and outcome in patients with early-onset metastatic colorectal cancer (mCRC). With the marked rise of early-onset metastatic CRC (mCRC), there is a gap in diagnosis and adverse events related to treatment. Patient outcomes have not been conclusively studied, so Lingbin Meng and team reviewed the potential age-related disparity and its causes. Using individual patient data from three clinical trials in Project Data Sphere, patients were categorized into three age groups and sorted by adverse events. Patients younger than 50 had shorter median overall survival, higher incidence of toxicity (abdominal pain, severe anemia, and nausea/vomiting), but lower incidence of severe diarrhea, neutropenia, and fatigue. This group had the earliest onset of these adverse events and was associated with worse overall survival. Some of these disparities may be explained by distinct genetic profiles, but overall, patients with early-onset mCRC had worse outcomes and endured greater overall treatment-related adverse events. This study provides a basis for developing a personalized treatment plan when selecting patients for chemotherapy, providing counseling, and monitoring adverse events.
  2. Modifiable and non-modifiable risk factors associated with early-onset colorectal cancer: Analysis of the National Health Interview Survey. Risk factors for EAO-CRC are largely understudied, while on the other hand, there is a rapid increase in incidence. Hyeun Ah Kang and Yahan Zhang of The University of Texas at Austin studied modifiable and non-modifiable risk factors associated with the rise. Their cross sectional study analyzed data from the 2004-2018 National Health Interview Survey (NHIS). Individuals between the ages of 18 and 49 with a history of CRC diagnosis at the time of the interview were compared with their non-cancer counterparts. Additionally, the researchers also compared their non–age-related characteristics to those with late-onset CRC, meaning after 50. One hundred and fifty six patients with EAO-CRC were identified. Results from the comparisons showed that greater odds of EAO-CRC were associated with older age, living in the Midwest, and history of alcohol consumption. Lower odds were associated with Hispanic or Asian race and a lifestyle of vigorous physical activity. This study points to both modifiable and non-modifiable characteristics of EAO-CRC risk. Further studies can help identify the associated risk in-depth.
  3. Racial disparities in receipt of guideline-concordant care for early-onset colorectal cancer in the U.S. Black patients diagnosed with EAO-CRC have worse survival than their white counterparts, even in lieu of early-stage disease. Leticia M. Nogueira and team studied these racial disparities, with specific focus on guidance-concordant cancer care.The study included newly diagnosed non-Hispanic black and white individuals  between the ages of 20 and 49. Demographics, comorbidities, and insurance coverage were added to multivariable models to predict their contribution in the disparities with quality measures. Out of the 84,728 colon and 62,483 rectal cancer patients, 20.8% and 14.5%, respectively, were black. They were less likely to receive guideline-concordant care than white patients, which was primarily driven by insurance coverage rather than demographics or comorbidities. Overall, black patients received worse and less timely care than their white peers. Health insurance, a modifiable factor, was identified as the largest contributor to this gap. This study suggests that access to care can significantly influence EAO-CRC outcomes.
  4. Racial parity in rectal cancer treatment and outcomes within an integrated healthcare system. Hyunjee V. Kwak and team also looked at the survival outcomes of patients in the context of their race. They conducted a retrospective study of patients at the Kaiser Permanente Northern California health system, who were treated between 2010-2019. The study included over 3,500 patients diagnosed with rectal adenocarcinoma. Using self-reported race information, various analyses evaluated differences in race, age, stage of diagnosis, treatment, and overall survival. There was a greater proportion of Black patients with localized disease, who also had the longest overall survival. Hispanic patients were more likely to be male, younger, and have a shorter overall survival. These results show a gap in survival outcomes for patients treated at a large integrated healthcare system, where access to care is roughly equal. This calls for an improvement in outreach and screening, as well as awareness in these communities.
  5. Trends and disparities in the treatment of older adults with colon cancer. Half of the patients diagnosed with colon cancer are aged above 70, yet there is a huge gap in treatment for this population. Most are undertreated, perhaps due to age-related biases. Philip Q. Ding and team looked at age-related disparities in the realm of CRC care. Their retrospective, population-based study of adults diagnosed with CRC between 2010 and 2018 in Alberta, Canada included more than 10,000 patients, 48% of whom were over 70 years old. Upon further examination, it was found that older age correlated with more comorbidities and less advanced disease. Despite this, there was no statistically significant correlation between age and treatment status. As compared to the younger group, the odds of receiving surgery and systemic therapy were three and five times lower (respectively) among older patients. These two interventions continue to improve the outcomes of colon cancer in old and young patients alike, but the rates of treatment were lower in older patients and with minimal change over time. This study highlights a disparity in CRC care within the geriatric population.

Identifying these trends and disparities is just one step towards improved CRC care. It empowers patients to identify their personal risk and also gives their provider another factor to consider for treatment and prognosis. Understanding these correlations may be the next step in eliminating the gap in care for many populations.

 

Juhi Patel is a Colorectal Cancer Prevention Intern at the Colon Cancer Foundation.

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Computer-Assisted Colonoscopy Better at Detecting Precancerous Polyps 

Colonoscopy is the most effective test for colorectal cancer (CRC) screening and prevention. This procedure minimizes the incidence and mortality of colorectal cancer through early detection. During a colonoscopy, a physician inserts, and threads a flexible tube with a tiny camera called a colonoscope into the rectum and through the entire colon, or large intestine. This helps identify abnormal growths and excise any polyps which can then be sent for diagnosis.

However, research has shown that despite being the gold-standard for CRC screening, 23-30% of adenomas are overlooked and missed during a traditional colonoscopy, the success of which can vary depending on operator skills.

“Colorectal cancer is the second leading cause of cancer-related deaths in the United States and it is one of the few cancers that can be prevented if caught early,” said Aasma Shaukat, MD, MPH at NYU Grossman School of Medicine and the Robert M. and Mary H. Glickman Professor of Medicine and Gastroenterology and Director of Outcomes Research for the Division of Gastroenterology and Hepatology. “Our mission remains to improve and enhance the quality and efficacy of the colonoscopy across the board to provide the best care for patients.”  

In order to improve the efficiency and efficacy of colonoscopies, Dr. Shaukat and her team have developed an artificial intelligence (AI) platform to assist endoscopists. The findings of their  prospective, randomized, multicenter collaborative study to test the AI platform were recently published in the journal Gastroenterology. Between January and September 2021, twenty-two skilled, board-certified gastroenterologists performed colonoscopies on 1,440 patients. The patients were randomized to receive a traditional colonoscopy or a colonoscopy with computer-aided detection software —the software detects colorectal polyps during high-definition white-light colonoscopy procedures. This device can identify potential polyps and identify areas of concern, refining the results of the procedure in real-time. 

The researchers found that using AI during a screening colonoscopy increased the adenoma per colonoscopy rate by 22%: from 0.82 to 1.05. This evidence indicates that AI can be an effective and efficient tool for gastroenterologists and endoscopists to reduce the number of overlooked polyps left behind in the colon, many of which can be precancerous. 

Dr. Shaukat states, “Our findings add to the growing amount of literature that shows using computer-aided technology during an endoscopy procedure can improve the quality of exams performed and improve outcomes for our patients. Several software technologies are currently available for clinicians and incorporating the use of these resources will only enhance the care we provide our patients and improve the quality of exams we as physicians are able to perform.”

Sahar Alam is a Colorectal Cancer Prevention intern with the Colon Cancer Foundation.

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Younger Patients at Greater Risk of Distant Stage Early-Onset Colorectal Adenocarcinoma

With an observed increase of distant-stage colorectal cancer (CRC) among young patients in recent years, researchers have been searching for the reasons behind rising numbers and ways to counteract them. Carcinoids, a subtype of slow-growing cancer, have been found to contribute to the steadily rising incidence rate of early-onset colorectal cancer, which is diagnosed before the age of 50. This has created a need to assess the shifts toward distant-stage adenocarcinoma and its impact on public health.

Why Are We Seeing This Increase?

A study recently published in Cancer Epidemiology, Biomarkers & Prevention sought to understand how the proportions of distant-stage disease changed over time. Several studies have identified a significant increase (49%) in the average annual percent change for distant stage colorectal cancer in the 20-34 years age group. However, many of these studies do not report histological subtypes of CRC. 

With carcinoids increasing in younger patients, it is important to look at adenocarcinoma (most common cancer of the colon and rectum) staging independently from carcinoids (neuroendocrine tumors). Therefore, these researchers focused specifically on adenocarcinomas. Yearly adenocarcinoma incidence rates from the 2000-2016 Surveillance Epidemiology And End Results (SEER) data were stratified by stage, age, subsite, and race for 103,975 patients. Changes in the three-year annual incidence rate were calculated with the percent contribution of each cancer stage. Lastly, the subgroup with the highest proportion of distant-stage disease was determined.

The greatest percent increases were seen in distant-stage cancer when comparing data from 2000-2002 with 2014-2016. Here are a few significant findings of the study:

  • Colon-only distant adenocarcinoma increased most in 30-39-year-olds (49%)
  • Rectal-only distant-stage adenocarcinoma increased most in 20-29-year-olds (133%)
  • Based on race:
    • Distant stage proportions increased most for both colon- and rectal-only subsites in 20-29-year-old non-Hispanic Blacks (14% and 46%, respectively) 
    • The second most-impacted group was 20-29-year-old Hispanics with a 13% increase in the proportion of those affected by rectal-only, distant stage adenocarcinoma.

From these findings, we can conclude that the greatest burden of disease was on younger patients, highest in the non-Hispanic Black and Hispanic subgroups (despite relatively low absolute case counts). The researchers also uncovered that there is a decrease in early-stage disease in these early-onset groups. As we now know, younger patients are presented with higher risks, but the absolute incidence rates in the youngest subgroups remain relatively low.

These findings are important because they set a new precedent for patients under 50 who may not be aware that preventive screening for those at average risk of CRC starts at 45 years. Studies moving forward should also note that not all adenocarcinomas are categorized as early-onset CRC. Although this study is limited in its observational nature, it raises important questions in analyzing staging results, promoting screening opportunities, and keeping the general public aware of their risks. This study also presents potential solutions, including optimizing earlier screening and the risk-stratification of younger patients by family history and symptoms.

 

Juhi Patel is  Colon Cancer Prevention Intern.

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Golf Clubs, Colonoscopies, and Colorectal Cancer Awareness with Suzanne Miller

Mom, wife, realtor, runner, cellist, and colon cancer survivor for five and a half years. Suzanne Miller was taken aback when she was diagnosed with Stage I colon cancer at the age of 40. Colorectal cancer screenings start at 45 years for average-risk adults. She was in good health, trained for marathons, and ate well. Luckily, she was able to undergo surgery on November 18, 2016, to remove the cancer. 

Suzanne realized she aspired to turn this event in her life into something good rather than dwelling on the fact that she had cancer. Since her surgery, on the 18th of each month, she spreads awareness by posting on Instagram and Facebook to remind individuals to “keep their rear in the clear.” Everyone who is over 45, under 45 with symptoms, or has a family history of colon or rectal cancer should get screened for colorectal cancer. Those with a family history of colorectal cancer should start screenings at 40 years or 10 years prior to the earliest diagnosis age in their family.

Survivor and Colon Cancer Awareness Advocate

Suzanne came across the Colon Cancer Foundation (CCF) while she was researching for a marathon to run in New York while raising money for a charity. She reached out to the Foundation and planned to run in the 2020 marathon, but it was canceled due to the COVID-19 pandemic. That didn’t dampen Suzanne’s spirit. She completed the marathon in her hometown and raised the money with support from her friends and family members who participated in the run. She looks forward to running again in the 2023 Colon Cancer Challenge.

This past February, as a CCF Champion, Suzanne and her husband were invited to attend the Cologuard Classic in Tucson, Arizona. She represented CCF and was able to meet 90 other like-minded individuals who shared her passion to make a difference and prevent early onset of colon cancer. Inspired to raise money and awareness in her hometown, Suzanne partnered with her husband’s golf club to hold a fundraising golf tournament on May 16, 2022. She was supported in her efforts by her friend, a 10-year colon cancer survivor who also works to spread colorectal cancer awareness. The event had 10 sponsors, 13 teams, and 20 hole sponsors that covered most of the costs. Half of the profits will go to their local nonprofit, CRC Life, and the other half will go to CCF.

Suzanne emphasizes that people need to be more comfortable discussing colon cancer, as they do other topics. Ever since she began raising awareness on social media, Suzanne has received messages from individuals when they received a colonoscopy, got a polyp removed, or discovered they have a family history of colon cancer. Through her experience as a young, healthy woman diagnosed with colon cancer, she brings attention to the fact that cancer does not discriminate. She always tells individuals to remind their friends and family to get a colonoscopy. “Even having one person find out that they do not have cancer is a win,” she says. Suzanne loves that we live in a world where we can speak our mind, while being kind and courteous, and have people that listen and don’t discount the matter at hand. 

 

Kenadi Kaewmanaprasert is an intern with the Colon Cancer Foundation.

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Improving Colorectal Cancer Screening Rates in Mississippi

In past years, the rate of colorectal cancer (CRC) has become a serious public health problem in Mississippi. A study conducted in 2020 showed that Mississippi had one of the highest mortality rates from CRC as well as one of the CRC lowest screening rates between 2015 and 2019. The state also leads the nation in cardiovascular disease mortality rates as well as diabetes mortality. These are both known comorbidities for many types of cancers, including CRC. 

One theory as to why the screening rates are so low in Mississippi is that about 55% of the state’s population resides in rural locations, which may make it hard for some individuals to access regular medical care. The rural population in Mississippi has a high rate of uninsured individuals making it hard for this population to afford regular screenings. In 2016, 14% of the population under 65 were uninsured. 

Another theory as to why CRC rates are so prevalent in Mississippi is that the diet of many of the residents is high in red meat and low in fiber. This is in part due to a culture that relies on red meat and processed foods. This diet is also more prevalent in areas that have a low socioeconomic background, as it can be difficult to obtain healthy food if one lives in a food desert. 

Colorectal cancer-related mortality in those over 50 (2014-2018).
Data source: https://statecancerprofiles.cancer.gov/map/map.noimage.php.

Fortunately, the Mississippi government recognized the issue and has developed a plan to help increase the screening rate of residents in Mississippi and decrease mortality rates —70X2020 was initiated in 2014. Since the start of the program, there has been an increase in individuals who got screened, specifically in minority communities. So far, screening rates have improved from 55% in 2014 to 69.9% in 2020. For white individuals there was a compliance rate of just under 70% and for black individuals there was a compliance rate of just above 70% in 2020. 

From this case study, we are able to theorize that screening and diet play a crucial role in the development of CRC. We are also able to see that there is a strong correlation between screening rates and CRC mortality rates. 

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