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Race and Gender Impact CRC Diagnostic Testing Among Young Veterans With Iron-Deficiency Anemia

By Parker Lynch

The Veterans Health Administration recently conducted a retrospective study of data on veterans who received care between 1999 and 2019. This study included US veterans between the ages of 18 and 49 with diagnoses of iron-deficiency anemia (IDA) and/or hematochezia. When examined for their diagnostic testing completion rate and the time to diagnostic testing, race and gender were found to result in disparities.

Study Outcomes and Findings

For those with IDA, diagnostic test completion was characterized by whether or not these individuals had received bidirectional endoscopies (a procedure that includes both a colonoscopy and an upper endoscopy). For those with hematochezia, diagnostic test completion was defined as either receiving a colonoscopy or sigmoidoscopy (a less-invasive procedure in which the lower part of the large intestine is examined, rather than the entire organ).

Candidates were also evaluated with respect to age, sex, race, ethnicity, and hemoglobin test value.

Out of Among the 59,169 veterans with IDA:

  • 37,719 were aged 40 to 49 years
  • 28,667 were women
  • 24,480 were black
  • 4,161 were Hispanic
  • The estimated cumulative diagnostic test completion rates were 7% at 60 days and 22% at the end of the two years as per the evaluation period.

 

Out of the 189,185 veterans with hematochezia:

  • 106,730 were aged 40 to 49 years
  • 86.5% were men
  • 4,4939 were black
  • 17,317 were Hispanic
  • The estimated cumulative diagnostic test completion rates were 22% at 60 days and 40% at the end of the two years.

The study found very low diagnostic testing among both veterans with IDA as well as those with hematochezia. Additionally, black, Hispanic, and female veterans were less likely to receive testing than their white male counterparts.

This testing is vital to detecting and treating early onset colorectal cancer (CRC), so the low levels are concerning for healthcare professionals and researchers and may have resulted in missed opportunities for early diagnosis of CRC.

Veterans’ Inadequate Health Coverage

This study raises questions around why many veterans aren’t receiving the preventative screenings they need. A 2020 study conducted by Harvard and Public Citizen found that 1.53 million veterans nationwide were uninsured. On top of this, 1 in 12 veterans (approximately 2 million individuals) go without vital physician care annually due to the associated cost.

An estimated 9 million veterans are registered with the Veterans Health Administration, but not all of them are eligible for VA healthcare coverage. This leaves a lot of veterans (many of whom have chronic conditions) unable to receive adequate care, unless they are directly paying out of pocket or have the means to purchase private insurance.

Should veterans have proper health care coverage, there would hopefully be a substantial increase in the amount of diagnostic testing that is completed, and therefore a decrease in the national incidence rate of early onset CRC.

 

Parker Lynch is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

Image credit: Clker-Free-Vector-Images from Pixabay.

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Reviewing CRC From an Anthropological Lens: Who Is Most At Risk and Why?

By Parker Lynch

One cannot deny the importance of considering an individual’s risk of colorectal cancer (CRC) on the basis of their diet, exercising habits, and genetic predispositions. However, many other demographic factors can influence the likelihood of being diagnosed with CRC, as well as subsequent quality of life and survival outcomes. 

Lower socioeconomic status, for instance, is associated with a very high risk of developing CRC. Most of these community members are uninsured, which makes it difficult for them to receive the screenings that are otherwise readily accessible for those with insurance plans. A colonoscopy (one of the most important preventative screening measures for CRC) can cost anywhere from $500 to $6,000 without insurance, depending on the site where the procedure is conducted. For those on tight budgets, paying such amounts out-of-pocket every 5-10 years (depending on their personal risk of CRC) is quite unrealistic.

Tampa Bay Study

In a retrospective study conducted in 2021 by the CDC, researchers analyzed 13,982 uninsured patients with CRC who had received services at various free clinics in the Tampa Bay area between 2016 and 2018. These patients’ demographics are as follows: 

  • 5,139 (36.8%) were aged 50 years or older
  • Most were female (56.8%)
  • A large majority were non-Hispanic White (41.1%)
  • Majority were unemployed (54.9%)

Less than 7% of these patients had received any sort of preventive colorectal screening in their lives. 22.7% of these patients were smokers, and another 28.3% had diabetes. Not only are these patients more at risk for CRC because of their predisposed comorbidities, but they also don’t have the means to receive proper preventative screenings.

Bridging the Gap: Free Clinics

This study is one of many that sheds light on the healthcare treatment discrepancies among people of different socioeconomic statuses in America. The concerning statistics presented by these retrospective studies have motivated healthcare professionals and non-profit organizations to provide free clinics across the U.S. to make screening accessible to those who wouldn’t be able to otherwise afford it.

The NYC Health Department’s NYC Community Cares Project, for instance, provides free colonoscopies for uninsured residents referred from primary care sites. This program collaborates with various endoscopy centers and allows patients to work with primary care physicians, while also receiving free anesthesia and pathology services. Other interventions, such as the ColonoscopyAssist program, assists uninsured individuals in 30 states with the fees associated with CRC screening. This organization strives to eradicate a lot of the costs that are accumulated when someone gets preventative screening done, and reduces a colonoscopy’s cost to around $1,000 for a patient. Though this program doesn’t entirely eradicate colonoscopy costs, it still helps patients by significantly reducing the price, inherently making them much more feasible. 

Moving Forward

These public health interventions are vital to treating patients that suffer from America’s healthcare inaccessibility issues that run rampant throughout the country. Even though the U.S. spends more money on healthcare than any other wealthy country in the world, we have struggled to match other countries in patient satisfaction, accessibility, and life expectancy. 

Movements like the Community Cares Project in NYC, ColonoscopyAssist program, and other free/reduced-cost screening resources across the country are making huge strides in the CRC community. Should these endeavors continue to be subsidized by non-profit organizations, philanthropies, donations, and government support, uninsured individuals can receive timely preventative screenings. Increased access to these resources can ensure that patients from all socioeconomic backgrounds can receive the care that they need. 

 

Parker Lynch is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

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Bridging the Care Gap: ASCENDS Project Aims to Reduce Cancer Disparities

By the ASCENDS team, University of Alabama at Birmingham

In the dynamic realm of cancer treatment, one persistent challenge demands our attention: the accessibility of care is far from straightforward.

Factors such as geographical location, income, employment status, and demographics can significantly influence the quality of care received. It’s high time we reshape this narrative, particularly for those colon cancer patients who face barriers to optimal cancer care.

And here’s the exciting part – you can be a driving force behind this transformation by simply sharing your story.

ASCENDS, an acronym for Advancing Surgical Care and Equity in the Deep South, is an initiative designed to revolutionize cancer care, especially for individuals in rural and minority communities who live in the states of Mississippi and Alabama.

ASCENDS is led by Dr. Maria Pisu and Dr. Daniel Chu, is funded by the National Institutes of Health, and is based at the University of Alabama at Birmingham.

How Can You Participate?

If you reside, or were treated, in the states of Mississippi or Alabama, we invite you to share your name and contact information. A member of the ASCENDS team will reach out to you for a one-time phone survey. And if you weren’t treated in these states but know someone who was, please consider sharing this opportunity!

ASCENDS is eager to hear about your experiences, triumphs, and even the challenges you’ve encountered. Why?

Because your voice can stir conversations, instigate change, and construct bridges within the landscape of cancer care. Your stories can influence policies, shape healthcare practices, and bridge long-standing gaps in the delivery of care.

 

There is also a little extra incentive – participants in the survey will be compensated for their time!

While the results of the study will drive the direction of the implementation, your results will be compiled into a plan of care recommendation that will be shared with healthcare providers in the deep South. Participants will be able to receive the study results once they are compiled. All personal information will be excluded.

Curious to Learn More?

Visit our website or connect with us on Facebook. Let’s work together to make a lasting impact on the world of cancer care!

 

This was an invited commentary from the ASCENDS team at the University of Alabama at Birmingham.

Photo credit: Tumisu on Pixabay.

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Race May Hinder Appropriate Diagnosis and Treatment for Early-Onset CRC

Systemic racism remains an impediment  for the progress of public health in the U.S. Racial disparities continue to reduce access to quality healthcare in the country, as was confirmed by a recently published study. 

The study, published in the Journal of Clinical Oncology (JCO), found that young Black individuals (18-49 years) in the U.S. diagnosed with colorectal cancer (CRC) have a higher death rate than their White counterparts. The authors suggest that young Black patients with CRC are less likely to receive timely and guideline-concordant care (guideline-concordant is the minimal treatment patients should receive according to the National Comprehensive Cancer Network standards), which may be responsible for the increased mortality in that population. Specifically, the study found that Black CRC patients had longer times to receive adjuvant chemotherapy for colon cancer and neoadjuvant chemoradiation for rectal cancer compared to White patients. 

Racial disparity has a long and profound history in the U.S., affecting everything from the housing sector to the criminal justice system to the healthcare system and the economy. But when it comes to healthcare, it becomes even more worrisome and disturbing because the system’s ongoing inequities are impeding the progress made through years of public health effort. As a national goal, the Agency for Healthcare Research and Quality is dedicated to reducing racial disparities in health outcomes across the country. 

Interestingly, the American Cancer Society reports that, with the exception of pancreatic and kidney cancer, Black people had lower survival rates than White people for all cancer types. 

Barriers to CRC Screening and Treatment

Back to the JCO study – the authors found that access to CRC screening is difficult for Black people in the U.S. for a number of reasons, including:

  • Health insurance coverage: Often your health insurance determines the type of healthcare you receive. However, obtaining quality private health insurance is primarily dependent on having a job. But when it comes to employment, a substantial percentage of Black people are disadvantaged. Compared to White people, Black people have the highest unemployment rate in the country and are more likely to work in blue-collar jobs. Consequently, Black individuals have lower rates of private insurance coverage. 
  • Facility type: Black people are more likely to receive treatment at facilities with limited resources and are less likely to have access to high-performing facilities like teaching hospitals and cancer centers with a National Cancer Institute designation. However, research indicates that there could be a 5% reduction in the disparity in the provision of guideline-concordant care if Black and White patients were treated in the same healthcare facilities. 
  • Access to specialists/Lack of diversity in the medical workforce: For Black patients with metastatic CRC, fewer consultations with specialists and subsequent multimodality therapy treatments are provided. Nonetheless, even in cases when the rates of specialist visits are comparable to those of White patients, Black people are less likely to undergo treatment for CRC. A lack of cultural sensitivity and diversity in the medical workforce erodes good patient-provider communication, including the kind and caliber of information that clinicians deliver to patients, and makes the health care system appear less trustworthy. Disparities in patients’ access to high-quality care can be made worse by this, which can result in clinicians making insufficient treatment recommendations and creating obstacles to treatment adherence for patients from marginalized populations.

Over the years, a lot of work has been done to boost access to healthcare and remove barriers that might prevent it. Despite that, racial disparities in healthcare in the U.S. remain. However, no one should be denied access to high-quality healthcare due to the color of their skin or race. More work is needed to eradicate the disparities that Black Americans and other minority races face throughout the country.

 

Emmanuel Olaniyan is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

 

Photo credit: Nathan Dumlao on Unsplash

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NEHI Report Proposes Solutions for CRC Screening Disparities

The Network for Excellence in Health Innovation (NEHI) conducted research to shine a spotlight on disparities in colorectal cancer (CRC) screening and has proposed short-term and long-term recommendations to address these disparities. The report, Addressing Persistent Disparities in Colorectal Cancer Screening Among Racially and Ethnically Diverse Populations, proposes solutions that would help close existing gaps and legislative involvement for long-term resolutions.

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Tackling Fresh Food Inequality: Navigating the Landscape of Food Deserts and Nutrition

Nutrition & Colorectal Cancer Prevention Series: Blog 2

The first installment of this blog series provided an overview of the molecular pathways that enable dietary interventions to prevent and reduce the spread of colorectal cancer (CRC) cells in the body. These pathways have laid the foundation for this week’s installment: addressing the systemic barriers that prevent individuals from accessing the nutrition they need to reduce CRC risk. 

Connecting the Dots: Access, Healthy Food, and CRC

The link between food deserts (areas with limited access to low-cost yet nutritious food) and health outcomes is well established. Like most health disparities in the U.S., black, brown, and low-income communities are more likely to live in locations with sparse options for fresh, healthy dietary choices. Individuals living in these food deserts often need to drive an extended distance to access fresh fruits and vegetables, as the options near their residences are canned, frozen, or unavailable. Additionally, food swamps are similarly deficient in healthy nutritional options but are marked by a high ratio of fast food to fresh food options. Lack of proximity to fresh and less processed foods contribute to the social determinants of health and make it far more difficult for individuals in these communities to engage in proactive prevention. 

In an article published in May of this year, researchers explored the epidemiologic links between counties with high food desert and food swamp scores and obesity-related cancer mortality rates. Individuals residing in counties with high food swamp scores were found to have significantly (77%) higher odds of obesity-related cancer mortality. The authors similarly identified a positive dose-response relationship between obesity-related cancer mortality and food desert and swamp scores. 

Improving Access to Fresh Foods in These Communities

While individuals living in these geographic locations have substantial barriers, local organizations can help provide services that bridge the gap. Many local food pantries have developed programs to bring fresh foods to communities in need. Volunteers will pack pre-selected boxes of fresh ingredients and set up a free farmer’s market in a community that lacks access to those ingredients, eliminating the transportation barrier and making dietary prevention, or the process of maintaining a balanced and nutritious diet to prevent disease, a more accessible goal. 

Feeding America has an online tool that locates mobile food pantries with a click and a zip code. Local food pantries may also provide delivery services to elderly or disabled individuals, so check in with your local organization to learn more!

Emma Edwards is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

Picture credit OpenClipart-Vectors from Pixabay.

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Serving the Underserved: Transportation, Physician Access for CRC Prevention

By Deepthi Nishi Velamuri

Colorectal cancer (CRC) remains a serious health issue in the U.S. It is the second most common cause of cancer-related deaths in both men and women, and it is the third most frequently diagnosed cancer. An average of 50,000 Americans die from CRC each year. However, CRC is quite treatable if diagnosed early through routine screenings for average- and high-risk adults. The incidence and mortality rates associated with this disease are being reduced through public health initiatives, such as awareness campaigns and improving access to screenings. To prevent and identify CRC in its earliest stages, people must fully comprehend the risk factors, symptoms, and significance of regular screening.

The studies in the infographic below were presented at Digestive Disease Week 2023 and were focused on understanding the factors that impact screening rates for CRC in the U.S. The researchers delved into various aspects such as patient education, healthcare policies, socioeconomic disparities, and the effectiveness of screening methods and aimed to enhance screening efforts, raise awareness, and develop targeted interventions to increase screening rates.

 

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Breaking Barriers: Effective Approaches for Boosting Colorectal Cancer Screening Rates

By Deepthi Nishi Velamuri

Colorectal cancer (CRC) remains a serious public health issue in the U.S. that affects people from all walks of life, independent of race, gender, or age. The third most commonly diagnosed cancer in the U.S., an estimated 150,000 new cases and 53,000 deaths are attributed to CRC each year, highlighting the urgency for effective prevention and early detection strategies. [1]

Early and regular screening can improve detection rates and lead to better outcomes for CRC. However, there are significant disparities in the rates of CRC screening for some groups, such as medically underserved communities. Race and ethnicity, socioeconomic status, and access to healthcare services have a significant impact on CRC screening rates . 

During the annual Digestive Disease Week 2023 meeting,  several research studies were presented that identify interventions to improve CRC screening rates, specifically in medically underserved populations. The following interventions were identified in the systematic review to increase CRC screening rates among medically underserved populations:

  1. Multicomponent interventions: These interventions involved multiple elements, such as patient education, provider reminders, patient navigators, and mailed outreach. [2][3]
  2. Patient navigation: Interventions that included the use of patient navigators, who assist patients in navigating the healthcare system and overcoming barriers to screening, were effective in increasing screening rates. [3]
  3. Mailed stool-based kits with provider letters: Sending screening kits to patients by mail, along with a letter from their healthcare provider recommending the screening, was found to be a successful intervention. [3]

Multiple Elements to a Successful Screening Program

The study conducted by Shailavi Jain et al., [3] highlighted the impact of a multicomponent health system intervention to increase screening participation among patients with a family history of CRC. This intervention involved:

  • Electronic health record reminders to primary care providers
  • Reminders to patients to schedule a colonoscopy
  • Additional educational resources about familial CRC risk and the colonoscopy procedure 

The intervention increased colonoscopies ordered, scheduled, and completed among high-risk patients.

Another study focused on using patient-level structured data elements to optimize population-based CRC screening. The study utilized individualized health data, such as laboratory results and diagnosis codes, to identify patients with significant comorbidities who were unlikely to complete routine screening. This approach allowed for targeted screening efforts to be directed towards patients most likely to complete screening as intended by their primary care team. [4]

A meta-analysis examined the efficacy of an opt-out outreach method  to optimize screenings. [5] This approach involved giving patients the option to either opt-in or opt-out of receiving fecal immunochemical test (FIT) kits. The analysis showed that patients who were given the option to opt-out had a significantly higher FIT completion rate compared to those who were given the option to opt-in. 

Additionally, a quality improvement project evaluated the effectiveness of mailed reminders in increasing uptake of FIT. Mailed reminders were found to be an effective strategy in improving screening rates. [6]

Overall, these studies highlight the effectiveness of various interventions, including multicomponent approaches, patient navigation, mailed reminders, and opt-out outreach methods in increasing CRC screening rates among medically underserved populations and individuals with a family history of CRC. These interventions can inform the design of programs aimed at improving CRC screening in these populations.

References-

  1. American Cancer Society.
  2. Vella J., Patel, S, Bowman B., et al. Interventions to improve colorectal cancer screening among medically underserved populations: A systematic review. In: Digestive Disease Week 2023; May 6-9, 2023; Chicago, IL.
  3. Jain S, Galoosian A, Badiee J., et al. Impact of a multicomponent health system intervention to increase colorectal cancer screening participation in patients with a family history of colorectal cancer: A systematic review. In: Digestive Disease Week 2023; May 6-9, 2023; Chicago, IL.
  4. Corren R., et al. Flagging comorbidities using patient-level structured data elements to optimize population-based colorectal cancer screening: A systematic review. In: Digestive Disease Week 2023; May 6-9, 2023; Chicago, IL.
  5. Battepati D., et al. The efficacy of opt-out outreach method to optimize colorectal cancer screenings: A systematic review and meta-analysis.: A systematic review. In: Digestive Disease Week 2023; May 6-9, 2023; Chicago, IL.
  6. Ahmad Abu-Heija, Abdelnour D, et al. Effectiveness of mailed reminders in increasing uptake of fecal immunochemical testing for colorectal cancer screening: A quality improvement project.: A systematic review. In: Digestive Disease Week 2023; May 6-9, 2023; Chicago, IL.

 

Deepthi Nishi Velamuri is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

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Genetic Disparity May Contribute to Worse CRC Outcomes Among African-Americans

Health disparities are present in a multitude of different health issues and drive inequity among populations. These populations can be defined by factors like race, income, gender, or even geographic location. Improving access to colorectal cancer screening involves addressing these populations. Researchers can utilize data to identify geographic disparities, but understanding racial disparities becomes more complicated due to sociodemographic and cultural considerations. Yet, scientists at the Memorial Sloan Kettering Cancer Center (MSKCC) may have discovered reasons for these disparities on a microscopic level.

MSKCC researchers analyzed DNA sequencing data of over 4,000 patients at the hospital over the course of 8 years and compared it to ancestry information. They found that patients with African ancestry had shorter median survival post-diagnosis, had less accurately predicted outcomes, and were less likely to have the genetic mutations needed to be considered for immunotherapy. Overall survival  for the African ancestry group was only 45.7 months post-diagnosis compared to 67.1 months for the European ancestry group.

Mutations in the adenomatous polyposis (APC) gene, which is a known tumor suppressor, are associated with better CRC outcomes. However, this mutation appeared to make no difference in survival for Black patients while improving survival rates among European, East Asian, and South Asian CRC patients.

Disparity in Treatment Response

When it came to treatment, the African ancestry group had less genetic markers for effective immunotherapy treatment as defined by the FDA. While the European ancestry group had a 20.4% qualification rate, the African ancestry group had only 13.5%. Even compared to those who did not qualify for immunotherapy treatments based on FDA guidelines, those with African ancestry still experienced less actionable genetic alterations than the European group (5.6% and 11.2% respectively). Researchers propose that this may be due to fewer BRAF V600E mutations in the African ancestry group. Patients who carry this mutation typically respond well to certain targeted treatments.

A limitation of this study is its exclusion of environmental and lifestyle factors that are important in CRC outcomes.

Addressing health disparities in screening and treatment benefits researchers and community efforts by identifying how and where to implement interventions. This study suggests that these large-scale issues may have solutions hidden within the population of interest itself.

 

Kaylinn Escobar is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

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Paying Attention to the Rise in Advanced-Stage Early-Onset CRC

March is National Colorectal Cancer Awareness Month – an ideal time to educate and inform the population about the trends of colorectal cancer (CRC) incidence and mortality in the U.S. New data released by the American Cancer Society predict that of the 153,020 new CRC cases predicted in 2023, 13% (nearly 20,000) will be in individuals younger than 50 years (early-onset CRC). This means improving screening rates in the 45-49 population is even more important. Also important is  improving awareness of the signs and symptoms of CRC.

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