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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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Colorectal Cancer: New Data Suggest Rising Rates, More Advanced Disease in Young Adults 

On March 1, 2023, the first day of Colorectal Cancer Awareness Month, the American Cancer Society released some alarming new statistics regarding early-onset colorectal cancer (CRC) diagnoses: in the U.S. population, people are increasingly being diagnosed with CRC at a younger age and with more advanced disease stage. Advanced-stage CRC diagnoses have risen by eight percent in the past two decades. Additionally, early onset diagnoses rose from one in ten individuals in 1995 to one in five in 2019. While CRC in the general population is declining, rates in younger people are on the rise. 

The complete report contains CRC incidence, mortality, and screening prevalence data that were derived from multiple national databases, including: 

  • National Cancer Institute
    • Surveillance, Epidemiology, and End Results (SEER) program
  • Center for Disease Control
    • National Program of Cancer Registries
    • Behavioral Risk Factor Surveillance System
    • National Center for Health Statistics
      • National Health Interview Survey
  • North American Association of Central Cancer Registries

The report projects that of the 153,020 expected CRC cases in 2023, 13% (nearly 20,000) will be in individuals younger than 50. Seven percent of projected CRC mortality will also be in individuals younger than 50. CRC mortality in individuals under the age of 50 is also on the rise, as the mortality rate in this population has risen one percent every year since 2004. 

Rising cancer trends in the younger U.S. population point to increased exposures to causal agents, and indicate the need for research that identifies newfound risk factors. The data from this report highlights the growing concern that is early-onset CRC incidence and mortality, pointing to a portion of the population that will need more research and funding in the CRC space. 

Efforts to improve screening rates at a health care center in New York City

Racial Disparity in CRC Incidence and Mortality

Racial disparities continue to exist in CRC incidence, mortality, and survival rates. Both incidence and mortality rates in the U.S. are highest among American Indian/Alaskan Native and non-Hispanic Black individuals. Alaskan Native individuals face the highest burden of CRC incidence than any other group (88.5 per 100,000 individuals). Risk factors that contribute to disparities in the Alaskan Native population are likely a combination of environmental factors (low sun exposure, diet low in fiber, smoking, and obesity) and low access to colon health care services. Alaskan Native individuals have the lowest screening rate in the U.S. 

Black Americans are more likely to be diagnosed with metastatic CRC than any other racial or ethnic group in the nation. Black patients also experience significant disparities in care, and are 21% less likely to receive colon cancer surgery and 28% less likely to receive rectal cancer surgery. Additionally, Black patients are more likely to develop right-sided tumors, which are correlated with a poorer prognosis. 

These updated data from the American Cancer Society point to the need for future research in early-onset incidence, racial disparities, and general risk factors for CRC. Scientists should aim to identify newfound risk factors that are contributing to the trend of CRC diagnoses under 50, and to identify factors specific to high-risk racial and ethnic groups as well.

You can learn more about the signs and symptoms of colorectal cancer on this page.

 

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

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Early-Age Onset Colorectal Cancer: Health Disparities in the Black Population

Colorectal cancer (CRC) is a leading cause of cancer-related deaths in the U.S., and the incidence of early-age onset CRC (EAO-CRC)—when the disease is diagnosed in those younger than 50 years—is rising. In the Black population, EAO-CRC makes up nearly 10% of all new diagnoses. The incidence of EAO-CRC in the Black population (8.4 cases per 100,000 people in 2019) is slightly lower than that of the White population (8.9 cases per 100,000 people in 2019), but this is reversed when it comes to the mortality rate. The mortality rate of EAO-CRC in the Black population is 2.4 deaths per 100,000 people, while it is 1.8 deaths per 100,000 people in the White population. Between 2015-2019, 5,329 new EAO-CRC cases were diagnosed among Black Americans.

Studies have shown that Black individuals are more likely to be diagnosed with EAO-CRC at a younger age and a more advanced stage than White individuals: 22% of White Americans receive a metastatic diagnosis compared with 26% of Black Americans. 

 

 

While additional research is needed to discern the higher incidence of EAO-CRC in the Black population, certain socioeconomic and environmental factors likely play an important role. These include limited access to proper healthcare services, the prevalence of food deserts leading to poor nutrition, and living in areas with high pollution rates. Additional resources to support research, prevention, and treatment efforts of EAO-CRC in this population are critical.  

Empowering the population via awareness and education campaigns around the early warning signs of CRC and the importance of screening in the Black community would also go a long way. Early warning signs of CRC include changes in bowel movements, blood in stool, unexpected weight loss, and continuous abdominal discomfort. If you are experiencing these symptoms, speak with your doctor. 

Additional information on prevention, symptoms, and diagnosis of CRC can be found under ‘Resources’ on the Colon Cancer Foundation’s website.

 

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

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CDC Report: Why Do Certain Populations Never Screen for Colorectal Cancer?

Cancer screening remains a powerful tool. Even limited screening has long-term benefits compared to no screening  and can lower the risk of cancer and related deaths. A recent study by researchers at the CDC compared data on adults who reported they had not received a colorectal cancer (CRC) screening test between 2012 and 2020 using information from the Behavioral Risk Factor Surveillance System (BRFSS). The study identified various trends, most notably that 22 states did not meet the CDC’s Healthy People 2020 goal of 70.5% adults screened for CRC.

The sample was limited to adults aged 50 to 75 years, with up to date screenings defined as one of the following:

  • Home stool-blood test within the past year
  • Sigmoidoscopy within five years with fecal occult blood test or within one year with fecal immunochemical test
  • Colonoscopy within ten years

The ‘never screened’ numbers were a composite of those who answered no to being screened or those who were not up to date. Those who declined to answer or reported uncertainty were excluded. Overall, the study identified:

  • A 5.8% decrease in unscreened adults between 2012 and 2020 
  • States with the largest improvements were also those with the largest unscreened population in 2012 

 

Despite these improvements, CRC screening goals have yet to be met and may be difficult to meet with the new Healthy People 2030 standards. The target of 74.4% screened may have been a challenge to meet, possibly further exacerbated by the COVID-19 pandemic.

Researchers noted that including just two more questions on the BRFSS in 2020, the percentage of up to date screenings increased to 71.6%. These two questions enquired about:

  • Stool DNA testing
  • Computerized tomographic colonography

It is important to note that the National Colorectal Cancer Roundtable—a membership organization established by the CDC and the American Cancer Society—has set its goal to 80% screening rates across the country.

Study authors recognized recall bias and an inability to distinguish between screening versus diagnostic tests as major study limitations. Additionally, social desirability bias and a low response rate may have also affected the results. However, financial factors and health disparities may also describe the differences between states.

Following implementation of the Affordable Care Act, researchers at the American Cancer Society found that CRC screening among low-income adults across the U.S. increased by up to 8%, with the greatest increases observed in early Medicaid expansion states. They also noted that a majority of those who were never screened also lived in a state without expansion (South Dakota). 

Nonfinancial factors such as health disparities were studied in a mixed-methods analysis conducted at the Virginia Commonwealth University’s School of Medicine. Here, researchers noted that participants of gender-specific and race-specific focus groups brought forth nuanced concerns regarding screening. This included lack of awareness of both the disease and the screening, lack of physician recommendation that is clear and rational, and fear of being diagnosed and complications associated with testing. These concerns, if unaddressed, may limit others from seeking out CRC screening.

To read more about the Healthy People 2030 CRC screening standards and the current progress, visit Healthy People 2030.

 

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

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Masculinity May be a Barrier to Completing Colorectal Cancer Screening

Man

Colorectal cancer (CRC) mortality is preventable with regular screening. Differences in early detection screening rates lead to disparities in CRC mortality among White, Black, and American Indian/Alaska Native (AIAN) men. Complicating the issue of racial disparity observed with CRC screening rates is the psychosocial aspect of men’s health. A recent study investigated the impact of masculinity barriers on CRC screening and found that they influence CRC screening completion.  

This survey-based cross-sectional study analyzed the association between the male thought process and the successful completion of CRC screening tests. Male respondents aged 18 to 75 years from across the U.S. who self-identified as Black, AIAN, or white were surveyed. Four Masculinity Barriers to Medical Care subscale were investigated:

  • Being strong
  • Acknowledging emotions and health issues
  • Positive attitude toward medical professionals and exams
  • Negative attitude toward medical professionals and exams

The highest score, which translates into the greatest barrier for screening, was for “Being strong” and “Negative attitudes towards medical professionals and exams”

Lower scores were observed for “Acknowledging emotions and health issues” and “Positive attitudes toward medical professionals and exams”

For all men, “being strong” was associated with a 54% decreased odds of CRC screening completion. 

Reluctancy to seek and engage in preventive health services, such as CRC  screening, due to fear of presenting as weak or vulnerable is associated with men who strongly support masculine ideals. The investigation also demonstrated that Black men who scored higher on negative attitudes toward medical professionals and exams subscale had lower odds of CRC screening uptake. The sensitivity analysis of the study reflected that AIAN men had lower odds of CRC completion than Black men. 

Medical mistrust is positively correlated with masculine ideologies. Despite decreasing CRC incidence and mortality rates in adults ages 50 years and older, early-onset CRC has increased among adults younger than 50 and is predicted to increase by 90% by 2030. Considering the above masculinity barriers in future population-based and intervention research is critical for increasing men’s participation in CRC screening.

 

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

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Clinical Decisions Support Systems May Exacerbate Healthcare Disparities

Clinical decision support systems (CDSS) are computer-based applications used to analyze data within electronic health records (EHRs). CDS algorithms are progressively being integrated into healthcare systems to expand patient care. However, research and development in ethical frameworks have uncovered that CDS applications can perpetuate bias in healthcare. A recent EHR quality improvement study has revealed significant differences in family history accessibility, availability, and comprehensiveness based on sex, race and ethnicity, and language preference. These findings propose that historically medically underserved populations are excluded from identification from CDS tools based on family history information, unintentionally reinforcing existing healthcare disparities and potentially creating more disparities in healthcare systems.

 

decision support system

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