As colorectal cancer (CRC) rates rise globally, especially in the early-onset population, identifying high-level risk factors for developing this disease becomes ever more critical. The link between diabetes and the incidence of colon and rectal cancers was discovered in 1998 and has been well-established since then, as many trials have uncovered the strength of the association between these two diagnoses.
In 2013, a meta-analysis of 26 observational studies among more than 200,000 patients assessed the relationship between CRC and all-cause mortality (death due to any cause), cancer-specific mortality, and disease-free survival. Interestingly, diabetes was found associated with poorer outcomes for all three categories. A key finding from this study: individuals who have diabetes and CRC have a 17% increased risk of death due to any cause.
A 2017 article on the epidemiology of the association between diabetes and CRC delved into the potential molecular mechanisms of this association and the therapeutic implications of treating both diseases, and found that:
Diabetes mellitus and CRC have many overlapping risk factors
Hyperinsulinemia, hyperglycemia, and hyperlipidemia may all play a role in the development of these dual diagnoses
Environmental and genetic risk factors may also play a role
Promising therapies for treating a dual diagnosis are statins, ACE inhibitors, anti-fibrotic agents, among others
A study among 2023 individuals evaluated the association between type 2 diabetes risk, cholesterol levels, triglyceride levels, and CRC. Additionally, the study assessed the association between Lynch syndrome—which results from a genetic mutation that can lead to CRC—and these other variables, and found that:
Individuals with Lynch syndrome, type 2 diabetes, and elevated cholesterol levels had an increased risk of CRC
High triglyceride levels in those with Lynch syndrome did not increase CRC risk
Hyperinsulinemia and hyperglycemia in diabetic patients may increase the risk of CRC
A more recent study looked at the clinical and therapeutic implications of diabetes treatment and CRC risk. They found that while not always the case, these drugs often reduced the risk of dual diagnosis. Newer therapies, such as anticancer drugs that target IGF-1R and RAGE receptors (receptors for advanced glycation end products), may also help prevent and treat diabetes-induced CRC.
It will be essential for future research to continue to explore the mechanisms behind these two diseases and to collaborate to create effective treatments for individuals experiencing dual diagnoses.
Emma Edwards is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.
https://coloncancerfoundation.org/wp-content/uploads/2022/10/DNA-in-a-test-tube.jpg450800Emma Edwardshttps://coloncancerfoundation.org/wp-content/uploads/2017/01/CCCF_Logo_Final_Color.pngEmma Edwards2023-05-09 09:12:162023-05-01 11:20:07The Link Between Diabetes and Colorectal Cancer: Exploring the Evidence
Millions of Americans risk losing free preventive care after a Texas judge ruled against the Affordable Care Act’s (ACA) preventive services requirement. This could potentially derail the gradual uptick in screening rates among 45-49-year-old Americans–the age group that was recently asked to start screening for colorectal cancer (CRC).
ACA requires insurers to offer full coverage of preventive services upon recommendation of the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices, or the Health Resources and Services Administration. This means that enrollees do not have to pay anything out of pocket for those preventive services. However, Texas federal judge Reed O’Connor ruled that the USPSTF is an independent panel of volunteers who are not officers of the U.S. government, and therefore, they are not qualified to determine which preventive services should be free.
The ruling applies explicitly to new and updated recommendations by the USPSTF since the ACA was established in March 2010. If it stands, additions and revisions to USPSTF recommendations made after March 2010 may be subject to out-of-pocket costs. These could include lung cancer screenings, medications to lower the risk of breast cancer for high-risk women, preexposure prophylaxis (PrEP) for HIV prevention, and statin use for heart disease prevention, among other recommendations.
ACA and Colorectal Cancer Screening
CRC is a leading cause of cancer-related deaths in the U.S., and its incidence among individuals younger than 50 is rising. For the longest time, average-risk adults were asked to start preventive screening for CRC at 50 years and continue till 74 years. In 2021, the USPSTF expanded its recommendation and lowered the screening age to include adults ages 45 to 49. It is this 45-49 age group that may potentially begin to face cost barriers to CRC screening if Judge O’Connor’s ruling stands.
The ruling does not immediately invalidate the complete coverage of preventive services under the ACA; however, millions will soon be required to pay for certain preventative care services, which could impact screening rates. Medically underserved communities that experience significant healthcare inequities, including access to preventive screening for CRC, could face additional barriers to CRC screening and disparities in CRC healthcare outcomes.
Sahar Alam is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.
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.
https://coloncancerfoundation.org/wp-content/uploads/2022/11/disparity_equity.jpg600800Kaylinn Escobarhttps://coloncancerfoundation.org/wp-content/uploads/2017/01/CCCF_Logo_Final_Color.pngKaylinn Escobar2023-04-25 09:04:362023-04-25 09:04:36Genetic Disparity May Contribute to Worse CRC Outcomes Among African-Americans
The applications of artificial intelligence (AI) goes beyond social media: scientists have found that it can be used to help physicians identify adenomas during screening. In Singapore, scientists affiliated with the Lee Kong Chian School of Medicine and Sengkang General Hospital evaluated the one year performance of AI colonoscopy and its impact on colorectal cancer (CRC) screening.
Adenoma Detection Rate (ADR) is the ratio of the number of colonoscopies that detect an adenoma to the total number of colonoscopies performed. Adenoma Detected Per Colonoscopy (ADPC) is the average number of adenomas detected per colonoscopy performed. These measures were used to determine the effectiveness of this emerging tool. This is not a new concept, however. Computer-aided detection (CADe) has previously been shown to improve ADPC rate by 22%. More information regarding this previous study can be found here.
AI Adds Value and Is Cost-Effective
Using a database of colonoscopy images, the GI Genius™ Intelligent Endoscopy Module is able to identify lesions that are potential polyps. The researchers recognize that there is a learning curve for providers to utilize the technology and there may be fatigue associated with using the technology for too long. Another risk involved is a longer procedural time due to the need for analyzing the results.
In order to determine if the benefits outweigh the costs, researchers used a prospective cohort study with CADe colonoscopies and traditional ones. They measured the polyp detection rate (PDR) which was the ratio of polyp-detected colonoscopies to the total number performed. Once these polyps were assessed in a lab via polypectomy, the ADR and ADPC rates were calculated.
Out of 843 CADe colonoscopies, the AI registered 1,392 hits with 71% of polypectomies being adenomatous. In the CADe group, the PDR was 45.6%, the ADR was 32.4%, and the ADPC was 2.08. Additionally, the mean procedural time for AI-aided colonoscopies and non-AI aided colonoscopies were not statistically significant, with the former taking an average of 19.9 minutes and the latter, 19.7 minutes.
Considering the cost of using AI assistance, the polypectomy rates increased revenue by more than $ US100,000 over the course of one year of AI-usage. This covered the subscription cost of the technology with $20,000 remaining. The study maintained that the AI-aided technology improved both ADR and PDR. Endoscopists also did not ignore the device prompts, indicating “adoption fatigue” was not an issue in this population.
Leveraging technology to improve CRC screenings ranges from social media advocacy to using AI in screening. As we look to the future of screening, technology may be a solution to improve CRC detection rates and decrease morbidity.
Kaylinn Escobar is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.
https://coloncancerfoundation.org/wp-content/uploads/2023/01/Doctors.jpg534800Kaylinn Escobarhttps://coloncancerfoundation.org/wp-content/uploads/2017/01/CCCF_Logo_Final_Color.pngKaylinn Escobar2023-04-11 09:00:482023-04-03 14:55:39Artificial Intelligence–Aided Endoscopy: A Cost Effective Way to Improve CRC Detection
The benefits of exercise for overall health and disease prevention are well known. While research overwhelmingly points to physical activity as a protective factor against colorectal cancer, more research is necessary to delineate how the timing of physical activity during one’s life impacts the risk of developing colon cancer. In a recently published study, researchers examined the differences in colon cancer incidence in relation to levels of physical activity at different stages of life.
Researchers conducted a baseline survey in 1995 and 1996 of adult men and women to measure exposures to moderate-to-vigorous physical activity (MVPA) and several other lifestyle-related factors among nearly 300,000 adults (50-71 years). Study follow-ups ceased in 2011 or following any diagnosis of colon cancer or death.
In the primary exposure assessment, participants were asked to report and quantify MVPA they had participated in at various stages of their life: at ages 15-18, 19-29, 30-35, and in the previous decade. MVPA levels were measured by time:
Rarely or none
Less than 1 hour a week
1-3 hours a week
4-7 hours a week
Greater than 7 hours per week
Pattern Recognition and Impact on Colon Cancer Risk
Researchers identified specific patterns of MVPA:
Maintaining the same general level of physical activity throughout the life course (whether low, moderate, or high levels of MVPA)
Raising levels of physical activity during the life course, either earlier or later in life (increasers)
Reducing the amount of MVPA over time, either earlier or later in life (decreasers)
Several key findings emerged from these patterns:
Participants who maintained high MVPA levels throughout their life had a 15% lower risk of colon cancerthan those who maintained low MVPA levels throughout their life
Participants who increased MVPA levels at a younger age had a 10% reduced risk of colon cancer, and participants who increased MVPA levels at an older age had an 8% reduced risk of colon cancer
Decreasing MVPA levels during the life course resulted in a 12% higher risk of colon cancer incidence when compared with individuals who maintained low MVPA levels throughout their life
These findings suggest that individuals who consistently engage in MVPA throughout their life and those who increase MVPA levels during their life have a lower risk of being diagnosed with colon cancer. They provide hope to individuals who may begin their fitness journey later in life.
Emma Edwards is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.
https://coloncancerfoundation.org/wp-content/uploads/2019/03/iStock-459241539.jpg8361254Emma Edwardshttps://coloncancerfoundation.org/wp-content/uploads/2017/01/CCCF_Logo_Final_Color.pngEmma Edwards2023-04-04 09:00:042023-03-30 15:48:04Fitness and Reducing Colon Cancer Risk: It’s Never Too Late to Start!
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.
https://coloncancerfoundation.org/wp-content/uploads/2022/09/52241140806_513839e5da_c.jpg421800Emma Edwardshttps://coloncancerfoundation.org/wp-content/uploads/2017/01/CCCF_Logo_Final_Color.pngEmma Edwards2023-03-27 11:08:462023-03-27 11:08:46Paying Attention to the Rise in Advanced-Stage Early-Onset CRC
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.
https://coloncancerfoundation.org/wp-content/uploads/2022/08/Screening-e1660914964831.jpg225400Emma Edwardshttps://coloncancerfoundation.org/wp-content/uploads/2017/01/CCCF_Logo_Final_Color.pngEmma Edwards2023-03-20 09:20:202023-03-20 09:20:20Colorectal Cancer: New Data Suggest Rising Rates, More Advanced Disease in Young Adults
Biomarkers allow scientists to identify certain diseases from a simple biological sample like urine, breath, or even feces. Volatile organic compounds (VOCs) are the byproducts of metabolic processes associated with cancer, necrosis, or other metabolic changes. Scientists have now identified a new biomarker associated with both colorectal cancer (CRC) and adenoma (noncancerous tumor) that can be used for detection.
The cross-sectional study included 24 newly diagnosed CRC patients, 24 patients with adenomas, and 32 individuals who had a normal colonoscopy between July 2017 and July 2020. Individuals with normal colonoscopies and those with adenomas had fecal samples collected before and after their colonoscopy. Samples were requested from CRC patients 3-4 weeks after diagnosis and before treatment.
Of the 60 VOCs identified, only 3 showed different peaks between CRC and the control groups: p-cresol, 1H-indole, and 3(4H)-DBZ. There was a statistically significant difference between p-cresol peak values in each group with the greatest difference between CRC and the control group. This was also the same for 3(4H)-DBZ. However, 1H-indole did not have a significant difference between the study groups.
After adjusting for sex, age, and body-mass index (BMI), the researchers found that only CRC was associated with increased p-cresol and 3(4H)-DBZ, and p-cresol seemed to be the best possible predictor of CRC. A combination of p-cresol and 3(4H)-DBZ “is also optimistic as a combined biomarker” according to the study authors.
p-cresol was also abundant among patients with adenomas compared to healthy controls. This was also the case after adjusting for age, sex, and BMI.
Although more work needs to be done to determine what processes produce these VOCs, these associations can launch a new set of studies to confirm its use in a clinical setting. Other biomarkers have been identified that can predict CRC occurrence and mortality. Overall, the ability to better detect CRC and precancerous adenomas play an important role in global prevention efforts. A better understanding of the biological processes involved in these diseases is crucial for those efforts to be successful.
Kaylinn Escobar is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.
https://coloncancerfoundation.org/wp-content/uploads/2023/03/NCI-on-Unsplash_medical-samples-scaled.jpg25601707Kaylinn Escobarhttps://coloncancerfoundation.org/wp-content/uploads/2017/01/CCCF_Logo_Final_Color.pngKaylinn Escobar2023-03-08 16:58:272023-03-08 16:58:27 Identifying New Biomarkers in Fecal Samples to Detect Colorectal Cancer
Interleukin 6 (IL-6) and tumor necrosis factor-alpha (TNF-a) are inflammatory biomarkers that are capable of activating Janus kinase signaling pathways, nuclear factor signaling pathways, and C-reactive protein (CRP) transcription. CRP tests are commonly used in cancer care to predict prognosis, as activation of the Janus kinase and nuclear factor signaling pathways can aid in tumor expansion and metastasis. Additionally, high-sensitivity CRP tests (hsCRP) are able to identify small amounts of CRP in blood samples.
One recent study assessed the association between these inflammatory biomarkers (IL-6, TNF-a, and hsCRP) with CRC recurrence and mortality in 1,494 stage III colorectal cancer (CRC) patients. This was the largest study assessing the relationship between these inflammatory biomarkers and CRC survival as of yet.
While the study recruited a diverse sample of individuals, the final sample was overwhelmingly White (82.3%) and non-Hispanic (94.5%). Future studies should prioritize racial diversity to more accurately assess this association, as racial disparities exist in CRC diagnoses and outcomes.
Researchers collected plasma samples from participants 3-8 weeks following their surgery but prior to chemotherapy. These plasma samples were then analyzed for IL-6, TNF-a, and hsCRP. The primary study outcome was disease-free survival and secondary outcomes were recurrence-free survival and overall survival. Participants who had higher concentrations of IL-6, TNF-a, and hsCRP were more likely to have CRC recurrence. High levels of these biomarkers were also found to be associated with an increased risk of mortality.
This study reveals that there is a significant association between inflammation following stage III diagnosis and poor CRC outcomes. Clinicians can utilize this information to better monitor their patients and improve CRC outcomes with evidence-based treatment solutions.
Emma Edwards is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.
https://coloncancerfoundation.org/wp-content/uploads/2022/08/colon-cancer-e1659559355726.jpg467700Emma Edwardshttps://coloncancerfoundation.org/wp-content/uploads/2017/01/CCCF_Logo_Final_Color.pngEmma Edwards2023-02-23 10:25:312023-02-23 10:25:31Inflammatory Biomarkers Can Predict Colorectal Cancer Recurrence and Mortality
Social media is a powerful tool that can be used to spread important information at unprecedented speed. Many users of TikTok, the short-form video app that has taken the world by storm, have utilized the platform to share their experiences with colonoscopy screenings. Users upload “vlogs” (video blogs) to the platform that document their entire experience in detail and talk to their audience throughout the process. While this may seem like oversharing, the authentic nature of these vlogs has grown popular on TikTok, as videos that do well on the platform often contain genuine and unfiltered content.
One example of this is @lucindabinney‘s three-part video series:
Lucinda Binney walks her audience through her experience with colonoscopy prep in a humorous, unfiltered manner that is popular among many lifestyle influencers. She details her experience with a liquid diet (she includes jello) and the standard practice of taking laxatives to prepare her colon for screening. Through this three-part vlog, she demystifies this screening procedure for her 340,000 followers, coming clean about both her anxiety surrounding the experience and her surprise that the laxative drink didn’t taste as bad as she thought.
While it is uncommon for people in their 20s to receive colonoscopies, as the U.S. Preventive Services Task Force does not recommend them until age 45 (a recent change from the previous age 50 guideline), individuals at high risk for colorectal cancer (CRC) may benefit from receiving a screening. CRC rates in the younger population have risen dramatically in the past two decades, with incidence jumping from 2.7 people per 100,000 in the year 2000 to 5.0 per 100,000 in 2019 in the 15-to-39 age group. While these incidence rates are still not high enough to warrant routine screenings in the general young adult population, they help make the case for increased screenings among those at higher-risk.
Haddon Pantel, MD, of Yale Medicine recommends that people in their 20s and 30s seek CRC screening if they experience any sudden changes in bowel movements, rectal bleeding, or any weight loss, abdominal pain, or appetite changes that are not otherwise explained. For more information about the signs of CRC, check out this resource.
Emma Edwards is a Colon Cancer Prevention Intern with the Colon Cancer Foundation.
https://coloncancerfoundation.org/wp-content/uploads/2023/02/social-media.jpg9051280Emma Edwardshttps://coloncancerfoundation.org/wp-content/uploads/2017/01/CCCF_Logo_Final_Color.pngEmma Edwards2023-02-14 09:00:472023-02-06 12:41:18Impact of Social Media on Colon Cancer Screenings
The Link Between Diabetes and Colorectal Cancer: Exploring the Evidence
As colorectal cancer (CRC) rates rise globally, especially in the early-onset population, identifying high-level risk factors for developing this disease becomes ever more critical. The link between diabetes and the incidence of colon and rectal cancers was discovered in 1998 and has been well-established since then, as many trials have uncovered the strength of the association between these two diagnoses.
In 2013, a meta-analysis of 26 observational studies among more than 200,000 patients assessed the relationship between CRC and all-cause mortality (death due to any cause), cancer-specific mortality, and disease-free survival. Interestingly, diabetes was found associated with poorer outcomes for all three categories. A key finding from this study: individuals who have diabetes and CRC have a 17% increased risk of death due to any cause.
A 2017 article on the epidemiology of the association between diabetes and CRC delved into the potential molecular mechanisms of this association and the therapeutic implications of treating both diseases, and found that:
A study among 2023 individuals evaluated the association between type 2 diabetes risk, cholesterol levels, triglyceride levels, and CRC. Additionally, the study assessed the association between Lynch syndrome—which results from a genetic mutation that can lead to CRC—and these other variables, and found that:
A more recent study looked at the clinical and therapeutic implications of diabetes treatment and CRC risk. They found that while not always the case, these drugs often reduced the risk of dual diagnosis. Newer therapies, such as anticancer drugs that target IGF-1R and RAGE receptors (receptors for advanced glycation end products), may also help prevent and treat diabetes-induced CRC.
It will be essential for future research to continue to explore the mechanisms behind these two diseases and to collaborate to create effective treatments for individuals experiencing dual diagnoses.
Emma Edwards is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.
Adults Aged 45-49 Risk Losing Free Colon Cancer Screening Services
Millions of Americans risk losing free preventive care after a Texas judge ruled against the Affordable Care Act’s (ACA) preventive services requirement. This could potentially derail the gradual uptick in screening rates among 45-49-year-old Americans–the age group that was recently asked to start screening for colorectal cancer (CRC).
ACA requires insurers to offer full coverage of preventive services upon recommendation of the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices, or the Health Resources and Services Administration. This means that enrollees do not have to pay anything out of pocket for those preventive services. However, Texas federal judge Reed O’Connor ruled that the USPSTF is an independent panel of volunteers who are not officers of the U.S. government, and therefore, they are not qualified to determine which preventive services should be free.
The ruling applies explicitly to new and updated recommendations by the USPSTF since the ACA was established in March 2010. If it stands, additions and revisions to USPSTF recommendations made after March 2010 may be subject to out-of-pocket costs. These could include lung cancer screenings, medications to lower the risk of breast cancer for high-risk women, preexposure prophylaxis (PrEP) for HIV prevention, and statin use for heart disease prevention, among other recommendations.
ACA and Colorectal Cancer Screening
CRC is a leading cause of cancer-related deaths in the U.S., and its incidence among individuals younger than 50 is rising. For the longest time, average-risk adults were asked to start preventive screening for CRC at 50 years and continue till 74 years. In 2021, the USPSTF expanded its recommendation and lowered the screening age to include adults ages 45 to 49. It is this 45-49 age group that may potentially begin to face cost barriers to CRC screening if Judge O’Connor’s ruling stands.
The ruling does not immediately invalidate the complete coverage of preventive services under the ACA; however, millions will soon be required to pay for certain preventative care services, which could impact screening rates. Medically underserved communities that experience significant healthcare inequities, including access to preventive screening for CRC, could face additional barriers to CRC screening and disparities in CRC healthcare outcomes.
Sahar Alam is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.
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.
Artificial Intelligence–Aided Endoscopy: A Cost Effective Way to Improve CRC Detection
The applications of artificial intelligence (AI) goes beyond social media: scientists have found that it can be used to help physicians identify adenomas during screening. In Singapore, scientists affiliated with the Lee Kong Chian School of Medicine and Sengkang General Hospital evaluated the one year performance of AI colonoscopy and its impact on colorectal cancer (CRC) screening.
Adenoma Detection Rate (ADR) is the ratio of the number of colonoscopies that detect an adenoma to the total number of colonoscopies performed. Adenoma Detected Per Colonoscopy (ADPC) is the average number of adenomas detected per colonoscopy performed. These measures were used to determine the effectiveness of this emerging tool. This is not a new concept, however. Computer-aided detection (CADe) has previously been shown to improve ADPC rate by 22%. More information regarding this previous study can be found here.
AI Adds Value and Is Cost-Effective
Using a database of colonoscopy images, the GI Genius™ Intelligent Endoscopy Module is able to identify lesions that are potential polyps. The researchers recognize that there is a learning curve for providers to utilize the technology and there may be fatigue associated with using the technology for too long. Another risk involved is a longer procedural time due to the need for analyzing the results.
In order to determine if the benefits outweigh the costs, researchers used a prospective cohort study with CADe colonoscopies and traditional ones. They measured the polyp detection rate (PDR) which was the ratio of polyp-detected colonoscopies to the total number performed. Once these polyps were assessed in a lab via polypectomy, the ADR and ADPC rates were calculated.
Out of 843 CADe colonoscopies, the AI registered 1,392 hits with 71% of polypectomies being adenomatous. In the CADe group, the PDR was 45.6%, the ADR was 32.4%, and the ADPC was 2.08. Additionally, the mean procedural time for AI-aided colonoscopies and non-AI aided colonoscopies were not statistically significant, with the former taking an average of 19.9 minutes and the latter, 19.7 minutes.
Considering the cost of using AI assistance, the polypectomy rates increased revenue by more than $ US100,000 over the course of one year of AI-usage. This covered the subscription cost of the technology with $20,000 remaining. The study maintained that the AI-aided technology improved both ADR and PDR. Endoscopists also did not ignore the device prompts, indicating “adoption fatigue” was not an issue in this population.
Leveraging technology to improve CRC screenings ranges from social media advocacy to using AI in screening. As we look to the future of screening, technology may be a solution to improve CRC detection rates and decrease morbidity.
Kaylinn Escobar is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.
Fitness and Reducing Colon Cancer Risk: It’s Never Too Late to Start!
The benefits of exercise for overall health and disease prevention are well known. While research overwhelmingly points to physical activity as a protective factor against colorectal cancer, more research is necessary to delineate how the timing of physical activity during one’s life impacts the risk of developing colon cancer. In a recently published study, researchers examined the differences in colon cancer incidence in relation to levels of physical activity at different stages of life.
Researchers conducted a baseline survey in 1995 and 1996 of adult men and women to measure exposures to moderate-to-vigorous physical activity (MVPA) and several other lifestyle-related factors among nearly 300,000 adults (50-71 years). Study follow-ups ceased in 2011 or following any diagnosis of colon cancer or death.
In the primary exposure assessment, participants were asked to report and quantify MVPA they had participated in at various stages of their life: at ages 15-18, 19-29, 30-35, and in the previous decade. MVPA levels were measured by time:
Pattern Recognition and Impact on Colon Cancer Risk
Researchers identified specific patterns of MVPA:
Several key findings emerged from these patterns:
These findings suggest that individuals who consistently engage in MVPA throughout their life and those who increase MVPA levels during their life have a lower risk of being diagnosed with colon cancer. They provide hope to individuals who may begin their fitness journey later in life.
Emma Edwards is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.
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.
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:
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.
Identifying New Biomarkers in Fecal Samples to Detect Colorectal Cancer
Biomarkers allow scientists to identify certain diseases from a simple biological sample like urine, breath, or even feces. Volatile organic compounds (VOCs) are the byproducts of metabolic processes associated with cancer, necrosis, or other metabolic changes. Scientists have now identified a new biomarker associated with both colorectal cancer (CRC) and adenoma (noncancerous tumor) that can be used for detection.
The cross-sectional study included 24 newly diagnosed CRC patients, 24 patients with adenomas, and 32 individuals who had a normal colonoscopy between July 2017 and July 2020. Individuals with normal colonoscopies and those with adenomas had fecal samples collected before and after their colonoscopy. Samples were requested from CRC patients 3-4 weeks after diagnosis and before treatment.
Of the 60 VOCs identified, only 3 showed different peaks between CRC and the control groups: p-cresol, 1H-indole, and 3(4H)-DBZ. There was a statistically significant difference between p-cresol peak values in each group with the greatest difference between CRC and the control group. This was also the same for 3(4H)-DBZ. However, 1H-indole did not have a significant difference between the study groups.
After adjusting for sex, age, and body-mass index (BMI), the researchers found that only CRC was associated with increased p-cresol and 3(4H)-DBZ, and p-cresol seemed to be the best possible predictor of CRC. A combination of p-cresol and 3(4H)-DBZ “is also optimistic as a combined biomarker” according to the study authors.
p-cresol was also abundant among patients with adenomas compared to healthy controls. This was also the case after adjusting for age, sex, and BMI.
Although more work needs to be done to determine what processes produce these VOCs, these associations can launch a new set of studies to confirm its use in a clinical setting. Other biomarkers have been identified that can predict CRC occurrence and mortality. Overall, the ability to better detect CRC and precancerous adenomas play an important role in global prevention efforts. A better understanding of the biological processes involved in these diseases is crucial for those efforts to be successful.
Kaylinn Escobar is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.
Photo credit: National Cancer Institute on Unsplash
Inflammatory Biomarkers Can Predict Colorectal Cancer Recurrence and Mortality
Interleukin 6 (IL-6) and tumor necrosis factor-alpha (TNF-a) are inflammatory biomarkers that are capable of activating Janus kinase signaling pathways, nuclear factor signaling pathways, and C-reactive protein (CRP) transcription. CRP tests are commonly used in cancer care to predict prognosis, as activation of the Janus kinase and nuclear factor signaling pathways can aid in tumor expansion and metastasis. Additionally, high-sensitivity CRP tests (hsCRP) are able to identify small amounts of CRP in blood samples.
One recent study assessed the association between these inflammatory biomarkers (IL-6, TNF-a, and hsCRP) with CRC recurrence and mortality in 1,494 stage III colorectal cancer (CRC) patients. This was the largest study assessing the relationship between these inflammatory biomarkers and CRC survival as of yet.
While the study recruited a diverse sample of individuals, the final sample was overwhelmingly White (82.3%) and non-Hispanic (94.5%). Future studies should prioritize racial diversity to more accurately assess this association, as racial disparities exist in CRC diagnoses and outcomes.
Researchers collected plasma samples from participants 3-8 weeks following their surgery but prior to chemotherapy. These plasma samples were then analyzed for IL-6, TNF-a, and hsCRP. The primary study outcome was disease-free survival and secondary outcomes were recurrence-free survival and overall survival. Participants who had higher concentrations of IL-6, TNF-a, and hsCRP were more likely to have CRC recurrence. High levels of these biomarkers were also found to be associated with an increased risk of mortality.
This study reveals that there is a significant association between inflammation following stage III diagnosis and poor CRC outcomes. Clinicians can utilize this information to better monitor their patients and improve CRC outcomes with evidence-based treatment solutions.
Emma Edwards is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.
Impact of Social Media on Colon Cancer Screenings
Social media is a powerful tool that can be used to spread important information at unprecedented speed. Many users of TikTok, the short-form video app that has taken the world by storm, have utilized the platform to share their experiences with colonoscopy screenings. Users upload “vlogs” (video blogs) to the platform that document their entire experience in detail and talk to their audience throughout the process. While this may seem like oversharing, the authentic nature of these vlogs has grown popular on TikTok, as videos that do well on the platform often contain genuine and unfiltered content.
One example of this is @lucindabinney‘s three-part video series:
Lucinda Binney walks her audience through her experience with colonoscopy prep in a humorous, unfiltered manner that is popular among many lifestyle influencers. She details her experience with a liquid diet (she includes jello) and the standard practice of taking laxatives to prepare her colon for screening. Through this three-part vlog, she demystifies this screening procedure for her 340,000 followers, coming clean about both her anxiety surrounding the experience and her surprise that the laxative drink didn’t taste as bad as she thought.
While it is uncommon for people in their 20s to receive colonoscopies, as the U.S. Preventive Services Task Force does not recommend them until age 45 (a recent change from the previous age 50 guideline), individuals at high risk for colorectal cancer (CRC) may benefit from receiving a screening. CRC rates in the younger population have risen dramatically in the past two decades, with incidence jumping from 2.7 people per 100,000 in the year 2000 to 5.0 per 100,000 in 2019 in the 15-to-39 age group. While these incidence rates are still not high enough to warrant routine screenings in the general young adult population, they help make the case for increased screenings among those at higher-risk.
Haddon Pantel, MD, of Yale Medicine recommends that people in their 20s and 30s seek CRC screening if they experience any sudden changes in bowel movements, rectal bleeding, or any weight loss, abdominal pain, or appetite changes that are not otherwise explained. For more information about the signs of CRC, check out this resource.
Emma Edwards is a Colon Cancer Prevention Intern with the Colon Cancer Foundation.