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

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

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

 

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

Globally, the COVID-19 pandemic has led to sharp declines in cancer screening rates. Screening tests were halted as national lockdowns began as healthcare centers needed to prioritize COVID-19 patients. A retrospective cohort study revealed that during the early days of the pandemic in 2020, fewer fecal immunochemical test (FIT) screenings and colonoscopies resulted in fewer patients being diagnosed with colorectal cancer (CRC) and advanced adenomas than in 2019. In April 2020, colonoscopy volumes were significantly lower than in April 2019, with a 26.9% decrease in colonoscopy volume. Overall, there was an 8.7% reduction in CRC cases diagnosed by colonoscopy in 2020. This has fueled concerns of a potential negative impact on cancer prevention and care.

The study mentioned above analyzed the effect of the COVID-19 pandemic on CRC screening and diagnostic testing among 18-89 year-olds enrolled in the Kaiser Permanente Northern California health plan in 2019 and 2020. Researchers measured changes in the number of mailed, completed, and positive FITs; colonoscopies; and cases of colorectal neoplasia detected by colonoscopy. Findings show that when the pandemic-related stay-at-home orders were issued in March 2020, there was a dramatic decline in FIT mailings. Similarly, in South Australia, retrospective analysis on surveillance colonoscopy in patients at high risk for CRC revealed that there was a 51.1% decrease in surveillance colonoscopy procedures from April–June 2019 compared to April–June 2020, the period where the region faced the most difficulty due to COVID-19. 

The reduction in CRC screenings during the pandemic suggests that patients may have been reluctant or unable to undergo screening. Furthermore, challenges with pre-pandemic CRC screening were amplified during the pandemic. For instance, stress levels in the general population increased and those who may have skipped screening due to work obligations were more likely to miss setting up a colonoscopy during the pandemic. Fear of contracting COVID-19 may have been another barrier. Another issue that was evident during the pandemic was healthcare inequities that disproportionately impacted medically-underserved communities. 

Given the massive delays in traditional methods of screening, healthcare centers had to develop alternative approaches to ensure continued screening after the initial wave of COVID-19, such as the increased adoption of telehealth services. For CRC screening, the use of FIT was arguably the best alternative to colonoscopy procedures during the COVID-19 pandemic. This remote option gives patients a lot of flexibility with their screening, as they are able to take the test safely in the comfort of their own homes. 

These findings may help inform the development of strategies for CRC screening and diagnostic testing during future national emergencies. 

 

Kitty Chiu is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation. 

A friendly bet resulted in a potentially life-saving procedure for actors Ryan Reynolds and Rob McElhenney. Reynolds bet McElhenney that if he learned to speak Welsh, Reynolds would let a camera crew document him as he underwent a colonoscopy. In partnership with Lead from Behind, Reynolds documented and shared his experience on YouTube

Both Reynolds and McElhenney turned 45-years-old this year. In May 2021, the US Preventive Services Task Force (USPSTF) revised the colorectal cancer (CRC) screening age for average-risk adults to 45 years instead of 50. Reynolds noted in his video description, “I made a bet. I lost. But it still paid off.” Reynolds’ colonoscopy, conducted by Jonathan LaPook, MD, a gastroenterologist with NYU Langone’s Colon Cancer Screening and Prevention Program, resulted in the detection and removal of an “extremely subtle polyp” on the right side of his colon. McElhenney also decided to undergo a colonoscopy, which resulted in the identification of three polyps. Dr. LaPook emphasized, “This [colonoscopy] saves lives. Pure and simple.”

Importance of Colorectal Cancer Screening

Colorectal cancer (CRC) is the third most diagnosed cancer and over 5 million people worldwide currently live with CRC. According to the American Cancer Society, the lifetime risk of developing CRC is 1 in 23 for men and 1 in 25 for women, and recent research indicates an increased incidence of CRC among individuals younger than 50 years of age. There will be an estimated 106,180 new colon cancer cases and 44,850 new rectal cancer cases in the United States in 2022. While CRC screening rates have significantly improved over the past 20 years, only 65%-70% of age-eligible individuals achieve screening nationally. Screening is a significantly effective and preventive method to detect CRC before it advances to an incurable stage. 

When to Schedule a Colonoscopy

The American Cancer Society and USPSTF recommend screening should begin at 45 years for average-risk adults. Individuals who are at a higher risk of developing CRC may need to be screened earlier.

What to Expect During a Colonoscopy

A colonoscopy detects swollen, abnormal tissues, polyps, or cancer in the large intestine (colon) and rectum. Before a colonoscopy, patients are required to empty their colon by following a specific diet recommended by their doctor, taking a prescribed laxative, and adjusting any daily medications as instructed by their doctor. On the day of the procedure, a long, flexible tube (colonoscope) is inserted into the patient’s rectum under anesthesia. A tiny camera at the tip of the tube allows the doctor to view the colon. If polyps and abnormal tissues are detected, they can be removed during the colonoscopy itself, just like in Reynolds’ and McElhenney’s procedures. According to the American Society for Gastrointestinal Endoscopy, more than 40% of adults over the age of 50 years have precancerous polyps in the colon.  

What Are Colorectal Cancer Symptoms?

CRC may not cause symptoms immediately. Screening is the most effective method to detect and remove polyps before they advance into malignant disease. Speak to your doctor if you are 45 or older, have a family history of CRC, or notice any abnormal symptoms.

Remember: CRC survival is 90% if detected at an early stage when the cancer is localized and has not spread to other sites or organs.

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

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

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

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

What Did the Study Find?

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

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

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

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

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

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

 

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

Diet has been recognized as an important modifiable risk factor for colorectal cancer (CRC). In particular, diets consisting of high fats and carbohydrates, such as red and processed meats, are considered high-risk. Now, a large-scale cohort study among U.S. residents has revealed that high consumption of ultra-processed foods might increase CRC risk in men—the third most diagnosed cancer in the U.S.. 

For the past two decades, researchers have witnessed a significant increase in the consumption of ultra-processed foods, industrial ready-to-eat or ready-to-heat products high in refined sugars, refined starch, and trans fats. Ultra-processed foods currently contribute to 57% of the total daily calories consumed by American adults. A growing pool of evidence suggests that ultra-processed foods increase CRC risk by altering the composition and diversity of gut microbiota and increasing the risk of obesity.  Some examples of these foods include bread and rolls, breakfast bars and cereals, hotdogs and other processed meats, packaged sweet snacks and desserts, jams and jellies, and condiments, among other things.

The above-mentioned study analyzed responses from over 200,000 participants—159,907 women from the Nurses’ Health Study (1986-2015) and 46,341 men from the Health Professionals Follow-up Study (1986-2014)—across three large prospective studies in the U.S. that assessed dietary intake. The follow-up period was between 24-28 years. At the time of study enrollment, none of the participants had any cancer diagnoses. Information on dietary intake, demographic characteristics, lifestyle factors, and medical conditions of the participants was obtained through food frequency questionnaires every four years. 

Of the 206,000 participants who were followed for more than 25 years, the research team documented 1,294 cases of CRC among men and 1,922 cases among women. The study findings indicated that those who consumed the highest amount of ultra-processed foods had a 29% higher risk of CRC compared to those with the lowest consumption. However, this was not observed among women. Among women, the risk of CRC was positively associated with higher consumption of ready-to-eat or ready-to-heat mixed dishes. In contrast, higher consumption of yogurt and dairy-based desserts was linked to a reduced risk of CRC among women. 

These findings support the importance of limiting certain types of ultra-processed foods for better health outcomes. Here are some additional resources on diet and lifestyle and how they can influence your colon health and overall wellness:

  1. Healthy Inside and Out: How Diet and Lifestyle Impact Colorectal Cancer
  2. Dietary Mindfulness Can Reduce the Risk of Colorectal Cancer
  3. Diet and Nutrition to Prevent Colon Cancer

 

Kitty Chiu is a Colorectal Cancer Prevention Intern with the Colon Cancer Foundation.

Image credit: Tim Toomey on Unsplash

A series of abstracts presented at the 2022 Annual Meeting of the American Society of Clinical Oncology identified ways to improve access to colorectal cancer (CRC) screening, including for minority and underserved populations; compared different screening modalities for efficiency; and highlighted ways to improve the impact of screening programs at health centers. The infographic below provides a snapshot of these research findings.

Abstracts presented at the 2022 Annual Meeting of the American Society of Clinical Oncology.

 

Details on the studies and their findings can be found below:

  1. https://meetings.asco.org/abstracts-presentations/208933
  2. https://ascopubs.org/doi/abs/10.1200/JCO.2022.40.16_suppl.11020
  3. https://ascopubs.org/doi/abs/10.1200/JCO.2022.40.16_suppl.10529
  4. https://ascopubs.org/doi/abs/10.1200/JCO.2022.40.16_suppl.3526
  5. https://meetings.asco.org/abstracts-presentations/206470
  6. https://meetings.asco.org/abstracts-presentations/206684

 

Juhi Patel was a Colon Cancer Prevention Intern with the Colon Cancer Foundation.

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

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

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

Universal Versus Guideline-Directed Targeted Testing for Hereditary Cancer 

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

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

 

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

 

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

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

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

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

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

Dr. Shahnaz Sultan

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

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

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

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

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

Continued on Page 2.

On June 17, 2022, the National Comprehensive Cancer Network (NCCN) held a policy summit to discuss cancer care in the workplace and building a 21st century workplace for patients, survivors, and caretakers.

One of the distinct portions of this summit was a panel on Patients, Survivors, and Caregivers in the Workplace: Contemporary Barriers and Solutions to Achieving Inclusive Workplaces. Panel moderator John Sweetenham, MD, FRCP, FACP, FASCO, Chair, NCCN Board of Directors, and Professor of Medicine, Associate Director of Clinical Affairs, UT Southwestern Simmons Comprehensive Cancer Center, noted that the disproportionate distribution of accommodations due to socioeconomic differences leads to inadequate care and suboptimal outcomes for certain populations.

Rebecca V. Nellis, MPP, Executive Director, Cancer and Careers, shared results from a 2021 Cancer and Careers/Harris Poll Survey, which found that for three-fourths of responders, work helped them cope and aided in their recovery. These statistics show us that we can work towards a healthier workplace environment for cancer patients  and subsequently influence their health outcomes. Lynn Zonakis, BA, BSN, Principal, Zonakis Consulting, former Managing Director of Health Strategy and Resources for Delta Air Lines, shared the strategies employed by Delta for combating the difficulties associated with a cancer diagnosis. “At all levels, I would say that people were very open to disclosure, and that was the vast norm, because in each work unit, at every level, there were multiple cancer survivors or survivorship in family members, so they understood that it was to their benefit to disclose.”

She did elaborate on the associated risks,  citing the example of pilots at risk of losing their jobs when disclosing mental health risks. This can be applied to a cancer diagnosis as well. “At a lot of organizations it can put you at risk. Some people will feel that their job could be vulnerable, and they won’t disclose it, so there’s no one size fits all,” she noted.

Workplace Flexibility for Patients and for Caregivers

Angela Mysliwiec, MD, Senior Medical Director, WellMed, touched on an important aspect of the support process: the caregivers. She spoke about a program at WellMed dedicated to assisting caregivers, who she explained are experiencing the same challenges as the person they’re caring for. “When it comes to work they need flexibility, they need to take care of themselves, they need their mental health cared for, and the organizations themselves who are often ill equipped to manage a person on staff with cancer can often be even more ill equipped to manage the caregiver,” Mysliwiec said.

Randy A. Jones, PhD, RN, FAAN, Professor, Associate Dean for Partner Development and Engagement, and Assistant Director of Community Outreach and Engagement at the University of Virginia, concurred with Mysliwiec. “Caregivers share the anxiety, they share the fatigue, along with some of the patients with cancer that they’re dealing with.” He also made a point about institutions having the resources to empower patients, especially since “people are more aware of these issues, you know people understand that there is an issue between how patients are getting benefits as well as how they may be navigating the system.”

Sweetenham and Nellis closed the panel by highlighting the importance of proactive planning instead of reactive planning. They recommended that organizations should implement workplace flexibility that should be communicated upfront to new employees, and then practice it on a regular basis instead of making adjustments and assumptions as events occur.

Employer Policies Play a Big Role 

Joanna Fawzy Morales, Esq., Chief Executive Officer, Triage Cancer, spoke to the audience about The Policy Landscape to Support Patients, Survivors, and Caregivers at Work. Morales pointed out that employment can be a contributor to financial toxicity in the form of lost wages, employee benefits, and more. She further elaborated on a point that Nellis had made about battling assumptions, saying that “Employers have assumptions about their employees who’ve been diagnosed with cancer and their ability to do their jobs. Health care professionals make a whole lot of assumptions about their patients and whether or not they want to work or they can work.”

Explaining the current and suggested employment rights and accommodations, Morales said that they play a big role in helping patients make educated decisions on next actions. While there is a significant lack of awareness of protections available through the law, there are several gaps that need to be bridged. “There are many opportunities to close those gaps to improve the quality of life of patients and their families and mitigate the financial toxicity of a cancer diagnosis,” she added. She concluded her talk by emphasizing the need to educate employers, health care professionals, and the cancer community.

From informing the employer to the employee to equitable care for patients and their caregivers, this policy summit discussed various aspects of cancer in the workplace, and how we can improve the experience for those involved.

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

Image credit: Mohamed Hassan, Pixabay

 

CCCF Research

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

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