Colorectal cancer: How do we approach health disparities?

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Colorectal cancerHow do we approach health
disparities?

• Marta L. Davila, MD, FASGE
• University of Texas MD Anderson Cancer Center

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Colorectal cancer (CRC)Facts

• Third most common cause of cancer
• Second leading cause of cancer-related deaths in
  men and women in the US
• An estimated 143,000 cases of CRC are expected to
  occur in 2012

American Cancer Society. Cancer facts and figures
2012. Atlanta American Cancer Society 2012
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Colorectal cancerFacts

• 51, 690 deaths from CRC are expected to occur in
  2012
• Americans have a 5 lifetime risk for CRC
• Rare before age 40 in both men and women, with
  90 of cases occurring after age 50

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Colorectal cancerFacts

• Incidence of CRC has been declining in the US by
  2-3 per year over the last 15 years
• CRC screening probably accounts for this decline
  by early detection and removal of polyps
• Good evidence shows that screening reduces
  mortality from CRC

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Polyp to Cancer Progression
A. Sessile polyp B. Pedunculated polyp C.
Colon cancer
Figure available at http//hopkins-gi.nts.jhu.edu
/pages/latin/templates/index.cfm?pgdisease3organ
6disease36lang_id1. Accessed March 18, 2009.
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Colorectal cancerFacts

• Modifiable factors associated with increased risk
  of CRC
• Obesity
• Physical inactivity
• Diet high in red or processed meat
• Alcohol consumption
• Long-term smoking
• Low intake of fruits and vegetables
• Early identification of patients with genetic
  conditions

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Cancer health disparities

• Definition ..adverse differences noted in
  cancer epidemiology that exist among specific
  groups in the U.S.
• Further defined by new cases (incidence), deaths
  (mortality) and associated psychosocial and
  financial burden
• These populations are characterized by age,
  education, ethnicity/race, gender, income and
  geographic location

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Cancer disparitiesCauses

• Social
• Economic
• Cultural
• Health system factors
• Inequities in work, wealth, education, housing,
  and barriers to prevention, early detection and
  treatment services

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American Cancer Society. Colorectal Cancer Facts
and Figures. 2011-2013 Atlanta American Cancer
Society. 2011
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American Cancer Society. Colorectal Cancer Facts
and Figures. 2011-2013 Atlanta American Cancer
Society. 2011
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CRC disparitiesAfrican-Americans

• Dietary / Nutritional factors
• Rates of physical inactivity
• Variability in screening rates
• Lower use of diagnostic testing
• Decreased access to high-volume hospitals and
  subspecialists
• Genetic susceptibilities
• Cancer biology

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American Cancer Society. Colorectal Cancer Facts
and Figures. 2011-2013 Atlanta American Cancer
Society. 2011
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Colorectal cancer screening guidelines
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CRC screening guidelinesUS Preventive Services
Task Force (USPSTF)

• For average-risk adults, screening should begin
  at age 50 and continue until age 75
• CRC screening in adults 76 to 85 years should be
  individualized

Test Time interval
Fecal occult blood test (FOBT) Annual
Flexible sigmoidoscopy 5 years
Colonoscopy 10 years
Ann Intern Med 2008149627-37
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CRC screening guidelinesAmerican Cancer Society
(ACS) , US Multi-society Task Force on Colorectal
Cancer (USMSTF) and the American College of
Radiology (ACR)

• Average-risk adult should start screening at age
  50

Test Time interval
Flexible sigmoidoscopy 5 years
Optical colonoscopy 10 years
Double-contrast barium enema 5 years
CT colonography 5 years
Fecal occult blood test (guaiac or immunochemical based) Annual
Stool DNA test Uncertain
Ann Intern Med 2012156378-386
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American Cancer Society. Colorectal Cancer Facts
and Figures. 2011-2013 Atlanta American Cancer
Society. 2011
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CRC screeningBarriers

• Cost and lack of access to health care
• Physician variability regarding screening
  recommendations
• Poor transmission of the benefits and risks of
  not getting screened
• Personal barriers
• Fear, embarrassment, distrust of the medical
  community

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Strategies to increase CRC screening

• Prompt one-on-one discussion about the
  potentially life-saving importance of screening
• Remove financial barriers to screening
• Help patients navigate through the healthcare
  system
• Use educational prompts to educate the community
  about Colonoscopy and other forms of screening

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Strategies to reduce CRC disparities

• Support increased funding for colorectal cancer
  programs and research at the NIH
• Support the CDC Colorectal cancer Control Program
• Goal to increase CRC screening rates in adults
  gt50 years to 80
• Support community programs targeting
  racial/ethnic minorities

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Summary

• Colorectal Cancer is a common, yet preventable
  disease that affects 140,000 individuals annually
• Colorectal Cancer mortality has declined over
  the past 3 decades largely due to increased
  screening
• Disproportionately higher cancer incidence and
  mortality rates in minority populations may be
  directly related to barriers to screening
• Identifying these barriers is key to improved
  outcomes