Reducing Colorectal Cancer Risk Among African Americans
2015; Elsevier BV; Volume: 149; Issue: 6 Linguagem: Inglês
10.1053/j.gastro.2015.08.033
ISSN1528-0012
AutoresSonia S. Kupfer, Rotonya M. Carr, John M. Carethers,
Tópico(s)Global Cancer Incidence and Screening
ResumoSee editorial on page 1323; Guindalini RSC et al on page 1446; and Huang C et al on page 1575. See editorial on page 1323; Guindalini RSC et al on page 1446; and Huang C et al on page 1575. Colorectal cancer (CRC) burden is not equal among populations in the United States. African Americans have the highest CRC incidence and mortality of all US populations, and rates are not decreasing to the levels of non-Hispanic Whites.1American Cancer SocietyCancer facts and figures 2015. American Cancer Society, Atlanta, GA2015Google Scholar In addition to increased cancer risk, adenoma risk is also higher in African Americans, and both adenomas and cancers occur more frequently in the proximal colon and at younger ages in African Americans.2Lieberman D.A. Williams J.L. Holub J.L. et al.Race, ethnicity, and sex affect risk for polyps >9 mm in average-risk individuals.Gastroenterology. 2014; 147: 351-358Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar Reasons for population differences are multifactorial and include differences in tumor biology and behavior, genetic risk, access to health care, and screening rates.3Tammana V.S. Laiyemo A.O. Colorectal cancer disparities: issues, controversies and solutions.World J Gastroenterol. 2014; 20: 869-876Crossref PubMed Scopus (53) Google Scholar, 4Carethers J.M. Screening for colorectal cancer in African Americans: determinants and rationale for an earlier age to commence screening.Dig Dis Sci. 2015; 60: 711-721Crossref PubMed Scopus (82) Google Scholar As demonstrated by the Delaware CRC screening program, strategies to maximize screening hold significant promise for correcting CRC disparities.5Grubbs S.S. Polite B.N. Carney Jr., J. et al.Eliminating racial disparities in colorectal cancer in the real world: it took a village.J Clin Oncol. 2013; 31: 1928-1930Crossref PubMed Scopus (134) Google Scholar Current US Multisociety Task Force guidelines recommend CRC screening for all populations at average risk beginning at age 50 years, and individuals at increased risk (such as those with family history, inherited genetic syndromes or inflammatory bowel disease) are recommended to begin screening earlier.6Levin B. Lieberman D.A. McFarland B. et al.Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology.CA Cancer J Clin. 2008; 58: 130-160Crossref PubMed Scopus (1427) Google Scholar Owing to increased and earlier neoplasia risk, some professional organizations recommend screening in African Americans starting at age 45.3Tammana V.S. Laiyemo A.O. Colorectal cancer disparities: issues, controversies and solutions.World J Gastroenterol. 2014; 20: 869-876Crossref PubMed Scopus (53) Google Scholar Others raise concerns about the impact of complicating existing standardized guidelines and the unclear benefit of earlier age screening in African Americans despite an increased proportion of CRC under the age of 50 years. They recommend that efforts should focus instead on improving screening efforts in African Americans starting at age 50. Given this controversy, it is timely to examine how our profession can take the lead in reducing CRC disparities among African Americans. Several strategies should be considered when prioritizing our efforts (Table 1).Table 1Strategies to Decrease Disparities in Colorectal Cancer (CRC) Among African Americans (AAs)StrategyAdvantagesDisadvantagesPatient educationDirect to consumerAddresses patient-level barriers (eg, fear, mistrust, etc)CostAbility to effectively reach certain target populations (ie, those with low health literacy)Provider educationAddresses lower rates of provider recommended screening of AAsNo data on effectivenessCostBroad target population (eg, gastroenterologists, primary care)Patient navigationEvidence for benefit in increasing colonoscopy screening for AAsCost effectiveCost and insurance coverageTrainingImplementationIncreased screening by any method at age 50Addresses lower screening rates among AAsMost CRCs develop after age 50AAs might prefer noncolonoscopy screeningConfusion about preferred modalityAAs have increased risk of right-sided neoplasiaModify age for screeningReduces burden of early-onset diseaseRaises awareness of increased riskLife-years gained by earlier screeningIncreased confusion in guidelinesNo prospective study of effectivenessMost CRCs develop after age 50 Open table in a new tab African Americans are less knowledgeable about CRC and screening guidelines compared with Caucasians,7Philip E.J. DuHamel K. Jandorf L. Evaluating the impact of an educational intervention to increase CRC screening rates in the African American community: a preliminary study.Cancer Cause Control. 2010; 21: 1685-1691Crossref PubMed Scopus (31) Google Scholar and are less likely to transmit a family history of cancer.4Carethers J.M. Screening for colorectal cancer in African Americans: determinants and rationale for an earlier age to commence screening.Dig Dis Sci. 2015; 60: 711-721Crossref PubMed Scopus (82) Google Scholar Both lack of knowledge about screening benefits and fatalistic views about cancer are associated with reduced likelihood of screening among African Americans.8Greiner K.A. Born W. Nollen N. et al.Knowledge and perceptions of colorectal cancer screening among urban African Americans.J Gen Intern Med. 2005; 20: 977-983Crossref PubMed Google Scholar Interventions designed to educate patients about CRC and screening guidelines can improve screening rates and attitudes,9Powe B.D. Ntekop E. Barron M. An intervention study to increase colorectal cancer knowledge and screening among community elders.Public Health Nurs. 2004; 21: 435-442Crossref PubMed Scopus (48) Google Scholar, 10Greiner K.A. Daley C.M. Epp A. et al.Implementation intentions and colorectal screening: a randomized trial in safety-net clinics.Am J Prev Med. 2014; 47: 703-714Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar and those that contain culturally sensitive materials have been shown to boost screening among African Americans.9Powe B.D. Ntekop E. Barron M. An intervention study to increase colorectal cancer knowledge and screening among community elders.Public Health Nurs. 2004; 21: 435-442Crossref PubMed Scopus (48) Google Scholar These and other studies suggest that lack of knowledge about CRC screening benefits is a surmountable barrier, but challenges remain. For example, ≤40% of African Americans aged 65 years and older in some US areas are estimated to read below a 5th-grade level,9Powe B.D. Ntekop E. Barron M. An intervention study to increase colorectal cancer knowledge and screening among community elders.Public Health Nurs. 2004; 21: 435-442Crossref PubMed Scopus (48) Google Scholar limiting the use of some CRC screening materials. In addition, standardized patient education approaches may not work in all populations and age groups, potentially necessitating individualized interventions and inclusion of personnel to engage in community-based education and outreach. The impact of provider endorsement on screening rates cannot be underestimated. Lack of provider recommendation is an important barrier to screening in African Americans.11May F.P. Almario C.V. Ponce N. et al.Racial minorities are more likely than whites to report lack of provider recommendation for colon cancer screening.Am J Gastroenterol. 2015 May 12; (Epub ahead of print)PubMed Google Scholar However, studies that evaluate the impact of provider education on CRC screening in African Americans are lacking. Continuing medical education seminars can increase CRC knowledge, but whether this translates to improved screening rates is not clear.12Nguyen B.H. Pham J.T. Chew R.A. et al.Effectiveness of continuing medical education in increasing colorectal cancer screening knowledge among Vietnamese American physicians.J Healthcare Poor Underserved. 2010; 21: 568-581Crossref PubMed Scopus (5) Google Scholar Just as there are no standardized approaches for patient education, there are no standardized strategies to improve provider education. Moreover, providers cite insufficient time as a barrier to recommending CRC screening to patients,13Guerra C.E. Schwartz J.S. Armstrong K. et al.Barriers of and facilitators to physician recommendation of colorectal cancer screening.J Gen Intern Med. 2007; 22: 1681-1688Crossref PubMed Scopus (116) Google Scholar potentially causing additional delay in timely CRC screening for this higher risk population. Strategies focused on physician education about the increased CRC burden among African Americans may improve CRC screening, but more research is needed to demonstrate this. Patient navigation is a proven strategy for increasing CRC screening rates in African Americans and also improves no show rates and bowel preparation.3Tammana V.S. Laiyemo A.O. Colorectal cancer disparities: issues, controversies and solutions.World J Gastroenterol. 2014; 20: 869-876Crossref PubMed Scopus (53) Google Scholar, 14Horne H.N. Phelan-Emrick D.F. Pollack C.E. et al.Effect of patient navigation on colorectal cancer screening in a community-based randomized controlled trial of urban African American adults.Cancer Cause Control. 2015; 26: 239-246Crossref PubMed Scopus (58) Google Scholar A randomized trial in older African Americans of phone navigation and printed material versus printed material alone found a 53% increase in endoscopic screening in the navigation group with health literate subjects showing a stronger effect from navigation.14Horne H.N. Phelan-Emrick D.F. Pollack C.E. et al.Effect of patient navigation on colorectal cancer screening in a community-based randomized controlled trial of urban African American adults.Cancer Cause Control. 2015; 26: 239-246Crossref PubMed Scopus (58) Google Scholar Financial modeling based on a program in New York City found patient navigation to be cost effective,15Ladabaum U. Mannalithara A. Jandorf L. et al.Cost-effectiveness of patient navigation to increase adherence with screening colonoscopy among minority individuals.Cancer. 2015; 121: 1088-1897Crossref PubMed Scopus (36) Google Scholar whereas a randomized trial noted greater costs for tailored navigation.16Lairson D.R. Dicarlo M. Deshmuk A.A. et al.Cost-effectiveness of a standard intervention versus a navigated intervention on colorectal cancer screening use in primary care.Cancer. 2014; 120: 1042-1049Crossref PubMed Scopus (32) Google Scholar Implementation of patient navigation from research studies into the "real world" can be complex and requires flexibility and cooperation among stakeholders.17Sly J.R. Jandorf L. Dhulkifl R. et al.Challenges to replicating evidence-based research in real-world settings: training African-American peers as patient navigators for colon cancer screening.J Cancer Educ. 2012; 27: 680-686Crossref PubMed Scopus (8) Google Scholar Thus, although patient navigation can increase screening among African Americans, logistics and cost are major barriers to widespread adoption. Efforts should focus on overcoming these barriers through education, research, and advocacy for patient navigation in CRC screening. A more controversial strategy is to lower the initial screening age recommendation for African Americans. Arguments supporting this strategy include increased rates of significant neoplasia, higher stage of CRC at younger ages, and proximal location of tumors among African Americans.3Tammana V.S. Laiyemo A.O. Colorectal cancer disparities: issues, controversies and solutions.World J Gastroenterol. 2014; 20: 869-876Crossref PubMed Scopus (53) Google Scholar Lieberman et al2Lieberman D.A. Williams J.L. Holub J.L. et al.Race, ethnicity, and sex affect risk for polyps >9 mm in average-risk individuals.Gastroenterology. 2014; 147: 351-358Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar showed that the rate of high risk polyps (>9 mm) was increased 17%–38% in African American men ages 50-69 years and 25%–50% in African American women ages 50-64 years compared with Caucasian men and women in these age groups. Although the risk of large polyps was not statistically different for African American men and women 9 mm in average-risk individuals.Gastroenterology. 2014; 147: 351-358Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar, 19Gupta A. Ahlquist D.A. The effectiveness of colonoscopy in reducing mortality from colorectal cancer.Ann Intern Med. 2009; 150: 817Crossref PubMed Scopus (2) Google Scholar To address this, a comparative effectiveness trial enrolling those starting screening before age 50 and at age 50 could be performed. Another argument is that the current screening guidelines are already complex and that population-based screening recommendations would further confuse patients and physicians. Further modifications to guidelines could potentially negatively impact screening knowledge and adherence; however, there are no studies to support this notion. Although changes in breast and prostate cancer screening led to some public confusion,20Harvey S.C. Vegesna A. Mass S. et al.Understanding patient options, utilization patterns, and burdens associated with breast cancer screening.J Womens Health. 2014; 23 Suppl 1: S3-S9Crossref Scopus (16) Google Scholar, 21Moyer CS. Conflicting data cause confusion on prostate cancer screening. 2012. Available at: www.amednews.com/article/20120813/health/308139946/4/. Accessed July 30, 2015.Google Scholar this was largely based on less intensified and reduced screening, not more. Given that African Americans have been shown to prefer non–endoscopy-based screening examinations,22Inadomi J.M. Vijan S. Janz N.K. et al.Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies.Arch Intern Med. 2012; 172: 575-582Crossref PubMed Scopus (448) Google Scholar perhaps focusing less on structural examinations and simplifying the message to encourage screening of any kind that is acceptable to the patient is the most appropriate initial comprehensive strategy. Increasing screening rates by 5%–10% has been argued to be as or more effective than reducing the screening age.19Gupta A. Ahlquist D.A. The effectiveness of colonoscopy in reducing mortality from colorectal cancer.Ann Intern Med. 2009; 150: 817Crossref PubMed Scopus (2) Google Scholar Although screening rates have been improving among African Americans and the gap with Caucasians is closing, there is certainly more work to be done. Finally, insurance coverage and access to endoscopy resources for earlier screening is a real concern and likely will only be changed if there is consensus among all bodies authoring screening guidelines. CRC burden among African Americans is unacceptably high, representing a major health disparity, and there are surmountable barriers to reduce this disparity. Patient and physician education as well as implementation of patient navigators can increase screening rates and should receive considerable attention. Whether implementing new population-specific screening guidelines will augment these efforts remains unclear; however, it is now time for our profession to establish consensus on this issue by establishing an expert panel to review the data and formulate updated evidence-based guidelines to reduce CRC disparities in African Americans, including a formal recommendation regarding the optimal screening age and modality. Such efforts will help us to make progress on health equity for all populations at risk for CRC and form a basis for an approach to care in this high risk population. Deciphering the Genetic Code of Gastrointestinal Diseases Among African AmericansGastroenterologyVol. 149Issue 6PreviewThe susceptibility of individuals to diseases is influenced by a complex interplay of their genetic makeup and interaction with the environment. Although we cannot change our genes, lifestyle modification and appropriate disease-specific medical interventions including screening may significantly minimize its risk or alter the course of disease. To prevent disease or treat it optimally, a thorough understanding of its pathogenesis is required. For many common diseases, ancestral events such as exposure to specific pathogens have shaped genetic susceptibility. Full-Text PDF Characterization of Genetic Loci That Affect Susceptibility to Inflammatory Bowel Diseases in African AmericansGastroenterologyVol. 149Issue 6PreviewInflammatory bowel disease (IBD) has familial aggregation in African Americans (AAs), but little is known about the molecular genetic susceptibility. Mapping studies using the Immunochip genotyping array expand the number of susceptibility loci for IBD in Caucasians to 163, but the contribution of the 163 loci and European admixture to IBD risk in AAs is unclear. We performed a genetic mapping study using the Immunochip to determine whether IBD susceptibility loci in Caucasians also affect risk in AAs and identify new associated loci. Full-Text PDF Mutation Spectrum and Risk of Colorectal Cancer in African American Families with Lynch SyndromeGastroenterologyVol. 149Issue 6PreviewAfrican Americans (AAs) have the highest incidence of and mortality resulting from colorectal cancer (CRC) in the United States. Few data are available on genetic and nongenetic risk factors for CRC among AAs. Little is known about cancer risks and mutations in mismatch repair (MMR) genes in AAs with the most common inherited CRC condition, Lynch syndrome. We aimed to characterize phenotype, mutation spectrum, and risk of CRC in AAs with Lynch syndrome. Full-Text PDF
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